PUBLIC HEALTH DEPARTMENT
SMOLENSK STATE MEDICAL ACADEMY
PROPAEDEUTICS OF INTERNAL DISEASES DEPARTMENT
E.L. TSEPOVA, V.G. PODOPRIGOROVA,
P.I. PODCHEKO
CLINICAL CASES
ON THE PROPAEDEUTICS OF
INTERNAL DISEASES
GUIDE FOR THE THIRD YEAR FOREIGN MEDICAL
STUDENTS
SMOLENSK, 2006
УДК 616.1/4(07)
Tsepova E.L., Podoprigorova V.G., Podcheko P.I. Case histories on the
propaedeutics of internal diseases (guide for the third year foreign medical students).
– Smolensk, SSMA, 2008. – 34 p.
Clinical cases on the propaedeutics of internal diseases are adapted according to the
programme of propaedeutics of internal diseases and curriculum of medical
academy for the third year foreign students as the manual for self-instruction for
classes and examination.
Language Editor: the head of foreign language department Z.M. Yaschenko.
© Smolensk State Medical Academy, 2005
© Tsepova E.L., Podoprigorova V.G., Podcheko P.I.
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INTRODUCTION
The work is intended for the third year medical students as the manual for selfstudying for classes and exam on the propaedeutics of internal diseases.
The work includes 5 units on case histories that cover certain of the disease
characteristics, which is necessary for diagnosis, questions and answer patterns.
It is required to give in the answer:
1) the full name of disease,
2) other than mentioned clinical findings that may be revealed by physical
examination,
3) additional methods of patient examination (laboratory and instrumental)
which are necessary for confirmation of diagnosis and their possible results.
In solving each clinical case try not to be tempted by reading the answers to the
questions in the part “Answer pattern”. You should better study the signs and
symptoms of the diseases.
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SECTION 1
DISEASES OF THE CARDIOVASCULAR SYSTEM
Clinical case 1
The patient was a 55-year-old male who presented with 2-week history of squeezing
retrosternal pain. Chest pain developed during usual walking for a distance 400-500
metres or climbing upstairs to the third storey. Pain was relieved by the 2-3 minutes
rest or by the sublingual intake of nitroglycerine.
1. What is the clinical diagnosis in this patient? Specify its clinical variant and
functional grade.
2. Specify the most probable cause of this disease.
3. What symptoms of this disease may be revealed by inspection, palpation,
percussion and auscultation of the heart out of pain attack?
4. What are the possible findings on electrocardiogram (ECG) out of pain attack?
5. What other additional methods of examination are used to confirm this clinical
diagnosis?
Answer pattern
1. Stable angina pectoris, class II severity1.
2. Stenosis of coronary arteries by atherosclerotic plaques.
3. Physical findings are often normal between episodes of angina.
4. The 12-lead ECG recorded at rest and in the absence of pain may be normal.
5. The chest roentgenogram may aid in the diagnosis when calcification in the
coronary artery or ventricular aneurysm is identified.
Electrocardiographic stress tests (treadmill and cycle ergometry ones) show
tall and hyperacute or deep and symmetrically inverted Т wave and/or ST
segment displacement as response to ischemia, it occurs during and
immediately following an exercise stress.
Coronary arteriography provides unequivocal information concerning the
presence or absence of coronary atherosclerosis in living patients. It also
permits estimation of severity of obstructive lesions which may be present.
Clinical case 2
The patient was a 57-year-old obese female with 3-year history of recurrent attacks
1
The Canadian Cardiovascular Society grading scale is used for functional classification of
stable angina severity, as follows:
• Class I – Ordinary physical activity does not cause angina. Angina only during
strenuous or prolonged physical activity.
• Class II – Slight limitation of ordinary activity, with angina only during vigorous
physical activity. Walking more than 500 metres or climbing more than one flight
causes angina.
• Class III – Symptoms with everyday living activities, i.e., moderate limitation. Walking
100-300 metres or climbing one flight causes angina.
• Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe
limitation. Walking less than 100 metres or climbing less than one flight causes angina.
4
of severe squeezing pain in the heart region radiating to the neck, down the inside of
the left arm and to left subscapular region. This pain occurred on slow walking for
a distance 100-200 metres or climbing upstairs to the one flight. Pain was relieved
by the 10-minute rest or by the sublingual intake of nitroglycerine.
1. What is the clinical diagnosis in this patient? What is its clinical variant?
2. What symptoms of this disease may be revealed by physical examination
during pain attack or immediately after it?
3. What are the possible findings on ECG during pain attack?
Answer pattern
1. Stable angina pectoris, class III severity.
2. During episode of angina the following findings may be revealed: patient is
motionless, he/she has facies dolorosa2, pale skin. Pulse is accelerated. Blood
pressure is slightly elevated or normal. Borders of the heart are not displaced.
Heart sounds are temporarily significantly muffled.
3. The 12-lead electrocardiogram recorded during pain attack generally
demonstrates ECG-features of temporary myocardial ischemia as tall and
hyperacute Т wave or deep and symmetrically inverted Т wave. The Т wave
may also be flattened or biphasic. Depression of ST segment may be found as
well as T wave changes.
Clinical case 3
The patient was a 50-year-old male who was hospitalized to the cardiological
department of the clinic with complaints of severe retrosternal pain radiating down
to the left arm. Pain lasted 3 hours and was relieved only by intravenous injection of
narcotics. The next day patient became febrile to 38.0°С. Examination of patient’s
cardiovascular system showed soft irregular pulse of 104 beats per minute, soft heart
sounds, “gallop” rhythm, blood pressure of 110/80 mm Hg.
1. What is the clinical diagnosis in this patient? What is the variant of its clinical
course?
2. Describe abnormalities on the patient’s ECGs at the time of his hospitalization
to the clinic and the next day.
3. Specify probable changes in full blood count during the course of disease.
4. Specify probable changes in blood serum revealed by its biochemical
examination.
Answer pattern
1. Myocardial infarction, acute phase, anginal (anginous) clinical variant.
2
Facial expression of an unhappy person or one sick or in pain is named facies dolorosa.
5
2. In acute phase of myocardial infarction ECG shows ST segment elevation
with a curve which is convex upwards in the leads corresponding to the site
of myocardial injury. ST segment elevation begins with the top or the
descending part of R wave and joins Т wave, i.e. “monophase curve”
(“tombstone”) is recorded. Then persistent pathological Q wave (it exceeds ¼
amplitude of next R wave and its length exceeds 0.03 sec) is recorded in the
leads overlying the necrotic zone. The more extensive necrosis is, the deeper
Q wave is and the less height of R wave is. QS wave is registered in transmural
myocardial infarction.
3. Haematological manifestation of myocardial infarction (MI) includes
neutrophilic leukocytosis (it starts within several hours after onset of MI, peak
elevation is on the 2nd-3rd day, it returns to normal range by the 7-10th day)
and raised ESR (it starts on the 2nd-3rd day after onset of MI, peak elevation is
on the 8-10th day, it returns to normal range within 2-3 weeks).
4. Biochemical study of blood serum demonstrates increased activity of cardiac
enzymes such as troponins (its subunits troponin T and troponin I are now
considered the criterion standard in defining and diagnosing MI) and creatine
kinase (its myocardial muscle isoform, i.e. CK-MB) and increased myoglobin
level. Aspartate aminotransferase, lactate dehydrogenase (its 1st fraction) are
also increased. C-reactive protein may be positive.
Clinical case 4
Patient was a 48-year-old male who developed attack of dyspnoea (mainly
inspiratory), asphyxia, cough with production of serous frothy pinkish sputum.
Diminished vesicular breathing and bubbling rales were found by auscultation all
over the surface of the lungs.
ECG revealed foci of myocardial necrosis, injury and ischemia.
1. Name the clinical diagnosis of the patient including clinical variant of disease
and its complication.
2. Specify possible auscultatory findings on heart examination.
Answer pattern
1. Myocardial infarction, acute phase, asthmatic clinical variant, complicated
with acute left-ventricular failure (pulmonary oedema).
2. Auscultation of the heart commonly reveals tachycardia, irregular rhythm (in
arrhythmias), muffled or soft 1st and 2nd heart sounds, pathological 3rd and/or
4th heart sounds, “gallop” rhythm, systolic murmur over apex (due to papillary
muscle dysfunction leading to mitral regurgitation).
6
Clinical case 5
The patient was a 54-year-old male who was just admitted to the department of
intensive care. He complained of pain in epigastric region, nausea and vomiting
giving no relief, palpitation, intermissions in heartbeats and dyspnoea.
ECG revealed sinus arrhythmia, zones of ischemia, injury and necrosis.
1. Name the clinical diagnosis of the patient including clinical variant of disease.
2. What is the most probable localisation of site of myocardial damage in this
case? Specify ECG leads which represent this part of the heart.
3. What rhythm disorders are possible in the presence of this disease?
Answer pattern
1. Myocardial infarction, acute phase, abdominal clinical variant.
2. The most probable localisation of site of myocardial infarction is inferior
(diaphragmatic) wall of left ventricle. Its features are found in the leads III,
aVF and II.
3. Sinus tachycardia, extrasystolic arrhythmia, bundle branch block.
Clinical case 6
The patient was a 41-year-old male with a history of several previous attacks of
severe pain in joints associated with fever.
On prophylactic examination physician listened to soft 1st heart sound over apex,
soft 2nd heart sound in right 2nd intercostal space and harsh systolic murmur at the
same point that was also heard in jugular fossa and over carotid arteries.
1. What heart valvular disease does the patient have? Specify its possible
aetiology.
2. List the symptoms of this valvular disease revealed by inspection.
3. List the symptoms of this valvular disease revealed by palpation of the
cardiovascular system.
4. List the symptoms of this valvular disease revealed by percussion of the heart.
5. Specify possible changes of blood pressure (BP) in this valvular disease.
Answer pattern
1. Aortic stenosis of rheumatic origin.
2. Pale skin, visible high, forceful apex beat slightly displaced to the left and
downward; visible pulsation in the 2nd intercostal space to the right of the
sternum.
3. Small-volume, slow-rising, rare pulse (pulsus parvus, tardus and rarus); high,
forceful, diffuse apex beat slightly displaced to the left and downward;
pulsation in the 2nd intercostal space to the right of the sternum; systolic thrill
over the 2nd intercostal space to the right of the sternum.
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4. Moderate displacement of the left border of relative cardiac dullness to the
left and downward, unchanged absolute cardiac dullness, increased left
dimension of the heart, aortal cardiac silhouette.
5. Systolic BP tends to be low, diastolic BP is normal or slightly raised, pulse
pressure is reduced.
Clinical case 7
The patient was a 30-year-old female who had had 3 rheumatic fever attacks in
history.
Physical examination of the patient revealed acrocyanosis, cardiac beat, epigastric
pulsation, small-volume different pulse, mitral cardiac silhouette, blood pressure of
105/90 mm Hg.
1. What heart valvular disease does the patient have?
2. List the symptoms of this valvular disease that also may be revealed by
percussion of the heart.
3. List the symptoms of this valvular disease revealed by auscultation of the
heart.
4. Specify possible changes of heart chambers for this valvular disease.
5. List ECG changes that may be found in this heart valvular disease.
6. Specify possible type of insufficiency of blood circulation that develops in
decompensation of this valvular disease.
Answer pattern
1. Mitral stenosis.
2. Upward displacement of the upper border of the relative cardiac dullness,
displacement of the right border of relative cardiac dullness to the right (in
developed dilatation of right atrium), enlargement of absolute cardiac
dullness.
3. Loud snappy 1st heart sound over the heart apex, accentuated 2nd heart sound
over the pulmonary trunk, opening snap over the heart apex – “quail” rhythm;
diastolic (presystolic) murmur over the heart apex.
4. Hypertrophy with subsequent moderate dilatation of left atrium and right
ventricle.
5. Rhythm is regular (sinus) or irregular (due to atrial fibrillation), right axis
deviation, features of right ventricular hypertrophy, features of hypertrophy
of left atrium (P-mitrale).
6. Right-ventricular heart failure (congestion of blood in veins of systemic
circulation).
Clinical case 8
The patient was an 18-year-old male who suffered from recurrent exacerbations of
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chronic tonsillitis and pain in large joints associated with their redness and swelling.
Physical examination of the patient revealed soft 1 st heart sound, accentuated 2nd
heart sound over pulmonary trunk and systolic murmur over heart apex radiated to
the left axilla.
1. What acquired heart valvular disease does the patient have? Specify its
possible aetiology.
2. List the symptoms of this valvular disease revealed by special inspection of
the heart region.
3. List the symptoms of this valvular disease revealed by palpation of the
cardiovascular system.
4. List the symptoms of this valvular disease revealed by percussion of the heart.
5. Specify possible changes of heart chambers for this valvular disease.
Answer pattern
1. Mitral insufficiency (regurgitation) of rheumatic origin.
2. Visible high and diffuse apex beat displaced to the left and downward.
3. High, diffuse, forceful apex beat displaced to the left and downward,
unchanged characteristics of pulse.
4. Displacement of the left border of relative cardiac dullness to the left and
downward, upward displacement of the upper border of the relative cardiac
dullness, enlargement of left dimension, mitral cardiac silhouette.
5. Dilatation and hypertrophy of left atrium and left ventricle.
Clinical case 9
The patient was a 30-year-old female with a history of systemic lupus
erythematosus.
Physical examination of the patient revealed pale skin, de Musset’s sign, “carotid
shudder”, the Quincke’s sign, quick and large-volume pulse, apex beat of 6 cm2
located in the 6th intercostal space 5 cm laterally of the left midclavicular line, blood
pressure of 150/30 mm Hg.
1.
2.
3.
4.
5.
6.
What heart valvular disease does the patient have?
Specify possible changes of heart chambers in this valvular disease.
List the symptoms of this valvular disease revealed by percussion of the heart.
List auscultatory features of this valvular disease.
List ECG changes that may be found in this heart valvular disease.
Specify type of insufficiency of blood circulation that develops in
decompensation of this valvular disease.
Answer pattern
1. Aortic insufficiency (regurgitation).
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2. Tonogenic dilatation and hypertrophy of left ventricle.
3. Displacement of the left border of relative cardiac dullness to the left and
downward, unchanged absolute cardiac dullness, enlargement of left
dimension of the heart, aortal cardiac silhouette.
4. Soft 1st heart sound over heart apex; soft 2nd heart sound over the aorta;
blowing, decrescendo diastolic murmur over the aorta (in the 2nd and 5th main
points of auscultation of the heart); the Duroziez’s sign (VinogradovDuroziez double murmur) and the Traube’s sign over femoral artery.
5. Left axis deviation, features of left ventricular hypertrophy.
6. Left-ventricular heart failure.
Clinical case 10
The patient was a 60-year-old male who was delivered to the hospital by ambulance
car. On admission he complained of asphyxia developed during several hours, cough
with production of pinkish frothy sputum and pain in the heart region.
Auscultation of the lungs found bubbling rales in subscapular regions. Auscultation
of the heart revealed tachycardia, soft heart sounds, “gallop” rhythm, harsh systolic
murmur over aorta radiated to carotid arteries and jugular fossa. Blood pressure was
100/80 mm Hg.
1.
2.
3.
4.
What heart valvular disease does the patient have?
Specify the complication of this valvular disease.
Specify possible changes of chambers of the heart in this valvular disease.
Specify possible changes of position of electrical axis of the heart in this
valvular disease.
Answer pattern
1. Aortic stenosis.
2. Acute left-ventricular failure as pulmonary oedema.
3. Hypertrophy and dilatation of left ventricle and hypertrophy of left atrium.
4. Left axis deviation due to left ventricular hypertrophy.
Clinical case 11
The patient was a 42-year-old manager who complained of severe headache (in
occipital area), dizziness, nausea, vomiting giving no relief, visual impairment and
iridescent flashings before eyes. The day before he had emotional stress and took
alcohol. Inquiry of the patient revealed that several years prior to hospital admission
he had suffered from headache occurring at the changes of weather and relieved by
epistaxis3, his mother also had the similar symptoms.
3
Epistaxis is profuse bleeding from the nose.
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On inspection hyperaemia of face and skin of neck, chest and shoulders was
revealed. Apex beat of 4 cm2 was found in the 5th intercostal space 1 cm laterally of
the left midclavicular line. Blood pressure was 220/110 mm Hg.
1. What disease does the patient have? Specify its stage and current condition.
2. Specify the following for this clinical situation: abnormal characteristics of
pulse, position of left border of relative cardiac dullness, cardiac silhouette
and changes of heart sounds.
3. Describe possible changes of retinal vessels.
4. List ECG changes that may be found in this disease.
Answer pattern
1. Essential (primary) arterial hypertension, 2nd stage, 3rd degree of severity,
hypertensive crisis.
2. Hard pulse; displacement of left border of relative cardiac dullness to the left;
aortal cardiac silhouette; accentuated 2nd heart sound over aorta and soft 1st
heart sound over heart apex.
3. Narrowing of arteries and arterioles of retina, their increased tortuosity,
“nipping” of the venules at arteriovenous crossing; possible retinal
haemorrages, oedema and exudates.
4. Left axis deviation, features of left ventricular hypertrophy.
Clinical case 12
The patient was a 15-year-old female who complained of new-onset pain in heart
region, palpitation, dyspnoea at rest, severe pain in large joints, mild oedema of feet
and shanks. Two weeks prior to hospital admission she had been ill with scarlet
fever.
On admission her body temperature was 38.5°С, inspection found redness and
swelling of knees and ankles. Physical examination of patient’s cardiovascular
system revealed tachycardia, soft heart sounds, systolic murmur over heart apex,
blood pressure of 90/60 mm Hg. Physician also found the lower edge of liver of
2 cm below the right costal arch, it was rounded and slightly tender.
1.
2.
3.
4.
What disease does the patient have?
Formulate the clinical diagnosis on the basis of given information.
Specify probable changes in full blood count for this case.
Specify laboratory signs of this disease that are found by blood serum study.
Answer pattern
1. Rheumatic fever.
2. Main disease: rheumatic fever, first attack, active, carditis, polyarthritis.
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Complication: right-ventricular heart failure of IIA stage4.
3. Neutrophilic leukocytosis, raised ESR.
4. Positive C-reactive protein, increased serum α2- and γ-globulin content
leading to dysproteinemia, increased fibrinogen and seromucoid levels, rising
antistreptolysin O, antistreptohyaluronidase and antistreptokinase titres.
Clinical case 13
The patient was a 44-year-old female with a history of rheumatic mitral stenosis.
She complained of dyspnoea, palpitation, intermissions in heartbeats, pain and
heaviness in right hypochondrium, oedema of the legs.
Physical examination of the patient revealed irregular unequal pulse, pulse deficit as
10 beats. Lower edge of liver was rounded, slightly tender and was found 4 cm below
the right costal arch. Free fluid was detected in abdominal cavity.
1. Specify complications that developed during the course of this valvular
disease.
2. List the additional methods of examination to confirm the recognized
complications. Specify their possible results.
Answer pattern
1. Atrial fibrillation, right-ventricular heart failure of IIA stage.
2. ECG shows atrial fibrillation, right axis deviation, features of right ventricular
hypertrophy, features of left atrial hypertrophy (P-mitrale).
Venous pressure measured in the ulnar vein by the direct method exceeds
110 mm of water column.
4
Chronic circulatory insufficiency is classified as follows:
Stage I – the patient’s work capacity decreases, physical exertion provokes dyspnoea, palpitation.
These symptoms subside at rest.
Stage IIA – the patient develops dyspnoea during normal exercise (e.g. in walking), and his work
capacity decreases markedly. Examination reveals moderate cyanosis and oedema of shanks.
Congestion in the lungs is not pronounced. The liver is mildly enlarged.
Stage IIВ – marked congestion in the systemic and pulmonary circulation. Dyspnoea develops
even at rest which is intensified during slight physical exertion. Patients are fully disabled. Typical
signs of heart failure (pronounced cyanosis, oedema, ascites, dysfunction of various organs) are
revealed.
Stage III – pronounced metabolic disorders. The patient would be extremely asthenic, with
irreversible morphological changes in the lungs, liver, and kidneys.
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Test of 6 minute walking5 determines functional class of heart failure
according to NYHA classification6.
Echocardiography reveals decrease of cardiac output and pulmonary
hypertension.
Study of arterial blood gases usually reveals hypoxemia.
Clinical case 14
The patient was 40-year-old male with one month history of fever, mainly lowgrade, sometimes high fever up to 39.0°С accompanied with chills, excessive
sweats, recurrent episodes of epistaxis, palpitation and breathlessness during minor
physical activity.
On inspection petechial haemorrhages were found on the skin of forearms and eyelid
folds as well as subungual linear haemorrhages. Inspection also revealed rhythmical
pulsatory movements of the uvula (Muller’s sign) and pupils (Landolfi’s sign)
synchronous with the heart’s action. Pulse was quick and large-volume (pulsus celer
et magnus). Diastolic murmur was heard in the right 2 nd and left 3rd intercostal
spaces.
1. What disease does the patient have?
2. List the symptoms of this disease that also may be revealed by inspection.
3. List the symptoms of developed valvular disease that also may be revealed by
inspection.
4. Specify possible results of blood pressure measurement for this patient.
5. Specify possible results of palpation of abdominal cavity.
6. List possible complications of main disease.
5
6 minute walking test estimates severity of heart failure according to the distance that patient can
walk (including all pauses and stoppages), as follows:
▪ Class I – 426-550 metres;
▪ Class II – 300-425 metres;
▪ Class III – 150-300 metres;
▪ Class IV– less than 150 metres.
6
NYHA classification of heart failure:
• Class I: asymptomatic – No limitation in physical activity despite presence of heart disease.
This can be suspected only if there is a history of heart disease which is confirmed by
investigations, e.g., echocardiography.
• Class II: mild – Slight limitation in physical activity. More strenuous activity causes
shortness of breath, e.g., walking on steep inclines and several flights of steps. Patients in
this group can continue to have an almost normal lifestyle and employment.
• Class III: moderate – More marked limitation of activity which interferes with work.
Walking on the flat produces symptoms.
• Class IV: severe – Unable to carry out any physical activity without symptoms. Patients
are breathless at rest and mostly housebound.
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Answer pattern
1. Infective endocarditis.
2. Skin of coffee with milk colour, slightly icteric scleras, Janeway’s lesions,
Osler’s nodes, positive Rumpel-Leyde symptom.
3. Pale skin, “carotid shudder”, de Musset’s sign, the Quincke’s sign, pulsations
in jugular fossa and in the 2nd intercostal space to the right of the sternum;
high, diffuse apex beat displaced to the left and downward.
4. Systolic BP is high, diastolic BP is low, pulse pressure is increased.
5. Hepatomegaly and mainly splenomegaly are possible.
6. Thromboembolism of arteries of various parts of the body (with consequent
infarctions in kidneys, spleen, lungs, brain, intestine, etc.),
glomerulonephritis.
14
SECTION 2
DISEASES OF THE RESPIRATORY SYSTEM
Clinical case 15
Patient was a 40-year-old man who presented on the day of hospital admission with
2-week history of permanent right-sided chest pain, cough with poor sputum
production and constant high fever (39.0-40.0ºC). The next morning after intense
cough about 500 ml of foul-smelling purulent sputum were discharged within one
hour.
On examination performed after it bronchial breathing (amphoric respiration) and
consonating coarse bubbling rales were heard in right subclavicular region.
1. Name the patient’s disease and its stage.
2. What symptoms of this disease may be revealed by palpation, percussion of
the chest and determining vocal resonance?
3. What are the possible findings on chest X-ray in this patient?
4. What are the possible findings in full blood count in this patient?
5. What are the possible findings in sputum in this patient?
Answer pattern
1. Abscess of upper lobe of right lung, stage of drainage with bronchus.
2. Intensified vocal tactile fremitus and vocal resonance, tympanic percussion
note are found over projection of upper lobe of right lung.
3. Chest X-ray can reveal presence of cavity in the upper lobe of right lung.
4. Neutrophilic leukocytosis with a left shift, heavy granulation of neutrophils,
raised ESR.
5. Purulent sputum that may become two or three-layered on standing,
leukocytes that cover all fields of view, various microbial flora in large
numbers, elastic fibres, crystals of cholesterol and Dittrich’s plugs.
Clinical case 16
The patient was a 35-year-old man with 12-year history of smoking. He complained
of cough (mainly in the morning) with production of moderate amount of
mucopurulent sputum.
Vesicular breathing and sonorous dry rales were heard all over the surface of the
lungs.
1. What disease may be suspected in this patient?
2. What symptoms of this disease may be revealed by inspection, palpation and
percussion of the chest?
3. What are the additional methods of examination to confirm the clinical
diagnosis? Specify their possible results.
15
Answer pattern
1. Chronic bronchitis.
2. Symptoms of chronic bronchitis are not revealed by inspection, palpation and
percussion of the chest.
3. Bronchoscopy reveals hyperaemia of mucous membrane of bronchi covered
by mucus and/or pus.
Sputum is mainly mucopurulent (may be mucoid or purulent) of yellowishgreen colour, contains leukocytes in large numbers, ciliated epithelial cells.
Pulmonary function tests are used to confirm presence or absence of airway
obstruction (decrease of FVС, FEV1s is revealed in the presence of airway
obstruction).
Clinical case 17
The patient was a 25-year-old man who presented on the day of hospital admission
with 3-day history of disease suddenly arising after overcooling.
He complained of fever (up to 40°С) and shaking chills, left-sided chest pain
developing in deep inspiration and cough, cough with production of “rusty” sputum,
breathlessness, headache, excessive sweats and weakness.
Herpetic lesions on the lips, reduced chest wall movements on left side, dull
percussion note over projection of entire lower lobe of left lung were revealed by
physical examination of the patient.
1.
2.
3.
4.
5.
6.
Name the patient’s disease and its stage.
What symptoms of this disease may be revealed by auscultation of the lungs?
What are the possible findings in full blood count in this patient?
What are the possible findings in sputum study in this patient?
What are the possible findings in serum proteins?
What are the possible findings on chest X-ray in this patient?
Answer pattern
1. Croupous (lobar) pneumonia, the 2nd stage (height of disease or hepatization).
2. Pathological bronchial breathing and intensified vocal resonance over
projection of lower lobe of left lung.
3. Neutrophilic leukocytosis with a left shift, heavy granulation of neutrophils,
raised ESR.
4. “Rusty” sputum containing large number of leukocytes, erythrocytes, alveolar
cells, pneumococci in each field of view.
5. Positive acute phase proteins (positive C-reactive protein and increased
fibrinogen content); dysproteinaemia due to increased globulin content.
6. Consolidation (homogeneous opacity) of lower lobe of left lung.
Clinical case 18
Patient was an asthenic 19-year-old female who lived with her mother suffering from
16
tuberculosis of the lungs. Physical examination of the patient revealed moderate
fever (38.2 °С), reduced chest wall movements on right side as well as smoothness
of intercostal spaces on the same side, absence of vocal tactile fremitus below right
scapular and in the same place stony dull percussion note with oblique upper border,
top point of which was in right axilla.
1. Name the patient’s disease and its probable cause.
2. Specify the auscultatory findings in this patient.
3. Specify the results of chest X-ray and other additional methods of examination
to confirm the diagnosis.
Answer pattern
1. Right-sided pleurisy with effusion of tuberculous origin.
2. Breath sounds and vocal resonance are absent over the projection of fluid
(below the upper border of dull percussion note).
3. Homogeneous opacity of corresponding pulmonary area with oblique upper
border is found by chest X-ray. Pleural puncture is necessary in order to
confirm that pleural fluid is exudate and lymphocytes predominate in it;
detection of tuberculosis mycobacteria in pleural fluid is rare.
Clinical case 19
The patient was a 50-year-old man who presented with a history of gradually
developing disease. During first two days the body temperature was subfebrile (lowgrade fever), later as remittent fever; cough in the onset of disease was dry, and then
mucopurulent sputum up to 30-40 ml a day was discharged. By the day of hospital
admission inspiratory breathlessness also developed.
In auscultation of the lungs diminished vesicular breathing and consonating fine
bubbling rales were heard in right axillary region.
1. What is the clinical diagnosis in this patient?
2. What symptoms of this disease may be revealed by determining vocal tactile
fremitus and vocal resonance and by percussion of the chest?
3. What are the additional methods of examination to confirm the clinical
diagnosis? Specify their possible results.
Answer pattern
1. Bronchopneumonia in the lower lobe of right lung.
2. Intensified vocal tactile fremitus and vocal resonance; slightly dull (impaired)
percussion note over projection of the lower lobe of right lung.
3. There are leukocytes, ciliated epithelial cells, alveolar macrophages in large
numbers in sputum smear.
17
X-ray examination of the lungs reveals focal infiltrations.
Full blood count reveals mild neutrophilic leukocytosis and raised ESR.
Clinical case 20
The patient was a 30-year-old female who was delivered to the clinic by ambulance
car. She complained of expiratory dyspnoea attack developed during housework in
dust-laden room.
On examination the patient sat with support on hands. Inspection of respiratory
system found barrel-shaped chest and involvement of accessory muscles in
breathing, respiration rate of 28 breaths per minute.
1. What is the clinical diagnosis in this patient?
2. What findings may be revealed by comparative and topographic percussion
of the chest?
3. What findings may be revealed by auscultation of the lungs?
4. What are the most probable findings in sputum study in this patient?
Answer pattern
1. Bronchial asthma (allergic, exogenous, atopic).
2. Bandbox percussion note may be found all over topographic sites of the lungs;
enlargement of Kronig’s isthmuses is present, the lower borders of the lungs
are below normal levels, the mobility of the lower borders of the lungs is
limited.
3. Diminished vesicular breathing or harsh breathing, plenty of sibilant dry rales
(end-expiratory wheezing), decreased vocal resonance.
4. Glassy mucoid sputum containing eosinophils, Charcot-Leyden crystals,
Curschmann’s spirals.
Clinical case 21
The patient was a 65-year-old male with a long-term history of chronic obstructive
pulmonary disease (COPD) who complained of mixed dyspnoea during minor
physical activity, sensation of heaviness and pain in right hypochondrium,
permanent oedema of the legs.
Diffuse cyanosis, respiration rate of 24 breaths per minute, cardiac beat, accentuated
2nd heart sound over pulmonary trunk were revealed by physical examination.
1. Name complications of COPD in this patient.
2. Specify possible cause of heaviness and pain in right hypochondrium in this
case.
18
Answer pattern
1. Cor pulmonale; right-ventricular failure of IIA stage; heart failure of
functional class III (according to NYHA classification).
2. Heaviness and pain in right hypochondrium may be explained by distension
of thin liver capsule due to congestion of blood in it.
Clinical case 22
The patient was a 70-year-old male with a long-term history of chronic bronchitis.
Inspection of the chest determined equality of anteroposterior dimension and
transverse one, enlargement of intercostal spaces. Bandbox note was revealed by
comparative percussion of the chest.
1. Name complication of chronic bronchitis which symptoms were found in this
patient.
2. What findings may be revealed by determining vocal tactile fremitus?
3. What findings may be revealed by topographic percussion of the chest?
4. What findings may be revealed by auscultation of the lungs and determining
vocal resonance?
5. What are findings on pulmonary function tests in this patient?
Answer pattern
1. Pulmonary emphysema.
2. Reduced vocal tactile fremitus.
3. The lower borders of the lungs are below normal levels, the mobility of the
lower borders of the lungs is limited.
4. Diminished vesicular breathing and reduced vocal resonance.
5. Decrease of respiratory (tidal) volume, inspiratory and exspiratory reserve
volumes, vital capacity and peak expiratory flow, increase of residual volume.
19
SECTION 3
DISEASES OF THE ALIMENTARY SYSTEM
Clinical case 23
The patient was a 54-year-old man who presented with 2-year history of cramping
pain in umbilical region, borborygmi, diarrhoea with stool frequency of 5-6 times a
day, polyfaecalia, discharge of watery, foamy, homogenous, greasy and fatty stool
of light-yellow colour containing undigested residue of the food, weight loss and
weakness.
Inquiry revealed that the first symptoms of disease had developed 2 years prior to
admission, and then they remained with episodes of their subsiding and aggravation.
1.
2.
3.
4.
What disease may you suspect?
What symptoms of this disease may be revealed by inspection of oral cavity?
What symptoms of this disease may be revealed by palpation of abdomen?
Specify coprological syndrome that may be found by study of the faeces in
this patient.
Answer pattern
1. Chronic enteritis, stage of exacerbation.
2. Atrophy of mucous membrane of the tongue (bald tongue), tongue coated with
grey fur, angular fissures of the lips.
3. Tenderness in umbilical region, loud rumbling sounds in intestine under
palpation.
4. Enteric coprological syndrome which includes presence of muscle fibres of
the 2nd-3rd digestive stage (without striated pattern), amorphous starch, soaps
and fatty acids in large amount.
Clinical case 24
Patient was a 46-year-old female who presented with 5-year history of permanent
boring pain and fullness in epigastric region increasing soon after taking food, poor
appetite, weight loss and weakness.
Patient noted that symptoms had subsided and disappeared if she had taken meal
regularly and had drunk acid mineral water before meal.
On physical examination slight tenderness in epigastric region was revealed by
palpation.
1. What disease does the patient suffer from?
2. List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
3. Specify coprological syndrome that may be found by study of the faeces in
this patient.
Answer pattern
1. Chronic atrophic gastritis with secretory insufficiency.
20
2. The main method to confirm diagnosis of atrophic gastritis is gastrosopy with
target biopsy of mucous membrane of body and antral part of the stomach and
histological study of biopsy material. Tissue sampling is essential to establish
the topography of gastritis, to identify atrophy and intestinal metaplasia,
which may be patchy.
To confirm secretory insufficiency study of gastric secretion is performed.
Hypoacidity up to achlohydria (including histamine-resistant one) may be
found, sometimes achylia may occur.
Another way to confirm gastric insufficiency is pH-metry which may reveal
hypoacidity or anacidity.
3. Gastrogenous coprological syndrome which includes presence of digested
cellular tissue, connective tissue fibres, muscle fibres of the 1st digestive stage
(muscle fibres with preserved striated pattern) in large amount.
Clinical case 25
The patient was a 50-year-old male admitted to the clinic with complaints of
permanent intensive pain in left hypochondrium and epigastric region, radiating to
the back (engirdling character of pain), vomiting giving no relief, anorexia.
Several hours prior to hospitalization he had taken plenty of alcohol and fatty food.
The following findings were revealed by physical examination: fever (38.0°С), Grey
Turner’s sign (local areas of discoloration about the umbilicus and in the region of
the loins), considerable tenderness in the centre of epigastric region and MayoRobson’s point.
1. What disease do you suspect in this patient?
2. What symptoms of this disease may be revealed by inspection of oral cavity?
3. What other symptoms of this disease may be revealed by inspection and
palpation of the abdomen?
4. Name the most probable results of full blood count in this patient.
5. Specify the changes of amylase content in blood serum and urine.
Answer pattern
1. Acute pancreatitis.
2. Dry tongue coated with fur.
3. Moderate tension of anterior abdominal wall in epigastric region, skin
hypersensitivity may be revealed at the same site; other findings include
tenderness in Shauffard’s zone and Desjardin’s point, absence of pulsation of
abdominal aorta (Voskresensky’s sign).
4. Neutrophilic leukocytosis with a left shift, heavy granulation of neutrophils,
raised ESR.
5. Amylase content increases in blood serum and urine.
21
Clinical case 26
The patient was a 48-year-old male. Established diagnosis was pseudotumoral
variant of chronic pancreatitis with insufficiency of exocrine function of the
pancreas.
Yellow discolouration of the skin and scleras was found by inspection.
1. Specify the method of physical examination to estimate the condition of the
pancreas.
2. Specify additional methods of examination to estimate morphological
structure of the pancreas and their possible results.
3. Specify clinical features of pancreatic exocrine insufficiency.
4. Describe stool in the presence of pancreatic exocrine insufficiency.
5. Specify the type of jaundice that patient had.
Answer pattern
1. Palpation sometimes reveals enlarged consolidated tender pancreas.
2. Additional methods of examination are ultrasonography, x-ray (as hypotonic
duodenography), CT scan, radioisotope scanning of the pancreas.
The following abnormalities may be revealed: enlargement and deformity of
the pancreas, changes of its contour and density (swelling, consolidation,
sclerosis, calcification and cysts).
3. Clinical features of pancreatic exocrine insufficiency (decreased content of
pancreatic enzymes in pancreatic juice) are the following: diarrhoea, weight
loss, anorexia, weakness.
4. Gross findings include polyfaecalia, faeces of greyish colour, greasy and
fatty stool with foul odour. Microscopic findings include considerable
amount of neutral fat (steatorrhea7) and muscular fibres with preserved
striated pattern (creatorrhoea8), amorphous starch.
5. Mechanical (post-hepatic) jaundice due to compression of common bile duct
by enlarged head of the pancreas.
Clinical case 27
The patient was a 45-year-old obese male who had fallen ill in 5-7 hours after taking
plenty of fatty and fried food. Physical examination of the patient revealed body
temperature of 38.5°С, slightly icteric scleras, moderate tension of the abdomen in
Steatorrhea means presence of neutral fat in the faeces in large amount (more than 100 fatty
drops in the field of view) or fatty acids and soaps under condition that the patient has taken 7080 gram of fat within 2-3 days before examination.
8
Creatorrhoea means presence of poor digested muscular fibres (muscular fibres with preserved
striated pattern) in the faeces in large amount under condition that patient has taken enough amount
of meat (not less than 200 gram per day).
7
22
the right hypochondrium, and Blumberg’s sign at the same site.
1.
2.
3.
4.
What is the clinical diagnosis in this patient?
List complaints that are possible in such case.
List possible palpatory symptoms of this disease.
List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
Answer pattern
1. Acute cholecystitis.
2. Pain in the right hypochondrium radiating to the right side of the chest, right
shoulder and neck, vomiting of bile, bitterness and dryness in the mouth,
chills.
3. Murphy’s symptom (the patient catches breath in inspiration on palpation in
the right hypochondrium), Ortner’s symptom (pain during tapping over the
right costal arch by the edge of the hand), de Mussy’s symptom (tenderness
at the point of the phrenic nerve, between the heads of the sternocleidomastoid
muscle), Boas’s sign (tenderness in paravertebral points to the right of the 8 th
to 11th thoracic vertebrae), zones of skin hypersensitivity below the inferior
angle of the right scapula and in the region of right shoulder.
4. Full blood count shows neutrophilic leukocytosis, raised ESR.
Ultrasonography of gallbladder reveals change of its shape and thickening of
its walls.
Clinical case 28
The patient was a 48-year-old female who presented with 13-year history of almost
permanent pain in right hypochondrium, bitter taste and dryness in the mouth,
frequent nausea. Symptoms amplified after taking spicy, fried and fatty food.
Physical examination of the patient revealed Ortner’s symptom, Murphy’s sign,
Boas’s sign, zones of skin hypersensitivity below the inferior angle of the right
scapula and in the region of right shoulder. However gallbladder was impalpable.
1. What is the clinical diagnosis in this patient?
2. List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
Answer pattern
1. Chronic cholecystitis.
2. Full blood count shows raised ESR.
Ultrasonography of biliary system and cholecystography reveal changes of
size and shape of gallbladder, thickening of its walls, abnormal motility of
23
gallbladder and bile ducts. Gallstones may be found also in case of chronic
cholecystitis.
Clinical case 29
The patient was a 55-year-old male with a history of alcohol abuse. Ten years prior
to hospital admission he had been ill with virus C hepatitis. On admission he
presented with pain in right hypochondrium and vomiting of blood clots
(haematemesis).
Inspection revealed icteric skin and scleras. Abdomen examination showed its
enlargement due to bloating and ascites. Liver was palpated 3 cm below the right
costal arch. Lower edge of the liver was firm, sharp, and slightly tender. The size of
the spleen determined by percussion was 15×10 cm.
1. What is the clinical diagnosis? Specify the name of the main disease and its
complication.
2. What is the most probable source of bleeding in this case?
3. What other symptoms of this disease may be revealed by general inspection?
4. What other symptoms of this disease may be revealed by special inspection
of alimentary system?
Answer pattern
1. Main disease: Cirrhosis of the liver.
Complication: Portal hypertension.
2. Oesophageal varicose veins.
3. “Spider naevi” (“spider angiomas”, telangiectasis), hepatic palms and feet
(palmar erythema), gynecomastia, hemorrhagic eruption, xanthelasma,
oedema, muscular hypotrophy.
4. Crimson (raspberry-coloured) bald tongue, dilated subcutaneous veins of the
anterior abdominal wall (caput medusae).
Clinical case 30
The patient was a 20-year-old male who complained of dyspnoea and palpitation
during physical activity. Physical examination revealed icteric scleras, lemonyellow skin and splenomegaly. Full blood count showed red blood cell count as
2.5×1012/l, reticulocyte count was 160 ‰ (pro mil).
1. What type of jaundice did the patient have?
2. List additional methods and their possible results that confirm the type of
jaundice recognized by you.
Answer pattern
1. Pre-hepatic (haemolytic) jaundice.
24
2. Blood serum study determines hyperbilirubinemia due to increased content of
unconjugated bilirubin; urinalysis shows appearance of urobilinogen and
increased content of stercobilinogen in urine; study of stool reveals increased
content of stercobilin.
Full blood count shows presence of nucleated red blood cells and
poikilocytosis.
Clinical case 31
Patient was a 68-year-old male who complained of weight loss, boring pain in right
hypochondrium, skin itching, discharge of acholic faeces and deep-brown urine.
Inspection showed icteric scleras and greenish-yellow colour of the skin. Palpation
of abdomen revealed enlarged soft-elastic tender gallbladder in its point.
1.
2.
3.
4.
What type of jaundice did the patient have?
What is the most probable cause of this jaundice?
Name the symptom revealed by palpation of gallbladder.
List additional methods and their possible results that confirm the type of
jaundice recognized by you.
Answer pattern
1. Post-hepatic (obstructive, mechanical) jaundice.
2. Compression of common bile duct by enlarged head of the pancreas (the most
common disease is cancer of the pancreas).
3. Courvoisier’s sign.
4. Blood serum examination reveals biochemical syndrome of cholestasis
including presence of conjugated bilirubin, increased activity of alkaline
phosphatase and γ-glutamyl transpeptidase and hypercholesterolemia;
urinalysis reveals presence of conjugated bilirubin in urine; examination of
stool reveals absence of stercobilin.
Clinical case 32
The patient was a 40-year-old male who had had excessive alcohol consumption one
week prior to hospital admission.
Physical examination revealed icteric scleras and skin as well as hepatomegaly.
Laboratory examination showed hyperbilirubinemia (total bilirubin was 88 µmol/l,
conjugated one – 50 µmol/l, unconjugated one – 38 µmol/l), presence of conjugated
bilirubin and urobilin in urine, reduced content of stercobilin in stool.
1. What type of jaundice did the patient have?
2. Name the disease that led to the jaundice in this case?
3. List additional methods of blood serum examination and their possible results
25
that confirm the type of jaundice recognized by you.
Answer pattern
1. Hepatocellular (parenchymal) jaundice.
2. Toxic (alcoholic) hepatitis.
3. Blood serum examination reveals biochemical syndrome of cytolysis
including increased activity of alanine aminotransferase, aspartate
aminotransferase, γ-glutamyl transpeptidase, lactate dehydrogenase (its 5th
fraction).
Blood study demonstrates negative tests for viral hepatitis B and C.
Clinical case 33
Patient was a 32-year-old male with a history of peptic (gastric) ulcer disease. On
admission to the surgical department he presented with weakness, dizziness, nausea
and vomiting of blood (haematemesis), black stool.
1. Name the developed complication of peptic ulcer disease.
2. What symptoms of this condition may be found by inspection of the patient’s
skin?
3. What symptoms of this condition may be found by examination of the
patient’s cardiovascular system?
4. What urgent additional methods of examination are necessary to confirm
developed complication? Specify their possible results.
Answer pattern
1. Gastric haemorrhage (bleeding) that led to acute posthemorrhagic anaemia.
2. Pale and moist skin.
3. Rapid, soft, small-volume pulse, low blood pressure, tachycardia, functional
systolic murmur over heart area.
4. Full blood count shows normochromic anaemia (decreased content of red
blood cells, decreased hemoglobin level and decreased haematocrit [packed
cell volume]) and mild neutrophilic leukocytosis.
Faeces study shows black shapeless (tarry) stool [melena], tests for blood are
positive.
Upper GI endoscopy (oesophagogastroduodenoscopy) can specify the
possible source of bleeding.
26
Clinical case 34
Patient was a 39-year-old female who had been ill with acute dysentery 3 years prior
to hospital admission. Later intolerance of fresh milk occurred and diarrhoea
developed. Stool frequency was more than 6 times a day with discharge of porridgelike faeces containing admixture of mucus and streaks of blood.
Physician found tenderness of abdomen in the regions of projection of large intestine
especially in left iliac region. Spasm of sigmoid was determined by deep palpation.
1. What is the clinical diagnosis in this patient?
2. List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
Answer pattern
1. Chronic colitis.
2. Faeces study shows distal colonic coprologic syndrome (presence of pus,
mucus and blood on the surface of faeces), positive Triboulet’s test.
Lower GI endoscopy (proctosygmoidoscopy and colonoscopy) reveals
features of inflammation of mucous membrane: hyperaemia, possible
erosions and small haemorrhages, presence of cloudy mucus and pus on
intestinal wall.
Clinical case 35
The patient was a 24-year-old male with a history of vernal and autumnal occurrence
of gnawing or burning pain in epigastric region arising in 2-3 hour after taking food
or at night, heartburn, eructation, nausea and vomiting of acid contents developing
at the height of the pain and giving relief.
Tongue coated with white fur was revealed by inspection. Palpation of abdomen
determined tenderness in epigastric region to the right of midline. Positive Mendel’s
sign was found at the same place.
1. What is the clinical diagnosis in this patient?
2. List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
Answer pattern
1. Peptic ulcer disease (with localization of ulcer in duodenum or pyloric part of
the stomach).
2. Upper GI endoscopy (oesophagogastroduodenoscopy) reveals hyperaemia of
mucous membrane and ulcer in duodenum or pyloric part of the stomach.
Determining Helicobacter pylori infection may be done by study of biopsy
material (rapid urease tests, histology and culture) and urea breath test.
X-ray (barium meal) reveals symptom of a niche.
27
Gastric juice study finds increased volume of fasting gastric secretion,
increased basal and stimulated hydrochloric acid output.
Clinical case 36
The patient was a 30-year-old driver who visited the physician for the first time. He
complained of recurrent boring pain in epigastric region developing in 30-40
minutes after meal (especially after fried, salty and sour food) and relieved by
vomiting, nausea and sometimes vomiting of taking food. The patient’s family
history revealed that father of the patient had had the similar symptoms at young
age, and stomach resection had been done to him.
1. What is the clinical diagnosis in this patient?
2. What symptoms may be found by physical examination of the patient?
3. List additional methods of examination to confirm the clinical diagnosis and
specify their possible results.
Answer pattern
1. Peptic ulcer disease (with localization of ulcer in the body of the stomach).
2. Tongue coated with white fur is revealed by inspection. Palpation of abdomen
finds tenderness in epigastric region. Positive Mendel’s sign is found by
percussion at the same place.
3. Upper GI endoscopy (oesophagogastroduodenoscopy) reveals mainly solitary
ulcer in the body of the stomach. Malignant cells should be absent in biopsy
material.
Determining Helicobacter pylori infection may be done by study of biopsy
material (rapid urease tests, histology, and culture) and urea breath test.
X-ray (barium meal) reveals symptom of a niche.
Gastric juice study finds fasting gastric secretion, basal and stimulated
hydrochloric acid output mainly within normal limits.
28
SECTION 4
DISEASES OF THE KIDNEYS
Clinical case 37
The patient was a 35-year-old male with 10-year history of arterial hypertension who
presented with headache, poor vision and dull pain in lumbar region. Patient
informed physician that from time to time he had noticed reddish-brown
discolouration of his urine.
Physical examination revealed high blood pressure (210/110 mm Hg).
1. What is the clinical diagnosis in this patient? Specify its clinical variant.
2. What change of myocardium develops in this disease? What abnormalities
revealed by the patient’s physical examination may confirm it?
3. What symptoms may be revealed by inspection of the fundus of the eye?
4. Specify possible changes of urinalysis and function of kidneys in this case.
Answer pattern
1. Chronic glomerulonephritis, hypertensive clinical variant.
2. Left ventricular hypertrophy may be confirmed by determining high, forceful
apex beat displaced to the left, displacement of left border of relative cardiac
dullness to the left, aortal cardiac silhouette, soft 1st heart sound, accentuated
2nd heart sound over aorta.
3. Narrowing of arteries and arterioles of retina, their increased tortuosity,
“nipping” of the venules at arteriovenous crossings, presence of recurring
retinal haemorrhages, oedema and exudates.
4. Urinalysis shows urinary nephritic syndrome (haematuria, cylindruria,
proteinuria), decrease of urine specific gravity.
Function of kidneys worsens, it is reflected by progressive decrease of
glomerular filtration rate up to chronic renal failure (in that case increased
content of creatinine and urea is found in blood serum).
Clinical case 38
The patient was a 41-year-old male who was taken to clinic being in coma. On
examination patient had pale skin with scratch marks, oedema of the whole body
and puffy face, noisy slow breathing with very deep inspirations (Kussmaul’s
breathing), blood pressure of 230/150 mm Hg. Features of left ventricular
hypertrophy, pericardial friction rub and free fluid in abdominal cavity were found.
Uraemic smell was felt in air exhaled by the patient.
The urinalysis received by catheter showed light yellow colour, specific gravity of
1.003 g/cm3, protein concentration of 3.3 g/l, 3-5 leukocytes in the field of view, up
to 10-15 altered and unaltered red blood cells in the field of view, waxy casts.
29
1. Name disease, its clinical variant and complication that led to described
condition of the patient.
2. What additional methods of examination are necessary to confirm the
diagnosis? Give their possible results.
Answer pattern
1. Main disease: Chronic glomerulonephritis, mixed (nephrotic-hypertensive)
clinical variant;
Complication: Chronic renal failure (uraemic coma).
2. Biochemistry of blood serum reveals very high content of creatinine and urea,
hyperkalemia (hyperpotassemia); creatinine clearance (glomerular filtration
rate) is less than 10-20 mL/min.
Clinical case 39
The patient was a 40-year-old female who presented with fever (body temperature
raised up to 38.5°С), chills, dull pain in right-sided lumbar region and pollakiuria
(up to 10 micturitions a day) with painful voiding small urine portions.
1.
2.
3.
4.
What is the clinical diagnosis in this patient?
What symptoms of this disease may be revealed by physical examination?
List the probable changes in full blood count.
List the probable changes in urinalysis.
Answer pattern
1. Acute right-sided pyelonephritis.
2. Tenderness of right renal points (costal-vertebral and costal-lumbar) and
positive right-sided Pasternatsky’s symptom.
3. Moderate neutrophilic leukocytosis and raised ESR.
4. Urinary pyelonephritic syndrome: leukocyturia (up to pyuria), bacteriuria and
mild proteinuria.
Clinical case 40
The patient was an 18-year-old male with a history acute tonsillitis two weeks prior
to hospital admission. He complained of oedema of whole body, oliguria, urine
discolouration (urine of “meat wastes” colour), pain in lumbar region, headache,
palpitation and breathlessness during any physical activity.
1.
2.
3.
4.
What is the clinical diagnosis in this patient?
List possible changes of the skin.
List possible changes of the cardiovascular system.
List possible changes in urinalysis.
30
Answer pattern
1. Acute glomerulonephritis.
2. Pale skin and puffy face.
3. Elevated blood pressure (arterial hypertension), hard/tense pulse, muffled or
soft 1st heart sound over apex of the heart, accentuated 2nd heart sound over
aorta.
4. Urinalysis shows urinary nephritic syndrome (haematuria – presence of
altered and unaltered red blood cells, cylindruria [mainly hyaline and granular
casts], proteinuria), high urine specific gravity.
Clinical case 41
The patient was a 22-year-old male who presented with boring pain in lumbar region,
thirst, oedema of the whole body, enlarged abdomen, rare micturition with small
urine output, dyspnoea and weakness. In the prior two years he had also had three
hospitalizations. On physical examination patient had pale skin, anasarca and blood
pressure of 110/70 mm Hg.
1. What is the clinical diagnosis in this patient? Specify its clinical variant.
2. Specify probable changes in urinalysis in this case.
3. Specify probable contents of protein, cholesterol in blood serum in this case.
Answer pattern
1. Chronic glomerulonephritis, nephrotic clinical variant.
2. Urinary nephrotic syndrome: heavy protenuria and cylindruria (hyaline,
granular and waxy casts).
3. Dysproteinemia, hypoproteinemia, hypoalbuminemia, hyperlipemia,
hypercholesterolemia.
31
SECTION 5
DISEASES OF BLOOD
Clinical case 42
The patient was a 72-year-old male with a long-term history of autoimmune atrophic
gastritis who complained of marked weakness, fatigue, tinnitus9, dyspnoea,
palpitation and retrosternal pain during minor physical activity.
Inspection revealed pallor of skin and mucous membranes and slightly icteric
scleras, atrophy of papillae of the tongue (bald tongue). Neurological examination
showed features of lesions in posterior columns of spinal cord (numbness and
paresthesias in the extremities, ataxia).
Red blood count showed decreased number of erythrocytes and low haemoglobin
level.
1.
2.
3.
4.
5.
What is the clinical diagnosis?
What is the possible cause of this disease?
What symptoms may be found by palpation of pulse?
What are the possible findings in full blood count in this case?
List other additional methods of examination to confirm the clinical diagnosis
and specify their possible results.
Answer pattern
1. Vitamin B12-deficiency anaemia.
2. Deficiency of intrinsic factor caused by autoimmune damage of parietal cells
(Addisonian pernicious anaemia).
3. Rapid, soft, small-volume pulse.
4. Full blood count shows hyperchromic macrocytic anaemia, anysocytosis and
poikilocytosis of red blood cells, RBC with nuclear remnants (Howell-Jolly
bodies, Cabot’s ring bodies), reticulocytopenia, leukopenia and neutropenia
with a right shift, thrombocytopenia.
5. Bone marrow examination (aspiration from the sternum) reveals
megaloblastic haemopoiesis.
Biochemical examination of blood serum shows low concentration of
cobalamin (vitamin B12); mild hyperbilirubinemia and increased activity of
lactate dehydrogenase (its 1st fraction) are also may be found.
Gastric juice study confirms presence of achlorhydria.
Clinical case 43
The patient was a 27-year-old female vegetarian who had 3 children of 7, 4 and 2
years. She was delivered to the clinic after fainting. The patient complained of
dizziness, drowsiness, tinnitus, weakness, tiredness and palpitation. She noted that
9
Tinnitus is noises (ringing, whistling, booming, etc.) in the ears.
32
she had felt a desire for eating chalk.
Inspection of the patient revealed pallor and dryness of the skin, koilonychia10,
glossitis, angular stomatitis.
1.
2.
3.
4.
5.
What disease do you suspect in this case?
What are the possible causes of this disease in this clinical case?
What symptoms may be found by auscultation of the heart?
What are the probable findings in full blood count in this case?
List additional method of examination to confirm the clinical diagnosis and
specify its possible results.
Answer pattern
1. Iron-deficiency anaemia (IDA).
2. Increased requirement for iron and exhaustion of its supply in tissues (due to
pregnancies and lactations) and nutritional deficiency (due to vegetarianism).
Chronic blood loss due to menstruations contribute to development of IDA in
this patient.
3. Auscultation of the heart reveals tachycardia, loud heart sounds, functional
murmurs over heart (in all main points of auscultation), permanent Nun’s
murmur over jugular veins.
4. Microcytic hypochromic anaemia, hypochromia of red blood cells, normal
white-cell and platelets counts.
5. Biochemical study of blood confirms disorder of iron metabolism, low content
of iron, high total iron-binding capacity, low ferritin level.
10
Koilonychia is a malformation of the nails in which the outer surface is concave. Syn: spoon
nail.
33
ABBREVIATION LIST
BP – blood pressure;
COPD – chronic obstructive pulmonary disease;
CT – computed tomography;
ECG – electrocardiogram, electrocardiography, electrocardiographic;
ESR – erythrocyte sedimentation rate;
FEV1s – forced expiratory volume in 1 second;
FVС – forced vital capacity;
GI – gastro-intestinal;
IDA – iron-deficiency anaemia;
MI – myocardial infarction;
NYHA – New York Heart Association;
RBC – red blood cells.
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