example diagnostic task

1. Patient М., female, 37 years, complains of delicacy, fast fatigability, giddiness,

bad appetite, labored swallowing of nutrition, the desire to eat chalk and plaster.

The patient is of a satisfactory nutrition. The skin and visible mucosa are pale.

Peripheral lymphatic nodes are not enlarged. There is vesicular respiration at

auscultation of lungs. Pulse is 96 per minute, rhythmical. Cardiac sounds are loud,

systolic murmur - above heart apex and pulmonary artery. BP is 110/70 mm Hg.

The tongue is of pale pink color, papillae are flattened. There is a tenderness of

abdominal wall in epigastric region at palpation.

Common blood analysis: erythrocytes – 2,8×1012/l, hemoglobin - 70 g/l, color

index - 0,7, reticulocytes - 2 %, leucocytes - 4,6×109/l, eosinophyls - 2 %, stab

neutrophiles - 3 %, segmentonuclear neutrophiles - 64 %, lymphocytes - 26 %,

monocytes - 5 %, ESR - 17 mm/h. Serum iron - 3,3 mcmol/l, total iron-binding

ability of blood serum 140 mcmol/l (norm 50-84 mcmol/l).

What is your provisional diagnosis? What qualitative changes of erythrocytes are characteristic for this disease?

1

2. Patient В., male, 65 years, complains of general delicacy, bad appetite, difficulty

at a swallowing of food, dyspnea, edemas, unsteady gait, numbness of face and

inferior extremities. The patient thinks that he took ill about one half-year ago

when the above described complaints arose. Ten years ago he was operated on

tumor of stomach.

The state of the patient is serious. The skin and visible mucosa are pale with a

moderate icterus. Puffiness of face and edemas of inferior extremities are

expressed. Lymphatic nodes are not enlarged.

There is vesicular respiration at auscultation of lungs. Cardiac sounds are soft,

systolic murmur is above all points. Pulse is 108 per minute, rhythmical. BP is

90/60 mm Hg.

Tongue is bright red, sleek, with fractures. The liver is on 3-4 sm below the costal

arch, sensitive at palpation. The dimensions of liver according to Kurlov are 12-10-

8 sm. The inferior edge of lien is palpated.

Common blood analysis: erythrocytes - 1,1×1012/l, hemoglobin - 40 g/l, color

index - 1,3, reticulocytes - 0,1 %, thrombocytes - 160,0×109/l, leucocytes -

2,5×109/l, ESR - 42 mm/hour.

What is your provisional diagnosis? What are additional laboratory methods of examination?

2

3. Patient L., male, 42 years, complains of delicacy, sweating, rise in temperature.

Progressive deterioration of state has appeared within month, when pains of bones

and high body temperature have increased.

The state of patient is moderate. There are paleness and simple petechial

hemorrhages on the skin. Peripheral lymphatic nodes are not enlarged. Body

temperature is 37,2 ºС. Vesicular respiration is auscultated in lungs. Cardiac

sounds are clear. Pulse is 100 per minute. The liver and the lien are on 2 sm below

of costal arches, their edges are mild, and tender. The dimensions of the liver

according to Kurlov are 12-10-8 sm.


index - 1,0, thrombocytes - 107×109/l, leucocytes – 29,0×109/l, myeloblasts - 43 %,

promyelocytes - 9 %, myelocytes - 10 %, eosinophils – 8%, basophils – 4%,

segmentonuclear neutrophiles - 24 %, lymphocytes - 2 %, ESR - 30 mm / h.

What is your provisional diagnosis? What are additional laboratory methods of examination?

3

4. Patient L., female, 24 years, complains of delicacy, sweating, rise in

temperature, pain in mouth and throat, prolonged nasal and uterine bleeding.

Progressive deterioration of state has appeared within month, when pains of bones

and high body temperature have increased.

The state of patient is serious. There are paleness and multiple petechial

hemorrhages on the skin. Peripheral lymphatic nodes are not enlarged. There are

several ulcers at the mucous of oral cavity, gingival bleeding, bilateral purulo-

necrotic tonsillitis. Body temperature is 39,2 ºС. Vesicular harsh respiration and

dry rales are auscultated in lungs. Cardiac sounds are dull, accelerated. Pulse is 120

per minute. The liver are on 2 sm below of the costal arch, mild, and tender. The

dimensions of the liver according to Kurlov are 12-10-8 sm. The lien is palpated 8

sm below the left costal arch. The dimensions of the lien according to Kurlov are

17-12 sm.


index - 0,9, thrombocytes - 57×109/l, leucocytes – 69,0×109/l, myeloblasts - 80%,

segmentonuclear neutrophiles - 15 %, lymphocytes - 4%, monocytes – 1%, ESR -

64 mm / h.

What is your provisional diagnosis? What is additional laboratory method of examination?

4

5. Patient К., female, 53 years, has arrived in clinic with complaints to delicacy,

sweating, from time to time a rise in temperature up to 37,2-37,5ºС, enlargement of

lymphatic nodes - cervical, axillary, inguinal.

Last 3 years frequently she was sick of acute respiratory diseases. One year ago she

has transferred the serious form of acute tonsillitis. Last 3-4 months it has appeared

increasing delicacy, loss of weight. For the first time she has found small

lymphatic nodes on the neck and in the axillary fossa. Last month a rise in

temperature up to 37,5ºС was observed, lymphatic nodes have apparently

increased.

The patient is of correct body build, subnuorished. The skin and visible mucosa are

pale with slight icterus. Lymphatic nodes enlarged up to chicken eggs are palpated:

cervical, inguinal, axillary. Lymphatic nodes are mild, not matted together, and

painless. There are weakened vesicular respiration, and diffuse dry rales at the both

lungs. Cardiac sounds are soft, rhythmical. Pulse is 92 per minute, rhythmical. BP

is 110/70 mm Hg.

Tongue is covered with white coatings, wet. The liver is on 1,5-2 sm below the

right costal arch, sensitive at a palpation. The lien is on 4-5 sm below the left costal

arch, painless at a palpation, dense.

Analysis of a blood: erythrocytes - 2,3×1012/l, hemoglobin - 74 g/l, reticulocytes -

2 %, thrombocytes – 100,0×109/l, leucocytes 50,0×109/l, eosinophils - 1 %, stab

neutrophiles – 2%, segmentonuclear neutrophiles - 17 %, lymphocytes - 79 %,

monocytes -1 %, Botkin and Gumprecht cells 20 of 100 lymphocytes, ESR - 60

mm / h.


5

6. Patient H., male, 23 years, has arrived in clinic with complaints to delicacy,

sweating, from time to time a rise in temperature up to 39,5-40,0ºС, pain in mouth

and throat, prolonged nasal bleeding.

Disease began 3 weeks ago after a bathing in the river with a rise of body

temperature and pain in throat. Out-clinic treatment with antibiotics and aspirin

was ineffective.

The state of is serious. The skin and visible mucosa are pale with simple skin

hemorrhages. Lymphatic nodes enlarged up to chicken eggs are palpated: cervical,

inguinal, axillary. Lymphatic nodes are mild, not matted together, and painless.

There are several necrotic ulcers at the mucous of oral cavity, gingival bleeding,

bilateral purulo-necrotic tonsillitis. Body temperature is 39,0 ºС. There are

weakened vesicular respiration at the both lungs. Cardiac sounds are soft,

rhythmical. Pulse is 92 per minute, rhythmical. BP is 110/70 mm Hg.

Tongue is covered with brown coatings, dry. The liver is on 1,5-2 sm below the

right costal arch, sensitive at a palpation. The dimensions of the liver according to

Kurlov are 14-12-10 sm. The lien is on 4-5 sm from below the left costal arch,

painless at a palpation, dense. The dimensions of the lien according to Kurlov are

16-11 sm.

Analysis of a blood: erythrocytes - 2,0×1012/l, hemoglobin - 64 g/l, thrombocytes –

41,0×109/l, leucocytes 98,0х109/l, stab neutrophiles - 1 %, segmentonuclear

neutrophiles – 5 %, lymphoblasts - 84%, lymphocytes - 9 %, monocytes -1 %, ESR

- 68 mm / h.


6

7. Patient М., female, 35 years, is hospitalized in clinic because of the extremely

serious state. She complains of a strong extended pain over the whole abdomen.

Within several years there was repeatedly a punctulate hemorrhagic eruption on a

skin of hips and breeches. During the same time there was a moderate colicy pain

at the abdomen. Bloody stool was occasionally observed.

The state has worsened 3 days prior to hospitalization. Skin rash have appeared

again. Often calls to stool and bloody abjections instead of the formed feces were

during last 2 days.

The general state is serious. There are multiple spotted petechial skin rash at

extremities and breasts. Lymphatic nodes are not enlarged. Clear pulmonary sound

and vesicular respiration are revealed above both lungs. Respiration rate is 20 per

minute. Cardiac sounds are softened. Pulse rate is 120 per minute. BP is 90/70 mm

Hg. The abdomen is tensed and sharply painful in all departments at palpation.

Positive signs of the peritoneum irritation are revealed. Passage of gases is absent

Bloody abjections from the rectum are marked.

Common blood analysis: hemoglobin - 112 g/l, erythrocytes - 3,5×1012/l,

leucocytes 12,0×109/l, stab neutrophiles - 6 %, segmentonuclear neutrophiles - 78

%, lymphocytes - 16 %, thrombocytes – 42,0×109/l, ESR - 36 mm / h.

What is your provisional diagnosis?

7

8. Patient С., male, 63 years, complains of a sharp delicacy, giddiness,

discoloration of feces within 2 weeks (black stool).

He remembers that he was sick of influenza 3-4 weeks ago.

General state of the patient is serious. The skin and visible mucosa are pale. The

dotted hemorrhagic eruption is determined at the skin of face and extremities.

Peripheral lymphatic nodes are not enlarged.

Pulse is 110 per minute of satisfactory volume and strain, rhythmical. BP is 115/70

mm Hg. Cardiac sounds are softened, systolic murmur – above heart apex.

Respiration is vesicular at auscultation. Respiration rate is 20 per minute.

Abdomen is mild and painful at palpation in epigastrium. The dimensions of the

liver according to Kurlov are 9-8-7 sm. Pasternatsky's symptom is negative at both

sides. Stool is once a day, formed, of the black color.


index - 0,7, thrombocytes – 200,0×109/l, leucocytes - 13, ×109/l, aniso -

poikilocytosis (++),ESR - 70 mm / h.

Analysis of urine is normal. Coagulation tests are without pathologic changes.


8

9. Patient К., male, 50 years has arrived in clinic with complaints to the

general delicacy, giddiness, darkening in eyes, palpitation and abjection of mild

tarry feces during last day. He suffers a peptic ulcer of duodenum within 10 years.

General state is moderate. Consciousness state is sopor. Paleness of skin and

visible mucosa is present. Clear pulmonary sound and vesicular respiration are

revealed above both lungs. Respiration rate is 20 per minute. Cardiac sounds are

rhythmical, softened. Systolic systolic murmur is auscultated above the heart apex.

Arterial pressure is 85/50 mm Hg. Pulse is 96 per minute, rhythmical, of a small

filling and a strain. The tongue is wet, covered with white coatings. The abdomen

is mild and sensitive in at palpation in epigastrium. The liver and the lien are not

enlarged.

Common blood analysis: erythrocytes - 2,8×1012/l, hemoglobin - 76 g/l,

leucocytes - 5,3×109/l, eosinophiles - 2 %, stab neutrophiles - 2 %,

segmentonuclear neutrophiles - 60 %, lymphocytes - 30 %, monocytes - 6 %, ESR

- 8 mm / hour, thrombocytes 180 ×109/l, reticulocytes - 12 %.

Analysis of urine - without pathology.

Analysis of feces - Gregersen test is sharply positive.


9

10. Patient М., female, 50 years, scientist, complains of the general delicacy,

sleepiness, collapse of work capacity, constipation.

This disease began gradually more than 5 years after surgical operation on the

occasion of goiter.

The face is round, yellowish-pale, amimic. The patient looks more senior than the

age. It is revealed the puffiness on dorsal surfaces of hands and foots; at pressing a

fossa is not formed. The skin is cool and dry at the touch. Nails are fragile. The

thyroid gland is not palpated. Body temperature is 35,8ºС.

Pulse is 56 per minute. Cardiac sounds are softened, rhythmical. BP is 100/80 mm

Hg. Pathologies from the side of systems of respiration and digestion are not

revealed.

ECG: Sinus bradycardia, small voltage of waves, elongation PQ up to 0,22 sec.

Radioisotope research: absorption of radioiodine - in 2 h of 2,6 %, in 4 h of 5,2 %,

in 24 h of 1,5 %.


10

11. The patient D., female, 27 years has arrived in clinic with complaints of

irritability, interrupted sleep, sweating, palpitation of heart at the rest, loss of

weight on 10 kg. Deterioration has been for last 3 months after acute respiratory

virus infection.

Body height is 175 sm, body weight is 42 kg, body temperature - 37,6ºС.

During the examination it is noticed a labile behavior of the patient, fast change of

mood, tearfulness, quick speech, exophthalmus, tremor of hands. Positive signs of

Grefe and Moebius are detected. The skin is mild and hot at the touch. At

swallowing the thyroid gland is visible. At palpation it is mild, painless. Peripheral

lymphatic nodes are not enlarged.

Clear pulmonary sound and vesicular respiration are revealed above both

lungs. Respiration rate is 18 per minute. Apex beat is at lin. medioclavicularis

sinistra, the area - of 3 sm, low, not resistant. The left border of the relative heart

dullness -is at lin. medioclavicularis sinistra. Pulse is 100 per minute, arrhythmic,

of irregular filling and strain. Arterial pressure is 150/60 mm Hg. Cardiac sounds

are accelerated, arrhythmic. Amplified I sound - at the heart apex, systolic murmur

- above heart apex and pulmonary artery. Abdomen is mild, painless. The height

of hepatic dullness is 11-10-9 sm. The edge of the liver is acute, mild, and

painless. The dimensions of the lien are 8-4 sm. Edemas are not present. Stool is

2-3 times a day, semi-liquid, brown, without pathological admixtures.


leucocytes - 8,2×109/l, ESR - 5 mm/hour, segmentonuclear neutrophiles - 68 %,

lymphocytes - 25 %, monocytes - 7 %.

ECG: atrial fibrillation 80-110 per minute, normal position of electrical axis

of the heart, smoothness of T-wave in V4-6 I, II, аVL.


11

12. Patient D., female, 28 years, is delivered in clinic in unconsciousness state. A

thirst, bad appetite, headache, delicacy have appeared during 2 weeks after

influenza. The day before there was abdominal pain, numerous vomiting (the

anamnesis is taken from words of the husband).

The general state is serious. The consciousness is absent, patient’s position is

passive. Respiration is deep and noisy (Kussmaul's respiration). Respiration rate is

32 per minute. The fruit odour from mouth is present. Skin is dry. Tongue is dry

and red. Pulse is 120 per minute, of the small filling and strain. BP is 95/60 mm

Hg. Abdomen is mild at palpation.

Common blood analysis: glucose - 45,4 mmol/l, creatinine - 0,12 mmol/l.

Analysis of urine: glucose - 16,2 mmol/l, protein - 0,9 g/l, specific gravity - 1030,

Lange's test (acetone) - positive.


12

13. Patient А., female, 43 years, has arrived in hospital department with complaints

of delicacy, sweating, numbness of lips and of tongue, sensation of general

trembling of the body, anxiety. Deterioration of the state has begun within day.

She suffers a diabetes mellitus during 1 year, accepts hypoglycemic tablets

Glurenorm. Within day she has eaten nothing (from words of the daughter).

The general state is serious. At the survey of patients convulsions have developed,

and then she has lost consciousness.

The skin is wet. Pupils are wide, pupillary reflex on light is absent. Respiration is

superficial, 20 per minute. Pulse is 84 per minute. BP is 120/60 mm Hg. From the

side of internal organs pathological changes are not revealed. Abdomen is mild,

painless. The liver according to Kurlov is 9-8-7 sm. Edemas are not present.

ECG: sinus rhythm of 80 per minute minute, RII> RI> RIII.

Common blood analysis: glucose - 1,4 mmol/l, creatinine - 0,009 mmol/l.

Analysis of urine: specific gravity - 1009, protein - absent, glucose - absent,

Lange's test (acetone) - negative.


13

14. Patient В., female, 27 years, complains of burning sensation, shortage of air,

shooting-pains at the left half chest, giddiness at the time of intramuscular injection

of Penicillinum. In 10 minutes she has lost consciousness.

The general state is serious. At the survey it is marked expiratory dyspnea, and

paleness of the skin. At examination of lungs it is revealed a clear pulmonary

sound, respiration with prolonged expiration, and whistling, diffuse rales.

Respiration rate is 28 per minute. Cardiac sounds are loud, arrhythmic. Pulse is

112 per minute. BP is 60/40 mm Hg. Abdomen is mild, sensitive in epigastrium at

palpation. The liver according to Kurlov is 9-8-7 sm, the lien is not enlarged.

Edemas are not present.


What is the urgent treatment?

14

15. The patient S., male, 34 years, complains of dyspnea, sweating, delicacy, the

increased appetite, enlargement of volume of the abdomen, loss of work capacity.

At survey - body height - 178 sm, weight - 112 kg, body mass index – 35,3

kg/m2. The skin is light pink, wet. The subcutaneous fat is distributed uniformly.

The width of skin fold is 5 sm on anterior abdominal wall, 3 sm -in subscapular

region, 3 sm – at the back surface of the shoulder, 5 sm – at the top of the thigh.

Abdominal circumference is 146 sm, circumference of the hip - 68 sm.


lungs. Respiration rate is 18 per minute. Borders of relative heart dullness: the left

- on 1 sm from lin. medioclavicularis sin., the right - on 1 sm to the right from the

edge of sternum. Cardiac sounds are softened, rhythmic. Pulse is 72 per minute,

BP - 150/90 mm Hg. The abdomen is protruding forward in vertical position of the

patient and uniformly flattened in horizontal position. At percussion the tympanic

sound is determined above whole abdomen in vertical, horizontal position and

lateral recumbent position of the patient. At palpation abdomen is mild, painless.

Liver inferior edge is palpated at the right midclavicular line 2 sm below costal

arch, rounded, painless, mild. The height of hepatic dullness is 14-12-11 sm.

Edemas are not revealed. The lien is not palpated.


leucocytes - 8,6×109/l, eosinophiles - 3 %, segmentonuclear neutrophiles - 68 %,

lymphocytes - 20 %, monocytes - 9 %, ESR - 11 mm/hour.

Biochemical blood analysis: glucose - 5,6 mmol/l, cholesterol - 7,8 mmol/l,

bilirubin – 14,8 mcmol/l, АsАТ - 0,34 mmol/l, АlАТ - 0,68 mmol/l.

ESG: sinus rhythm - 88 per minute, left axis deviation, RV 5-6> RV4, STV 5-6

below isoelectric line on 1 mm.


15

16. Patient G., female, 50 years, complains of thirst, dryness in the mouth,

frequent and abundant urination, itching of the skin in perineum. She has paid

attention to these signs about 2 months ago. About 3 years she suffers chronic

pancreatitis. Her mother suffered diabetes.

At survey: body height – 158 sm, body mass - 82 kg. The skin is dry, with

traces of scratchings, and redness of cheeks. Peripheral lymphatic nodes are not

palpated. The thyroid gland is not enlarged.


lungs. Respiration rate is 18 per minute. Cardiac sounds are rhythmic, softened.

Pulse - 76 per minute, of the satisfactory filling and strain. Tongue is dry, covered

with a white raid. At palpation abdomen is mild, painless. The dimensions of

height of hepatic dullness are 10-9-8 sm. The edge of the liver is pointed, mild,

and painless. Pasternatsky's symptom is negative at the both sides of lumbar

region. Daily diuresis is 2,5 l a day.

Common blood analysis: hemoglobin - 110 g/l, erythrocytes - 3, 2×1012/l,

leucocytes - 6,6×109/l, ESR - 2 mm / hour.

Biochemical blood analysis: glucose - 11,6 mmol/l, total protein - 72 g/l,

cholesterol - mmol/l.

Analysis of urine: specific gravity - 1030, glucose - 2,0 mmol/l, acetone (+),

flat epithelium - 2-3, leucocytes - 3-4.


16

Situational problems of blood and endocrine diseases

1. Iron-deficiency anemia

Anisocytosis with microcytosis, poikilocytosis, and hypochromia of erythrocytes

2. В12-deficiency anemia.

Bone marrow biopsy. Serum vitamin В12.

3. Chronic myeloid leucosis.

Bone marrow biopsy. Ph chromosome.

4. Acute myeloblastic leucosis. Bone marrow biopsy.

5. Chronic lymphoid leucosis. Bone marrow biopsy.

6. Acute lymphoblastic leucosis. Bone marrow biopsy.

7. Hemorrhagic diathesis, thrombocytopenic purpura (Werlhof's disease)

8. Hemorrhagic diathesis, hemorrhagic vasculitis.

9. Posthemorrhagic anemia10. Hypothyroidism.

11. Hyperthyroidism12. Diabetes mellitus, hyperglycemic coma.

13. Diabetes mellitus, hypoglycemic coma.

14. Acute anaphylaxis. Epinephrine, Dopaminum, glucocorticoids, Euphyllinum.

15. Alimentary obesity

16. Diabetes mellitus.

17

example diagnostic task

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