SITUATIONAL PROBLEM K002035

1. B12 deficiency anemia, severe.

2. The diagnosis was made on the basis of complaints of weakness, fatigue, shortness of breath and palpitations with little physical exertion, burning in the tongue, numbness in the soles of the feet; objective examination data: the skin and mucous membranes are pale with an icteric tinge, the face is edematous, the tongue is raspberry, shiny, the papillae are atrophied, reflexes are enhanced, sensitivity on the feet and hands is reduced; laboratory examination: clinical blood test: hemoglobin – 63 g / l, erythrocytes – 2.6 × 1012 / l, MCV – 110 fl, Jolly bodies and Cabot rings, poikilocytosis. Bilirubin – 55 µmol/l, indirect – 45 µmol/l. The results of sternal puncture: erythroid hyperplasia of the bone marrow, megaloblastic type of hematopoiesis, the ratio of erythroid and myeloid elements 1:1, the number of megakaryocytes is reduced, giant metamyelocytes are determined.

3. – Determination of vitamin B12 and folic acid;

– determination of methylmalonic and propionic acids in urine and/or blood.

4. Intramuscular injections of vitamin B12 (Cyanocobalamin, Oxycobalamin, Adenosylcobalamin).

5. – Increase in the level of reticulocytes;

– increase in hemoglobin level;

– decrease in the level of LDH and BL;

– MCV normalization.

CASE STUDY 143 [K002036]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

A 55-year-old patient received polychemotherapy and radiation therapy for lung cancer 5 years ago. Within six months, weakness, dizziness, shortness of breath when walking appeared. With a thorough examination of the patient, including CT scan of the chest and abdominal cavity, data for the progression of the underlying disease and the development of metastases were not obtained. Clinical blood test: hemoglobin – 65 g / l, erythrocytes – 2.1 × 1012 / l, reticulocytes – 0.5%, leukocytes – 1.9 × 109 / l, platelets – 90 × 109 / l, ESR – 35 mm /h The results of sternal puncture: the bone marrow is mainly represented by adipose tissue, in which rare and small islands of myeloid tissue are determined. Leukocyte formula without features.

Questions:

1. What is the most likely diagnosis for this patient?

2. Justify your diagnosis.

3. Make a plan for additional examination of the patient.

4. What is your further treatment tactics?

5. With what diseases is a differential diagnosis made?

SITUATIONAL PROBLEM K002036

1. Aplastic anemia.

2. The diagnosis was made on the basis of complaints of weakness, dizziness, shortness of breath when walking; medical history: 5 years ago received polychemotherapy and radiation therapy for lung cancer; laboratory examination data: hemoglobin – 65 g / l, erythrocytes – 2.1 × 1012 / l, reticulocytes – 0.5%, leukocytes – 1.9 × 109 / l, platelets – 90 × 109 / l, ESR – 35 mm /h The results of sternal puncture: the bone marrow is mainly represented by adipose tissue.

3. – Clinical blood test: normochromic (rarely hyperchromic) anemia; reticulocytopenia, leukopenia due to a decrease in the content of neutrophilic granulocytes (granulocytopenia); thrombocytopenia.

– Myelogram: changes in the picture of bone marrow hematopoiesis in accordance with the nature of the underlying pathological process (replacement with adipose tissue, infiltration with blast cells, etc.).

4. – Elimination of the identified cause;

– immunosuppressive therapy using antithymocyte immunoglobulin (ATG) and Cyclosporine A;

– glucocorticosteroids in the autoimmune mechanism of anemia;

– treatment with androgens (men only);

– splenectomy is indicated in the absence of effect from glucocorticoids.

– antilymphocyte globulin (in the absence of the effect of splenectomy and other treatments);

– transplantation of hematopoietic stem cells.

5. – Hyperplastic processes that affect hematopoiesis;

– systemic diseases (reticulosis);

CASE STUDY 144 [K002037]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

A 38-year-old patient came to the clinic with complaints of night pain in the epigastric region, fatigue, dizziness, palpitations during exercise.

From the anamnesis: from the age of 17 he suffers from duodenal ulcer, which was treated twice in hospital. During the last 3 months, there were episodes of deterioration of health, weakness, dizziness, dark color of the stool. Objectively: the general condition is relatively satisfactory. The skin and mucous membranes are pale in color. Vesicular respiration in the lungs.

Rhythmic heart sounds, heart rate – 80 beats per minute, blood pressure – 110/70 mm Hg. Art. The abdomen is soft, moderately painful in the epigastric region. The liver and spleen are not enlarged.

Clinical blood test: hemoglobin – 73 g / l, erythrocytes – 3.2 × 1012 / l, color index – 0.71, reticulocytes – 1%, leukocyte formula – without features, ESR – 10 mm / h, MCV – 70 fl ., serum iron – 7 µmol/l. OZhSS – 115 µmol / l.

Conclusion FGDS: Ulcer of the bulb of the duodenum with a diameter of 0.8 cm.

Questions:

1. What is the most likely diagnosis for this patient?

2. Justify your diagnosis.

3. Make a plan for additional examination of the patient.

4. What is your further treatment tactics?

5. Indications for bone marrow examination.

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