What syndromes can be distinguished in a patient?
What additional laboratory and instrumental studies should be carried out to clarify the etiology of the disease?
Task 2
The local doctor of the clinic is called to a 32-year-old patient who complains of the appearance of a liquid, watery, plentiful stool, greenish-yellow in color up to 5-6 times a day; noisy rumbling and a feeling of ―transfusion‖ in the abdomen, followed by loosening of the stool; unpleasant sensations, a feeling of pressure and unsharp, pulling pains around the navel, not associated with eating.
Sick for 3 days. There was nausea, there was vomiting several times, after 3-4 hours the temperature rose to 37.5 ° C. Soon there was rumbling in the abdomen, loose stools, and general weakness began to build up.
Objectively: a state of moderate severity. Temperature 37.3 ° C. The patient is dynamic. The skin is pale, dry. The abdomen is moderately swollen, participates in the act of breathing. A loud rumbling is heard in the distance. With percussion over the entire surface of the abdomen, a tympanic sound. On palpation: the abdomen is slightly tense, moderately painful in all departments, especially in the umbilical region. Symptom Shchetkina-Blumberg negative.
Analysis of feces: feces unformed, liquid, yellow, slightly alkaline reaction (pH = 7.5), reaction to blood with benzidine - posit, stekobilin - posz, muscle fibers that retained striation - ++, lost striation - +, soaps - +++, fat detritus, intracellular starch - +, extracellular - ++, digestible fiber - +, indigestible - +++, white blood cells - 10-15 in n / a (changed), red blood cells - 5-6 in n / sp
What syndromes can be distinguished in a patient? Task 3
Patient M., 50 years old, called an ambulance doctor at home. At night, after eating fatty foods on the eve, painful cramping pains suddenly appeared in the right hypochondrium, radiating to the right shoulder blade, right shoulder; there was nausea, vomiting repeatedly with an admixture of bile, which did not bring pain relief. Similar attacks began to occur in the patient over the past 2 years, as a rule, after errors in the diet, stopped by the use of antispasmodics.
On examination: a patient with increased nutrition. Groans and rushes about in bed. With superficial palpation of the abdomen in the area of the projection of the gallbladder.
What syndrome can be distinguished in a patient based on the data obtained?
What instrumental studies should be carried out to confirm the diagnosis?
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Task 4
Patient L., 48 years old, came to the clinic with complaints of cutting pains in the right hypochondrium, radiating to the right shoulder, under the right shoulder blade. Concerned about nausea and repeated vomiting of bile, chills, sweating, fever up to 38.3 ° C. On the eve of the patient ate fried pork.
On examination: moderate condition. Pulse 120 in min. With superficial palpation, painlessness and muscle tension in the gallbladder are noted. The positive symptoms of Murphy, Ortner, Zakharyin, Vasilenko and Shchetkin-Blumberg in this area are determined.
Blood test: leukocytosis (16x109), ESR - 45 mm / hour
What syndromes can be distinguished in a patient based on the data obtained?
What disease should I think about?
What clinical syndromes can be distinguished?
Task 5
Patient A., 40 years old, complains of a feeling of fullness in the epigastrium after eating a small amount of food, belching with the smell of rotten eggs, nausea after eating, sometimes vomiting food eaten the day before.
From the anamnesis: considers himself ill for 12 years, when ―hungry‖ epigastric pains began to bother, decreasing after eating or artificially induced vomiting and intensifying at night. It was mainly treated on an outpatient basis with antacid drugs. Exacerbations almost annually (mainly in spring). During remission, no complaints. Last year, the nature of the disease has changed: gradually growing sensations of heaviness and overflow in the epigastrium after eating and belching with a ―rotten egg‖ appeared. The patient began to lose weight.
On examination: the patient is pale. The subcutaneous fat layer is poorly developed. The tongue is covered with a thick white coating. The Traube space is not defined. On palpation in the epigastrium, slight pain is noted, the symptom of Vasilenko (late splashing noise to the right of the midline) is positive.
What syndromes can be distinguished in a patient based on available data?
What disease and its complication is most likely in this patient?
Task 6
Within 2 weeks, patient S., 36 years old, underwent an outpatient treatment with a diagnosis of exacerbation of chronic gastritis. Worried about epigastric pain that occurs 1.5-2 hours after eating, night pain, as well as constipation. When conducting pH-metry, the pH of the gastric contents is 1.4 (hyperacid state). On the 15th day, the patient had repeatedly vomited the color of ―coffee grounds‖, there was a sharp weakness, dizziness, palpitations, the next day - loose stools of black color. The patient was immediately hospitalized in the clinic.
Upon admission to the clinic, a moderate condition. The skin and visible mucous membranes are pale, cold to the touch. Pulse - 130 beats per minute, rhythmic, weak filling and tension. HELL - 90 and 60 mm Hg The abdomen on palpation is soft, painful in the epigastrium. Symptoms of peritoneal irritation are negative.
In the blood test: red blood cells 3.9 × 1012, hemoglobin - 110 g / l, hematocrit - 25% (normal - 40-54%), color index - 0.84 ESR - 18 mm / hour.
What syndromes can be detected in this patient?
What is the disease in this patient?
Task 7
Patient B., 57 years old, was admitted to the hospital with complaints of constant dull, aching pain in the epigastric region, aggravated after eating, especially plentiful. Pain decreases after vomiting of food eaten; a feeling of rapid satiety, a feeling of heaviness and overflow in the epigastrium; nausea, lack of appetite, aversion to meat food; general weakness, decreased performance, loss of interest in the environment.
From the anamnesis: for 15 years suffers from chronic anacid gastritis. The complaints described above appeared the last 2-3 months. The patient lost 6 kg during this time.
Upon admission: satisfactory condition. Body weight is reduced. The skin is pale with an earthy tint. Skin turgor reduced. To the left in the supraclavicular region, a dense, painless lymph node (virchovsky) is palpated. When examining the abdomen, a slight bulging in the epigastric region is revealed more on the left. On palpation of the abdomen, diffuse moderate soreness and local muscle protection in the epigastrium are noted. The liver and spleen are not palpable.
When radiography of the stomach: filling defect with uneven contours along the lesser curvature, stiffness of the
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stomach wall along the lesser curvature with the transition to greater curvature.
What syndromes can be distinguished in this patient?
What disease can be thought of, given the combination of these syndromes?
What additional research is needed to clarify the diagnosis?
Task 8
Patient A., 57 years old, went to the doctor with complaints of severe skin itching, worse at night, after taking a bath, when the body comes in contact with clothing.
From the anamnesis it is known that skin itching has bothered the patient for the past 2 years. At the onset of the disease, itching occurred in the area of the palms and feet, mainly at night, had a progressive character, over the past month acquired a generalized character, became more intense.
On examination: The skin is swarthy, with traces of calculations on the legs, arms and back. The sclera and frenum of the tongue are icteric. For centuries, xanthelasma. When examining the abdomen, an enlarged liver is palpated. Its lower edge protrudes from the costal arch by 3 cm along the right midclavicular line, smooth, smooth, dense, rounded, painless to the touch. The spleen is not enlarged.
In blood tests, a 4-fold increase in alkaline phosphatase, 7-fold increase in gamma-glutamyltranspeptidase, 3-fold increase in serum cholesterol, 1,5-fold increase in total bilirubin, mainly due to the direct fraction. In the analysis of feces, the reaction to sterkobilin is positive. In the study of urine: urobilinoids are above normal, bile pigments are positive. An ultrasound revealed hepatomegaly, diffuse changes in the liver, bile duct is not expanded, intrahepatic bile ducts are not visualized.
What are the main (clinical and laboratory) syndromes in a patient?
What causes skin itching in this syndrome?
Task 9
Patient M., 52 years old, was admitted to the hospital with complaints of an increase in the volume of the abdomen, a feeling of heaviness in the right hypochondrium, loss of appetite, general weakness, weight loss (he lost 8 kg over the past six months).
From the anamnesis it is known that a patient by profession is a locksmith, lives alone, eats irregularly, has been drinking alcohol (the average dose of ethanol is 45 g) over the past 20 years six months ago, a sensation of bloating appeared, weakness, and the abdomen sharply increased in size.
On examination: a moderate state, euphoric, emotionally labile, criticism is reduced, the rhythm of sleep and wakefulness (sleepiness during the day and sleeplessness at night) is disturbed. The skin and visible mucous membranes with a jaundice, on the skin of the shoulder girdle ―vascular asterisks‖; palmar erythema. Body weight is reduced. Hypotrophy of the muscles of the limbs. Gynecomastia The abdomen is sharply increased in size due to flatulence and free fluid. The shortening of sound in the lateral regions, shifted by a change in body position. The liver protrudes from the edge of the costal arch by 7 cm along the right mid-clavicular line. The edge of the liver to the touch is smooth, smooth, pointed, dense, painless. The spleen is enlarged: the lower pole 5 cm protrudes from under the left costal arch, dense consistency.
What syndromes can be distinguished in the clinical picture of the disease?
For what disease are these syndromes characteristic?
What is the most likely etiology of the disease?
Task 10
Patient M., 55 years old, was admitted to the hospital with complaints of an increase in the size of the abdomen, dull aching pains in the right hypochondrium, worse after eating and physical exertion; sharp weakness, decreased performance and appetite; weight loss of 3 kg in the last month; nausea, a feeling of heaviness in the epigastrium, flatulence, a tendency to diarrhea, especially after eating fatty foods; subfibrillar temperature; nosebleeds.
From the anamnesis it is known that at the age of 25 he suffered from serum hepatitis, about which he was in an infectious diseases hospital. Deterioration of health notes over the past month.
On examination: moderate condition. The skin and visible mucous membranes are subicteric. On the skin of the shoulder girdle - ―spider veins‖, there is palmar erythema; on the extremities, multiple subcutaneous hematomas. The lips are bright, shiny, the tongue is raspberry colored, ―varnished‖. Gynecomastia Body weight is reduced. The abdomen is increased in volume due to ascites. There is a ―caput Medusae‖ on the skin of the abdomen. The liver protrudes from under the costal arch by 3 cm along the right midclavicular line. Its edge is smooth, dense, rounded, sensitive to palpation. The spleen is enlarged, dense, painless.
Clinical blood test: erythritol - 3.1x1012, hemoglobin - 9.0 g%, color chart - 0.87, white blood cells - 3.0x109, platelets - 80x1010, ESR - 50 mm / hour.
Blood biochemistry: ALT - 85 units, AST - 45 units (normal 20-40), total bilirubin - 3.5 mg% (direct - 32.0 mg%, indirect - 1.5 mg%), cholinesterase, serum albumin and prothrombin the index is reduced, gamma globulin is increased.
List the main clinical and laboratory syndromes in this patient.
What disease can be thought of in this case?
Task 11
Patient U., 60 years old, was admitted to the hospital with complaints of moderate intensity aching pain, not associated with food, in the epigastric region and right hypochondrium; Intense jaundice weight loss of 10 kg in recent months; weakness.
FROM an anamnesis: Considers himself ill the last six months, when there were pains in the epigastrium and right hypochondrium, he began to lose weight. 2 weeks ago jaundice appeared, which gradually progressed. He drew attention to the darkening of urine, discoloration of feces.
On examination: Intense jaundice with a greenish tint of the skin, sclera ikteretic. On palpation of the abdomen, pain is absent. Positive symptom of Courvoisier-Terrier.
In a blood test: total bilirubin is increased 15 times due to the direct fraction.
Urinalysis: ―beer color‖, bile pigments - sharply positive, urodilinoids - negative.
What syndromes can be distinguished on the basis of this clinical picture?
What is the most likely cause of the leading syndrome in this patient?
Task 12
Patient G., 45 years old, turned to the clinic with complaints of bouts of intense pain in the right hypochondrium. Attacks first appeared this year after eating, accompanied by nausea, vomiting of bile, and passed after 5-6 hours. The last attack lasted longer than usual (about a day), accompanied by the appearance of icteric staining of the skin and sclera, darkening of urine and discoloration of feces. The attack stopped 2 days before going to the clinic.
On examination: The skin is pale pink in color. Sclera is subicteric. On palpation of the abdomen, moderate pain at the point of projection of the gallbladder, positive symptoms of Ortner, Vasilenko.
What syndromes can be distinguished on the basis of the presented clinical picture?
What disease could cause the appearance of syndromes?
Task 13
Patient G., 35 years old, presents an emergency doctor with complaints of intense ―dagger‖ pain in the epigastric region.
From the anamnesis: about 10 years periodically, more often in spring and autumn, aching pains in the epigastric region disturb. It was treated on an outpatient basis with a diagnosis of chronic gastritis with antacid drugs. The last exacerbation began a few days ago. I did not contact the doctors. Suddenly, about 2 hours ago, ―dagger‖ pain appeared in the epigastrium. Relatives called an ambulance.
On examination: the patient is pale, lies on his back with his knees pressed to his stomach. The skin is moist, cold. The tongue is dry, coated with a white coating. Pulse - 115 rpm, weak filling and tension. Hell - 90 and 50 mmHg The abdomen is round, does not participate in the act of breathing. On palpation, the abdomen is ―board-shaped‖ (pronounced muscle tension of the anterior abdominal wall), severe pain on palpation in the epigastrium, there is also a positive symptom of Shchetkin-Blumberg.
What syndrome can be distinguished in a patient?
What could have caused the development of this syndrome and for what disease?
Task 14
Patient B., 55 years old, was admitted to the therapeutic department complaining of progressive weight loss over the past 5 years by 15 kg, loose loose stool with leftovers of undigested food and droplets of fat 3-4 times a day, bloating.
From 40 years, over five years, the patient had attacks of intense pain in the abdomen, accompanied by vomiting, over time, the intensity of the pain began to fade, the last 4 years the pain does not bother at all. From the age of 20 he regularly takes alcohol in large quantities.
On examination: low power. The skin is dry, turgor is reduced.
Coprological examination: feces of a grayish-yellow color, unformed, soft heterogeneous consistency, reaction to sterkobilin - positive, muscle fibers that retained striation - ++, lost striation - +++, neutral fat - +++, fatty acids - +, soap - +, extracellular starch - +++.
Select the leading clinical laboratory syndrome in this patient
The development of what disease can be assumed in the patient?
Indicate the main research methods that are necessary to confirm the diagnosis.
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Answers to the tasks to the section "Gastroenterology"
Task 1
Exudative colonic diarrhea syndrome, Inflammatory syndrome, Coprologic inflammatory syndrome
Sigmoidoscopy, Colonoscopy, Irrigoscopy, Clinical analysis of blood.
Task 2
Intestinal secretory diarrhea syndrome, Malabsorption syndrome (depletion, diarrhea, steatorrhea, represented by fat detritus, creatorrhea, amylorrhea, adynamia), Digestive insufficiency syndrome (dyspeptic symptoms - nausea, vomiting, rumbling in the stomach, diarrhea, amoebritis, cremation) , Inflammatory syndrome (clinical and coprological).
Task 3
Biliary colic syndrome.
Ultrasound examination, cholecystography, iv cholegraphy.
Task 4
Biliary colic syndrome, Inflammatory syndrome, Local peritonitis syndrome
Gallstone disease, acute calculous cholecystitis.
Task 5
The syndrome of gastric dyspepsia, a syndrome of impaired gastric evacuation function.
Peptic ulcer of the duodenum, complicated by pyloric stenosis.
Task 6
Gastrointestinal bleeding syndrome, Anemic syndrome.
Peptic ulcer of the duodenum.
Task 7
Syndrome of gastric dyspepsia, Syndrome of impaired gastric evacuation function, Intoxication syndrome
You should think about a malignant tumor of the body of the stomach
It is necessary to carry out esophagostroduodenoscopy with a biopsy.
Task 8
Cholestasis Syndrome, Hepatic Hyperbilirubinemia Syndrome
An increase in blood levels of bile acids, irritating the nerve endings in the skin.
Task 9
Portal hypertension syndrome, Hepatolienal syndrome, Chronic hepatic failure syndrome with the development of hepatic encephalopathy
The listed syndromes are characteristic for cirrhosis of the liver
Taking into account the history of the most probable alcohol etiology of the disease
Task 10
Chronic liver failure syndrome (clinically and laboratory), Portal hypertension syndrome, Hepatolienal syndrome with hypersplenism, Hepatic hyperbilirubinemia syndrome, Hemorrhagic syndrome, Cytolysis syndrome (laboratory), Mesenchymal inflammation syndrome
2. You can think of liver cirrhosis of viral etiology
Task 11
Subhepatic hyperbilirubinemia syndrome, pain, intoxication syndrome
You can think of a tumor in the head of the pancreas.
Task 12
Biliary colic syndrome, Subhepatic jaundice syndrome
Gallstone disease
Task 13
Acute stomach syndrome
Probably, the patient had a perforation of the ulcer with the development of peritonitis.
Task 14
Syndrome of exocrine pancreatic insufficiency, pain syndrome, intestinal dyspepsia syndrome
Probably the patient has chronic pancreatitis of alcoholic etiology
Ultrasound, computed tomography, study of enzymes in blood serum and urine.
5. NEPHROLOGY