Examination Card 2

APPROVED___________________________________________

Vice-Rector on Academic Work M.D., Prof. V.V. Simrok

„ ” 2007 y .

MINISTRY OF PUBLIC HEALTH OF UKRAINE

LUGANSK STATE MEDICAL UNIVERSITY

MEDICAL DEPARTMENT

SPECIALTY GENERAL MEDICINE COURSE VISUBJECT INTERNAL MEDICINE

EXAMINATION CARD № 20

Patient, 41 year, delivered by the doctor of first-aid in the induction centre. Patient complained of severe headache, dizziness, scintillation before eyes, heart pain, tremor in all body. He suffers from hypertention 5 years, level of blood pressure usually 140 and 90 - 150 and 95 mm Hg

Examination: redness of the skin. In lungs vesicular respiration. Heart sounds are rhythmic, clear, systolic murmur on an heart apex, accent of II tone, above an aorta. Pulse 105 beats per a minute. BP is 195 and 105 mm Hg. Liver at the margin of costal arc. The peripheral edemas are not present. Blood test: a general cholesterol – 6,0 mmol/L; level of lipoproteins high density – 1,1 mmol/L; level of lipoproteins low density – 4,04 mmol/L; level of lipoproteins very low density – 0,86 mmol/L; triglycerides – 2,2 mmol/L.

Electrocardiogram: sinus rhythm, regular, 105 beats per a minute, horizontal electric heart axis deviation, impairment repolarization of ventricles in leads V5, V6. Questions:

1. Emergency measures.

Approved at the Chair Meeting Minutes №6. The 22.01.2007 year.

Head of the chairM.D., Professor Yu. N. Kolchin

APPROVED___________________________________________


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MEDICAL DEPARTMENT



Task: patient 45 years, doctor of ambulance. Complains: during a few months period-ically 1-2 times per a month between a 4-5 o'clock a.m. she feels the attack of tightening pain behind a breastbone, proceeding from 5 to 10 minutes. In daily time she feels healthy, well carries the physical exercises. At examination: the state is satisfactory, pulse 86 beats per a minute, the borders of the heart are not changed, Heart sounds are rhythmic, clear. BP is 125 and 70 mm Hg. Item a menstrual cycle not is broken.During the rest, after physical exercises,electrocardiogram is normal.

Blood test: HB is 130 gm/dL, WBC - 5,0x109/L, erythrocyte sedimentation rate - 4 mm/hr, beta-lipoproteins 10 mmol/L. In the period of nightly duty in an interruption be-tween the calls there was the attack described higher, and which proceeded about 10 min-utes. On an electrocardiogram during an attack was registered the expressed getting up of ST interval in leads I, II, aVL, V2-V6. After the reception of nitroglycerine the state of pa-tient and indexes of electrocardiogram was fully normalized.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



Task: patient, 39 years old, addmitted to cardiologic department in an urgent condi-tion with complaints on the intensive pain behind a breastbone, not diminishing after the reception of nitroglycerine, breathlessness. Two last years He was observed by cardiolo-gist with ischemic heart disease: stable angina on exertion, functional class II. Examina-tion: skinning covers were pale, death-damp on face. In lungs weakened vesicular respira-tion. Heart tones were muffled; regular rhythm, 74 beats per a minute, BP 110/70 mm Hg. Stomach is soft, painless.

On an electrocardiogram the complexes of QR are registered in II and III, aVF, V5-V6 leads, in the same leads the segment of ST is displaced up with the wave T, high wave R in the I; in leads V1-V3 the segment of ST is displaced down, meets with the wave T.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



Task: patient 60 years old, at night had an intensive attack of tightening pain behind a breastbone, by duration more then 2 hour, palpitation. At examination: he was blurring, skin was pale, acrocyanosis. BP was 80/40 mm Hg. Pulse 89 beats per a minute, irregular, weak filling. Heart sounds were deaf, cardiac fibril-lation, 140 beats per a minute. Pulse deficit 51 per a minute. From the other systems any changes not exposed.Blood test: troponin T - 0,3 mg/L, myoglobin - 94 mg/L, creatine kinase-MB – 120 U/L, lactate dehydrogenase - 507 U/L, lactate dehydrogenase 1 - 129 U/L. Electrocardiogram: registered chaotic and irregular, different in a due form and am-plitude of waves with frequency to 200 in a minute, wave Q - duration 0,04 seconds, its amplitude - ¼ amplitudes of wave R, displaced up segment ST and negative wave T in III, aVF leads.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



Task: patient 44 years old, after physical exercises and jog ride delivered with com-plaints about suddenly pain in the right half of abdomen, the pain extending in a right lum-bar region during 2 hours. Before now similar disorders never was. There was the single vomiting. A patient is uneasy, tumbling, adopts knee-elbow position. The temperature of body is 37,40C, 90 beats per a minute. The right half of stomach is tense, sharply painful. Symptom of irritated peritoneum is negative. Symptom of Pasternatsky positive on the right side. Blood test: WBC -9,2x109/L Hb-132 g/L, RBC - 4,3x1012/L; erythrocyte sedi-mentation rate -20 mm/hour. Urine tests: tracks of albumen; fresh RBC - 5-8 in visual fields; leucocytes - 10-12 in visual fields; plenty of salts - acid urates.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



Task: patient 32 years after the emotional overstrain complains about the cramping pain in the stomach, attended with a frequent liquid defecation with plenty of mucus, gen-eral weakness. At examination: spastic pain in the different parts of colon during palpa-tion.

Blood test: HB is 130 gm/dL, RBC - 4,3x1012/L, WBC – 4,8x109/L, segmented neu-trophils – 68%, monocytes – 2%, eosinophils – 1%, lymphocytes – 28%, erythrocyte sedi-mentation rate - 8 mm/hr. Serum potassium – 3,7 mmol/L, sodium – 135 mmol/L, calcium – 2,2 mmol/L, urea – 5,7 mmol/L. Urine tests: amount - 100,0, specific gravity - 1015, RBC - 0-1 in visual fields; WBC - 5-8 in visual fields; single epithelial cells. Fecal test: designed excrement, pH is neutral, single muscular fibers, increased mucus. Result of colonoscopy: mucous colon of rose color, pathological formation are not exposed. Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



Task: a young man 19 years old during play the football suddenly felt breathlessness, sharp pain in the right half of thorax, general weakness, sense of fear of death.

At examination: diffuse cyanosis, tachypnea 32 per a minute. The right half of thorax does not participate in the act of breathing, intercostal intervals are smoothed out. At per-cussion above the right half of thorax a tympanic sound is determined, is not hearkened to respiratory noises.

Blood test (clinical): hemoglobin - 127 gm/dL, RBC - 4,1x1012/L, reticulocytes – 1%, Platalets – 250x109/L, WBC – 6,2x109/L, stab neutrophils – 3%, segmented neutrophils – 68%, eosinophils – 1%, basophils – 1%, lymphocytes – 32%, monocytes – 3%, erythro-cyte sedimentation rate - 7 mm/hr.

X-ray of organs of pectoral cavity in a direct projection: left lung without features, in place of right lung the brightening area deprived pulmonary picture is visible, displace-ment of organs of mediastinum in left, flat the right dome of diaphragm.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



Patient B., 42 years old, Subacute (pernicious) glomerulonephritis, exacerbation, chronic renal failure II was diagnosed in nephrological department. During first day the patients condition got worse bluntly. Patient was blurring, without contact, pain sensibility was keeped.

Physical findings: skin was dry, pale with the tracks of combs. The face was puffi-ness. The abdomen was increased, the legs were edematous, there were muscular fibrillar cramps. The breath was deep, noisely, with smell of urea from the mouth. The pupils were narrow. During percussion the short percuting sound was listened in bothside of low lobes, auscultation - impaired vesicular breathing. The heart tones were rhythmic, deaf, 96 beats in minutes, the heart borders widened in left side.

Blood analysis: RBC- 2,7×1012/l; Нb – 80 g/L; WBC- 5,0×109/L; creatinine – 1,052mmol/L; urea – 23 mmol/L; Mg – 1,3 mmol/L; Ca – 1,7 mmol/L; GFR – 20 ml/min. Urine analyses: daily diuresis – 850 ml; spacific gravity – 1005; protein – 1,1 g/L; hyaline cylinders– 16-18 in visual fields; RBC – 7-9 in visual fields.

Ultrasound findings: size of right kidney 6,0*10,0 sm, left - 6,5*10,5 sm, the size were decreased, parenchyma was thick with bad differntiation of margions and renal cup-pelvical system (7,5-12 sm).

Questions:




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MEDICAL DEPARTMENT



Patient F., 22 years old, addmitted to hospital in severe condition. 4 weeks ago he suf-fered from inluenza, severe form.

Physical findings: the patients condition was severe, patients position was obligeted - orthopnoea. Face was cyanosis, acrocyanosis. Body temparature was 38oC.The breathing was noiseling, boiling, superficial, arrhythmical, 40 in 1 min. The rosy, foamy sputum was coughed. During auscultation moist small and middle bubbly rales were listened in bothside, in some part of lungs the breath wasn`t listened. The heart beats were very deaf, tachicardia, 120 in 1 min., BP – 175/115 mm Hg. The heart bodies were widered in both-side. The liver size was increased (12*11*10 sm), The sizes of lien and kidneys were normal. The legs were edematous.

Laboratory indexis: Blood analysis: RBC-3,9×1012/l; Нb – 120 g/L; WBC – 15,0×109/L, rod nuclear cells – 11%, segmented L. – 53%, lymphocytes – 31%, monocytes – 5%; Pl. - 250*109/L, ESR – 22 mm/ h, general protein – 58g/L, albumin – 38%, globulin – 62% (α1 – 9,3%, α2 –15,2%, β – 12,3%, γ - 18%), A/G quotient - 0,61.

X-ray: the bothside clouds in low parts and near the both lungs roots, the heart shadow was wided in bothside, the pulsation was little. Electrocardiogram: sinus arrhythmia, RR – 0,55-0,48 sec, PQ – 0,22 seс, voltage QRS was decreased.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



The patient D., 47 years old, addmitted to hospital in severe condition and suffered from frequent attacks of dyspnea, cough with poor sticky transparent sputum, breathless-ness during small physical activity. During last 3 years she suffered from bronchial asthma. About 1 week ago, after influenza the attacks of asthma increased to 2-3 times per day, she used 2 or 3 inhalations of salbutamol. Last attack of dyspnea was more than 4 hours. During two last hours 8 inhalations of salbutamol was made but attacks of dyspnea was not removed.

Physical findings: the patients condition was severe, patients position was obligeted - orthopnoea. Face was cyanosis, acrocyanosis; without peripheral edema;dystanse dry rales, the breath with prolonged expiration, 30 in minutes; the thoracic muscles partici-pated in the breath. During auscultation dry whistling rales were listened in bothside, in some part of lungs the breath wasn`t listened. The heart beats were deaf, tachicardia, 112 in 1 min., BP – 110/70 mm Hg.

Laboratory indexis: sputum analysis: yellow colour, mucos, sticky, cells of pave-ment epithelium - 1-3 in visual fields, epithelium of bronchi - ordinary, alveolar macrophages - 1-2 in visual fields, WBC - 3-5 in visual fields, eosinophiles – big quantity, RBC - 1-2, spirals of Curshman, crystals of Sharko-Leiden.

Spirometry: VC - 54,6%, FVC - 66,8% FEV1 - 50,5%, FEF25-75% - 46,1% FEF25% - 49,3% FEF50% - 39,7% FEF75% - 35,3%.

PaO2 - 75 mm Hg, PaCO2 – 60 mm Hg.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



The patient B., 20 years old, addmitted to hospital in comas condition.Relatives said: during last 4-5 days patient suffered from severe thirst, abudant urination, weight loss, ap-petites absence. Patients mother suffered from diabetes mellitus.

Physical findings: the patient wasn`t consciousness, skin was dry, skin turgor de-creased, lips mucous membrane was dry, tongue was covered with white fur, the acetons smell from the mouth. The pupils were narrow, eyeballs were soft. The breathing was noisely as Cussmaule - 22 in min.; the heart tones were rhythmic, deaf, 90 beats in min-utes, BP – 100/60 mm Hg. The abdomen was increased in volume a little. The livers size was normal (9-8-7 sm).

Laboratory indexis: glucose in blood – 25 mmol/L, urine analyses: glucose in urine – 35 g/L, ketonuria - ++, renal epythelium – 10-15 in visual fields, RBC – 10-12 in visual fields, hyaline cylinders – 2 - 8 in visual fields.

Ultrasound findings: size of liver, gall bladder – without pathology, size of pancreas - 27·15·20 mm, contour was uneven, changing in structure of pancreas; renal structure was-n`t legible.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



The Patient K., 75 years old, after sleeping, during 2 hours, felt muscular weak-ness in right arm and leg, disorder of speech.

Physical findings: the face skin was pale, pulse rate was failing, rhythmical, BP was 150/90 mm Hg, consciousness was preserved. He didn`t say any word. He understood speech. The strength in right extremities was: in arm – 3 points, in leg - 4 points; reflexes D < S.

Investigation of oculus fundus: optic disks were pale-rozy colour with clear boders, the arteries were sclerotic, the veins were convolute.

Investigation of liquor: liquor was transparent, without colour, cytosis – 6 cells in 1 mkL, glucose – 3,2 mmol/L, protein 0,3 g/L, Cl – 7,5 g/L.

MRI: There was the focus of falling density in left fronto –temporo-parietal region with size 26 х 33 х 45 mm.

Questions:




APPROVED___________________________________________


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MEDICAL DEPARTMENT



The patient A., 52 years old, complained on the severe pain in right subcostal region, nausea, single vomiting with bile, brash in mouth, constipation. The pain irradiation was in right scapula and shoulder. During last 6 year patient suffer from the pain attack in right subcostal region after eating fat food.

Physical findings: patient was thick, body temperature was 37,1oC, in lungs - vesicular breathing, puls – 82 beats in min., BP – 130|80 mm Hg, tongue was covered with white fur.The abdomen was painfull in epigastrium, right subcostal region. Symptoms of Orth-ner, Ker, Merphy were positive. Symptoms of irritation of peritoneum were negative. Liver, lien, intestine, colon were normal.

Laboratory indexis: Blood analysis: RBC- 3,85×1012/l; Нb – 130 g/L; WBC – 9,2×109/L; ESR – 22 mm/ h, total bilirubine – 20,1 μmol/L, ALT – 60 U/L, AST –70 μmol/L; α-amylex – 1232 g/h*L.

Ultrasound findings: size of gall bladder - 15,2*4,8 sm, the wall – 0,4 sm, there were stones in gall bladder more than 2/3 of gall bladder volume.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



A man, 52 year old, has present to cardiology department with a diagnosis of macro-focal transmural anteroseptal-apical myocardial infarction.

Objective: auscultation - arrhythmical activity of heart, the sounds are muffled, blood pressure of 140/90 mmHg. The pulse is 80 beats per one minute. A gallop rhythm is aus-cultated. After 5 hours, the state of the patient has worsened considerably. He complains of a sharp retrosternal pain. Objective: the patient is uncomfortable. Dermal integuments cyanotic, to the touch cold and clammy. A blood pressure of 80/40 mmHg. The pulse is 120 beats per minute, arrhythmical. Pulse is weak and low volume. The cardiac sounds are considerably weakened, arrhythmical, tachycardic. Downstroke of a diuresis - 20 mls / h.

Analysis of a blood: RBC - 4,2 x 1012/L; WBC – 12×109/L; еos. - 3%, neut. - 71%, lymph. - 22%, mon - 6%, ESR - 16 mm/h АSТ – 68 U/L; Creatinine Phosphokinase - 60 U/L.

ECG: a sinus rhythm, frequency of heart is 120/min., sharp rise of the ST segment and Т waves above isoline in electrocardiographic leads V1- V4.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



The patient К., 42 years, has called the family doctor to the house. He complains of an attack of dyspnoea (on expiration), giddiness, palpitations. He has been sick for more than three years. The general state has worsened in the last three days with attacks of dysp-noea becoming more frequent. Constant presence of diurnal and night signs: restrained in a chest with laboured expiration, marked restriction of physical activity.

Objective: the patient has dyspnea, respiration rate 30 per minute, in mild dissipated sonorous dry rhonchi, remote rhonchi. Pulse is 120 per minute, blood pressure of 120/80 mmHg, heart sounds amplified, the second hear sound is loud in pulmonary artery. The other organs and systems are without any essential pathology.

Home use of the peakflowmeter showed variation diurnal of peak expiratory flow rate (PEFR) of more than 30 %. 2 days ago he was reviewed in the polyclinic: On spirogram – FEV1 53% of expected. Analysis of a sputum sample showed - eosinophils up to 20 %. Analysis of blood: haemoglobin - 130 g/L, WBC - 8,5x109/L, ESR - 8 mm/h. Positive dermal assays with allergens: a domestic dust, fluff and feather.

Questions:




APPROVED___________________________________________


„ ” 2007 y .



MEDICAL DEPARTMENT



The patient Н., 62 years, presented to hospital with complaints of infringement of dream, sharply expressed delicacy, headache, pain in the right hypochondrium, abdomen distension, pruritus of the skin, a rise in temperature up to 38оС. From the anamnesis: more than 10 years of alcohol abuse. Consists on a dispensary observation at expert in nar-cologist, gastroenterologist. Last deterioration has occurred after an alcoholic excess.

Objective: the patient is adynamic, offensive hepatic breath, skin and sclerae are dis-colored with icterus. The face is red and puffy. The skin on the trunk «vascular sprockets» with traces of pruritus. The heat sounds are muffled with heat rate of 96 per minute and blood pressure of 100/70 mmHg. The abdomen is distended, dull percussion in the left and right transabdominal range. The dimensions of a liver of Kurlov 12х10х9 sm. He has constipation with painless opening of bowels.

Analysis of blood: HBG - 90 g/l, RBS - 2,5 х 1012/L MCH - 30pg, WBC - 10х109/L, ESR-30 mm/h, GGT-160 МЕ, bilirubin - 60 mol/L, ALT-64 U/L, AST-45 U/L, alkaline phosphatase -240 U/L, prothrombin ratio -60 %.

Ultrasound findings: the size of the liver was increased, non-homogeneous parenchyma with loci of hyperechogenicity, v.porte – 18 mm, ascitic fluid more than 90 ml. Gall bladder, pancreas, kidney are without pathology.

Questions:




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MEDICAL DEPARTMENT



The patient К., 52 years old had tuberculosis in 20.05.1998г. In the last 2 years due to intermittent aggravation of symptoms, he has treated in hospital. There is marked contin-ued present of bacteria of on analysis of his sputum. Three days ago sputum expectorated in the morning was streak with blood. Two hours ago the patients condition deteriorated, having had a fit of coughing, haemophysis, bringing up half a glass of scarlet blood. Now haemophysis has settled down to sneaking in sputum coughed up.

Objective: his general state is satisfactory and he is acyanotic. The patient is eu-phoric. The pulse is 90 per minute with satisfactory volime. The blood pressure is 120/80 mm Hg. He is dysphoeic and examination there is dullness on percussion of the upper right lung and there is bronchial breathing on auscultation of the subclavial areas bilater-ally. Varigated wet rhonchi are auscultated in this area too. Muffled heart sounds. The liver is not enlarged.

Analysis of a blood: RBC - 3,6x1012/L, HBG - 82 g/l, WBC - 9,4x109/L, eos - 1%, neut. - 78 %, lymph. - 17 %, mon - 4 %, ESR - 25 mm / h. Pneumonogram: In the upper lobe at a level II of the rib there is a cavity 3,5х4 cm irregularly-shaped and thick-walled. An intrinsic contour of the cavity is picked up and the exterior contour is less dense. Around the cavity the image shows high density with distortion and loci of various den-sity. In the left here are mild simple dense loci.

Questions:




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„ ” 2007 y .



MEDICAL DEPARTMENT



A man of 34 years age is taken to hospital by ambulance after radioactive accident on production with application of the open radioactive substances. Due to on incident about 4 hours back, he has received an unstated dose of general irradiation. Now he complains of vomiting with nausea and moderate headache 1,5 hours after eating.

Objective: he is conscious, hyperaemic, seen mucous, in lung vesicular respiration, pulse 90 beats per minute. His temperature has increased up to 37,4o, other objective in-dices are unchanged.

Questions:




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MEDICAL DEPARTMENT



The patient К., 32 years old on presenting to his family doctor with complains on pain in the lower abdomen, nausea, multiple episodes of vomiting, dry mouth, delicacy, flaccidity, with temperature up to 38,2o, opening of bowels up to 10 times with mucous and blood streaks. Patient was acutelly ill 2 days ago with pain in the abdomen, frequent opening of bowels up to 10 times and mucous in character. Then the nausea and vomiting appeared.

Objective: patient is gravely unwell. Adynamic patient, flaccid. Skin is acyanotic, dry. Mucosae are acyanotic. There is reduced vesicular respiration in the lung and the res-piration rate is 14 per minute. Heart - dummy sounds are a little weakened with a low, weak pulse of 112 per minute, blood pressure of 70/50 mmHg. There is pain in the left il-iac range of abdomen, sigmoid colon is palpable as a dense cylinder. The liver is not en-larged and lien is not palpated. A stool – sample reveals mucous with blood streaks.

Analysis of blood: WBC - 10,4x109/L, eos.-2 %, neut. – 75%, lymph.-18 %, mon.- 5%, ESR-20 mm/h. Analysis of urine: specific gravity -1026, protein – very little. On proctosigmoidoscopy: there is not obstraction and hemorrhoidal clusters in range of a rec-tum. Mucous of sigmoid colon is hydropic and hyperemic. There are dotted haemorrhages. The ulcers are not seen.

Questions:




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„ ” 2007 y .



MEDICAL DEPARTMENT



Patient 19 years old is delivered by the doctor of ambulance in municipal hospital 12.08.05. The patient complains of edema of the face and neck, hoarseness of a voice, del-icacy, giddiness, laboured respiration. The oedema has arisen several minutes after inges-tion of honey. Independently, the patient has taken a tablet of Suprastinum, but the oedema continued to increase, the dyspnoea has amplified and a cough has appeared. Within one month the rhinitis were marked.

Objective: the oedema of the face and neck, laboured an expiration, respiration noisy, arterial pressure 110/60 mmHg, pulse 90 beats per minute. Chest auscultation reveals vesicular respiration without rales. Cardiac activity is rhythmical and the heart sounds are muffled. The abdomen is soft and painless.

Analysis of a blood: RBC- 4,5x 1012/L, HGB -120 g/L. MCH – 30 pg, WBC -7,5x 109/L, eos - 10 %, bas. - 1 %, lymphocytes - 30 %, neut. – 55%, monocytes 4 %. Common IgE 200 mg/mls, cytology of sputum and rhina secretions - 10 % eosinophils, the thrombo-cytopenic test - 28 %. The scarification test in a remission: an allergen an ambrosia plant -blister diameter - 18 mm, hyperaemia, orach plant- blister 5 mm, hyperemia.

Questions:




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