examination card 4

8/6/2019 Examination Card 4

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Vice-Rector on Academic Work

M.D., Prof. V.V. Simrok

2007 y .

MINISTRY OF PUBLIC HEALTH OF UKRAINE

LUGANSKSTATE MEDICAL UNIVERSITY

MEDICAL DEPARTMENT

SPECIALTY GENERALMEDICINE COURSE VI

SUBJECT INTERNAL MEDICINE

EXAMINATION CARD 11

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. Theperipheral 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. Interpretation the results of instrumental findings.

Approved at the Chair Meeting Minutes 6. The 22.01.2007 year.

Head of the chair

M.D., Professor Yu. N. Kolchin


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EXAMINATION CARD 10

Task: patient 45 years, doctor of ambulance. Complains: during a few months

periodically 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 therest, 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

between the calls there was the attack described higher, and which proceeded about 10

minutes. 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

patient and indexes of electrocardiogram was fully normalized.

Questions:



Head of the chair



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EXAMINATION CARD 9

Task: patient, 39 years old, addmitted to cardiologic department in an urgent

condition with complaints on the intensive pain behind a breastbone, not diminishing after

the reception of nitroglycerine, breathlessness. Two last years He was observed by

cardiologist with ischemic heart disease: stable angina on exertion, functional class II.

Examination: skinning covers were pale, death-damp on face. In lungs weakened vesicular

respiration. 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:



Head of the chair



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EXAMINATION CARD 8

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 fibrillation, 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

amplitude of waves with frequency to 200 in a minute, wave Q - duration 0,04

seconds, its amplitude - amplitudes of wave R, displaced up segment ST and

negative wave T in III, aVF leads.

Questions:



Head of the chair



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EXAMINATION CARD 7

Task: patient 44 years old, after physical exercises and jog ride delivered with

complaints about suddenly pain in the right half of abdomen, the pain extending in a right

lumbar 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 sedimentation 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:



Head of the chair



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EXAMINATION CARD 6

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,

general weakness. At examination: spastic pain in the different parts of colon during

palpation.

Blood test: HB is 130 gm/dL, RBC - 4,3x1012/L, WBC 4,8x109/L, segmented

neutrophils 68%, monocytes 2%, eosinophils 1%, lymphocytes 28%, erythrocyte

sedimentation 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:



Head of the chair



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EXAMINATION CARD 5

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

percussion 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 - 4,1x10

12

/L, reticulocytes 1%,Platalets 250x109/L, WBC 6,2x109/L, stab neutrophils 3%, segmented neutrophils

68%, eosinophils 1%, basophils 1%, lymphocytes 32%, monocytes 3%,

erythrocyte 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,

displacement of organs of mediastinum in left, flat the right dome of diaphragm.

Questions:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 4

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

puffiness. 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 bothsideof 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- 2,71012/l; b 80 g/L; WBC- 5,0109/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:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 3

Patient F., 22 years old, addmitted to hospital in severe condition. 4 weeks ago he

suffered 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

bothside. The liver size was increased (12*11*10 sm), The sizes of lien and kidneyswere normal. The legs were edematous.

Laboratory indexis: Blood analysis: RBC-3,91012/l; b 120 g/L; WBC

15,0109/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% (1 9,3%, 2 15,2%, 12,3%, - 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 se, voltage QRS

was decreased.

Questions:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 2

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,

breathlessness 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

participated 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

pavement 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:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 1

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,

appetites absence. Patients mother suffered from diabetes mellitus.

Physical findings: the patient wasn`t consciousness, skin was dry, skin turgor

decreased, 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

minutes, BP 100/60 mm Hg. The abdomen was increased in volume a little. The liverssize 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 -

271520 mm, contour was uneven, changing in structure of pancreas; renal structure

wasn`t legible.

Questions:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 20

The Patient K., 75 years old, after sleeping, during 2 hours, felt muscular

weakness 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 33 45 mm.

Questions:



Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 19

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

Orthner, Ker, Merphy were positive. Symptoms of irritation of peritoneum were negative.

Liver, lien, intestine, colon were normal.

Laboratory indexis: Blood analysis: RBC- 3,851012/l; b 130 g/L; WBC

9,2109/L; ESR 22 mm/ h, total bilirubine 20,1 mol/L, ALT 60 U/L, AST 70

mol/L; -amylex 1232 g/h*L.

Ultrasound findings: size of gall bladder - 15,24,8 sm, the wall 0,4 sm, there were

stones in gall bladder more than 2/3 of gall bladder volume.

Questions:



Head of the chair



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EXAMINATION CARD 17

The patient ., 42 years, has called the family doctor to the house. Hecomplains of an attack of dyspnoea (on expiration), giddiness,palpitations. He has been sick for more than three years. The generalstate has worsened in the last three days with attacks of dyspnoeabecoming more frequent. Constant presence of diurnal and night signs:

restrained in a chest with laboured expiration, marked restriction ofphysical activity.Objective: the patient has dyspnea, respiration rate 30 per minute, in

mild dissipated sonorous dry rhonchi, remote rhonchi. Pulse is 120 perminute, blood pressure of 120/80 mmHg, heart sounds amplified, thesecond hear sound is loud in pulmonary artery. The other organs andsystems are without any essential pathology.

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

Questions:




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Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 16

The patient ., 62 years, presented to hospital with complaints ofinfringement of dream, sharply expressed delicacy, headache, pain inthe right hypochondrium, abdomen distension, pruritus of the skin, arise in temperature up to 38. From the anamnesis: more than 10years of alcohol abuse. Consists on a dispensary observation at expertin narcologist, gastroenterologist. Last deterioration has occurred afteran alcoholic excess.

Objective: the patient is adynamic, offensive hepatic breath, skin and

sclerae are discolored with icterus. The face is red and puffy. The skinon the trunk vascular sprockets with traces ofpruritus. The heat sounds aremuffled with heat rate of 96 per minute and blood pressure of 100/70mmHg. The abdomen is distended, dull percussion in the left and righttransabdominal range. The dimensions of a liver of Kurlov 12109 sm.He has constipation with painless opening of bowels.

Analysis of blood: HBG - 90 g/l, RBS - 2,5 1012/L MCH - 30pg, WBC -

10109/L, ESR-30 mm/h, GGT-160 , 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 18mm, ascitic fluid more than 90 ml. Gall bladder, pancreas, kidney arewithout pathology.

Questions:



Head of the chair


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MEDICAL DEPARTMENT



EXAMINATION CARD 15

The patient ., 52 years old had tuberculosis in 20.05.1998. In thelast 2 years due to intermittent aggravation of symptoms, he hastreated in hospital. There is marked continued present of bacteria of onanalysis of his sputum. Three days ago sputum expectorated in themorning was streak with blood. Two hours ago the patients conditiondeteriorated, having had a fit of coughing, haemophysis, bringing up

half a glass of scarlet blood. Now haemophysis has settled down tosneaking in sputum coughed up.

Objective: his general state is satisfactory and he is acyanotic. The patient is

euphoric. The pulse is 90 per minute with satisfactory volime. The bloodpressure is 120/80 mm Hg. He is dysphoeic and examination there isdullness on percussion of the upper right lung and there is bronchialbreathing on auscultation of the subclavial areas bilaterally. Varigatedwet rhonchi are auscultated in this area too. Muffled heart sounds. Theliver 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 cavity3,54 cm irregularly-shaped andthick-walled. An intrinsic contour of thecavity is picked up and the exterior contour is less dense. Around thecavity the image shows high density with distortion and loci of variousdensity. In the left here are mild simple dense loci.

Questions:




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Head of the chair



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MEDICAL DEPARTMENT



EXAMINATION CARD 14

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 objectiveindices are unchanged.

Questions:



Head of the chair



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EXAMINATION CARD 13

The patient ., 32 years old on presenting to his family doctor withcomplains on pain in the lower abdomen, nausea, multiple episodes ofvomiting, 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, frequentopening of bowels up to 10 times and mucous in character. Then thenausea and vomiting appeared.

Objective: patient is gravely unwell. Adynamic patient, flaccid. Skinis acyanotic, dry. Mucosae are acyanotic. There is reduced vesicular respirationin the lung and the respiration rate is 14 per minute. Heart - dummy sounds are a little

weakened with a low, weak pulse of 112 per minute, blood pressure of 70/50mmHg. There is pain in the left iliac range of abdomen, sigmoid colon ispalpable as a dense cylinder. The liver is not enlarged and lien is notpalpated. 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 obstractionand hemorrhoidal clusters in range of a rectum. Mucous of sigmoidcolon is hydropic and hyperemic. There are dotted haemorrhages. Theulcers are not seen.

Questions:



Head of the chair



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EXAMINATION CARD 12

Patient 19 years old is delivered by the doctor of ambulance inmunicipal hospital 12.08.05. The patient complains of edema of theface and neck, hoarseness of a voice, delicacy, giddiness, labouredrespiration. The oedema has arisen several minutes after ingestion ofhoney. 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 perminute. Chest auscultation reveals vesicular respiration without rales.Cardiac activity is rhythmical and the heart sounds are muffled. Theabdomen 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 thrombocytopenic 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:



Head of the chair


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examination card 4

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