SITUATIONAL PROBLEM K002065

1. B12-deficiency anemia (Addison-Birmer disease) severe. Complications: Anemic coma. funicular myelosis. Circulatory-hypoxic syndrome.

2. The criteria for B12-deficiency anemia are: a decrease in the content of erythrocytes (less than 3.0 × 1012/l); increase in color index (more than 1.1); macrocytosis;

the appearance of megalocytes;

polysegmentation of neutrophils, Jolly bodies and Cabot rings;

manifestations of funicular myelosis: pain in the lumbar region with sharp bends, paresthesia;

for the final confirmation of the diagnosis, it is necessary to identify the etiological cause of the B12 deficiency.

3. Anemic coma, funicular myelosis, circulatory-hypoxic syndrome.

4. Determination of the content of vitamin B12 and folic acid in the blood serum, iron and ferritin in the blood serum, sternal puncture with an assessment of the myelogram (exclude hematopoietic dysplasia), assessment of the reticulocyte crisis during therapy, fibrogastroduodenoscopy, fibrocolonoscopy (exclude diverticulosis of the large intestine), examination titer of antibodies to gastromucoprotein, stool on worm eggs (exclude helminthic invasion), scatological examination (exclude malabsorption).

5. Blood transfusions of erythrocyte mass, 250-300 ml (5-6 transfusions), Cyanocobalamin, 1000 mcg intramuscularly for 4-6 weeks until the onset of hematological remission. After normalization of bone marrow hematopoiesis and blood composition, the vitamin is administered once a week for 2-3 months, then for six months 2 times a month in the same doses. This is due to the need to create a depot of vitamin B12. In the future, it is prophylactically administered 1-2 times a year in short courses of 5-6 injections or monthly at 200-500 mcg (for life).

Situational task 212 [K002071]

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

Main part

Patient V., aged 56, was admitted to the hospital with complaints of shortness of breath at rest, aggravated by the slightest physical exertion (because of shortness of breath, the patient could not leave the house), cough with purulent sputum, swelling of the legs, heaviness in the right hypochondrium, an increase in the abdomen. History: 20 years ago suffered from pneumonia. Since then, she has been worried about coughing with sputum, mainly in the morning, the cough intensified in autumn and winter.

Periodically, when the temperature rose to 37-39°C, he took antibiotics and sulfonamides. In the last 3 years, shortness of breath began to disturb. The condition worsened in the last 4 months, when, after a cold and a rise in temperature (up to 38°C), edema, pain and heaviness in the right hypochondrium, an increase in the abdomen first appeared.

Anamnesis of life. Smoked for 25 years, 1 pack of cigarettes a day. He works in a hazardous industry – in a foundry. He has not had tuberculosis before, he denies any contact with tuberculosis patients. Allergological anamnesis – without features.

The condition is severe, diffuse cyanosis, cyanosis of the lips is expressed. Decrease in muscle mass of the upper shoulder girdle. The extremities are warm to the touch, swelling of the legs, thighs. The position in bed is horizontal. The chest is barrel-shaped. Supraclavicular spaces bulge. Excursion of the chest is limited. With percussion over the lungs – a box sound and lowering of the lower borders of the lungs. Breathing is weakened, in some areas with a bronchial shade. On both sides, mixed wet rales and scattered dry rales on exhalation are heard. BH – 36 per minute. The borders of the heart are normal. Epigastric pulsation, muffled heart sounds, accent of II tone on the pulmonary artery. Pulse – 112 beats per minute, rhythmic. BP – 100/70 mm Hg. Art.

Neck veins swollen, especially on expiration. The abdomen is enlarged due to ascites. The liver protrudes from under the costal arch by 4-5 cm, elastic, painful on palpation.

X-ray – diffuse enhancement of the lung pattern, horizontal course of the ribs, signs of pulmonary emphysema, flattening of the dome of the diaphragm and limitation of diaphragm mobility during respiratory movements.

ECG: sinus tachycardia, rightogram. Signs of overload of the right atrium and right ventricle. Shift of the transition zone to the left up to V4.

Blood test: erythrocytes – 5.4 × 1012 / l, hemoglobin – 174 g / l, color index – 1, polychromatophilia, anisocytosis, poikilocytosis, reticulocytes – 3%, leukocytes – 12.5 × 109 / l, basophils – 0% , stab neutrophils – 5%, segmented neutrophils – 61%, lymphocytes – 34%, platelets – 33 × 109 / l, monocytes – 9%, ESR – 2 mm / h. SZ_General Medicine (part 3) – 2017

Questions:

1. Your presumptive diagnosis.

2. Criteria for the main diagnosis.

3. What complications of the underlying disease do you suppose?

4. Draw up and justify a plan for an additional examination of the patient.

5. Treatment tactics, choice of drugs.

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