Station № 3
"Management of emergency conditions in the clinic of internal
medicine."
Situational task 1
Patient V., male, 56 years old. The patient is treated in the cardiology
department. The patient has dilated cardiomyopathy. The patient suddenly
lost consciousness in the corridor of the department. Non-smoker. Alcohol
does not abuse.
Objectively. The general condition is very serious: the patient is noncontact, does not answer questions, there is no pulsation on the carotid
arteries, there is no breathing. Blood pressure is absent.
ECG: Isoline, QRS absent.
Tasks:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Sudden cardiac death
Asystole
Tactics:
CPR 30:2
Intubation
Oxygen therapy
Intravenous or intraosseous access
Epinephrine 1mg (1-3 mg), every 3-5 minutes + CPR
Situational task 2
Patient A., female, 58 years old. An emergency medical team is called
to the patient. The patient has an intense headache in the occipital region,
numbness of the left hand and slow speech. The patient had high blood
pressure 170/95 mm Hg. She did not take medication regularly, occasionally
- captopril. Complaints appeared after stress at work.
Objectively. The general condition is severe, inhibited. Hypersthenic
patient. The body mass index is 35.5 kg /m2. The skin is clean. S1 is
moderately weakened at the apex of the heart. Aortic accent of S2. Above
the lungs - vesicular breathing. Abdomen is soft, painless. Body
temperature: 36.5 ° C
ECG: rhythm is sinus, 80/min. P-Q - 0.14 msec, QRS - 0.09 msec, Q-T 0.36 msec. Left ventricular hypertrophy.
MRI of the brain: ischemic stroke of the right hemisphere of the brain
Tasks:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Arterial hypertension 3rd stage, 3rd degree
Emergency hypertensive crises
Ischemic stroke
Tactics:
Hospitalization and thrombolysis (Alteplase)
Neuroprotection (citicoline)
Control of glucose level and body temperature
Target level of BP: 185/100 (decrease not more than 25%)
Drugs:
Labetalol (Beta-Blocker)
Enalaprilat (ACE inhibitor)
Urapidil (Alpha adrenoreceptor inhibitor)
Nicardipine (Calcium channel blocker)
Situational task 3
Patient I., man, 42 years old. An ambulance team were called to the
patient. The patient complained to intense headache in the occipital region,
flashing "flies" before the eyes, dizziness. In the anamnesis patient had
hypotermia and acute pharyngitis 2 weeks ago. 2 days ago appeared edema
under the eyes, decreased urine excretion to 700 ml and changed color of
urine - "meat mud".
Objectively. The general condition is severe. The patient is having
convulsions during the examination. The skin is clean. In the lungs vesicular
breathing. Borders of the heart are not changed. Abdomen is painless.
Pasternacky symptom is negative. Body temperature: 36.5°C. Respiratory
rate: 20/min. Heart beat: 88/min., rhythmical. Blood pressure 245/130 mm
Hg
Urinalysis:
Indicator
Color
Reaction
Specific gravity
Protein, g/L
Sugar
WBC, in visual field
RBC, in visual field
Epithelial cells, in sight
Cylinders (microscopy), in
sight
Result
meat slop
7,5
1.021
0,099
absent
3-4
40-50
single
absent
Reference values
straw yellow
4,6-8,0
1.010-1.025
absent
absent
for man 0-5
for man 0-1
0-10
absent
ECG: rhythm is sinus, HR 86/min. PQ - 0.16 msec, QRS - 0.09 msec, QT 0.36 msec. Nonspecific diffuse changes in the left ventricle.
Tasks:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a group of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Acute glomerulonephritis
Nephritic syndrome
Secondary arterial hypertension
Emergency hypertensive crisis
Eclampsia
Tactics:
Sibazon / Diazepam (benzodiazepines)
Target BP: 150/100 or 140/100
Labetalol (beta blocker)
Urapidil (Alpha adrenoreceptor inhibitor)
Magnesium Sulfate (I/V)
Furosemide 40-80mg (I/V) or Torsemide 4mg (I/V)
Situational task 4
Patient M., 62 years old, called the ambulance for complaints of headache,
shortness of breath, turning into suffocation, pressing pain in the heart area.
This condition developed acutely 30 minutes ago after severe stress. The
patient has taken captopril 25 mg.
Anamnesis: hypertension in the last 6 years. The patient constantly takes
antihypertensive drugs (ACE inhibitor (enalapril 20 mg) and diuretic
(hydrochlorothiazide 12.5 mg)).
Physical examination: patient's condition is grave. The patient is agitated,
scared, breathes heavily, half-sitting position in bed. Pulse - 92/min,
rhythmic. Auscultation: SI is soft, accentuation of SII on the pulmonary
artery, additional SIII (gallop rhythm). BP - 180/120 mm Hg. Lungs
percussion - shortening of percussion sound over the lower parts of the lungs,
auscultation - moist fine rales and decreased vesicular breathing over the
lower parts of the lungs. Respiratory rate - 20 / min. Examination of the
abdomen - no pathological changes were found. Peripheral edema is absent.
ECG. Sinus rhythm, heart rate 94 / min. Left axis deviation. Signs of left
ventricular hypertrophy (RV5 and RV6> RV4; SV1 + RV6> 35 mm). In the
left chest leads V5, V6 - ST segment depression 2 mm below the isoline.
Troponin I - 0.25 ng / ml (N <0.5 ng / ml).
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Arterial hypertension 3rd stage, 3rd degree
Emergency hypertensive crises
Complicated by pulmonary edema (Killip 3 rd stage)
Tactics:
Hospitalization
Target BP: 25% decrease during the first hour
Nitroglycerine (I/V), Nitroprusside (I/V)
Furosemide 40-80mg (I/V) or Torsemide 4mg (I/V)
Oxygen therapy
Situational task 5
Patient S., 52 years old, man, driver.
The ambulance was called due to the prolonged (lasts 30 minutes) intensive
burning pain behind the sternum with irradiation in the epigastric area.
Admission of nitroglycerin was no effective. The pain arose acutely during
exercise.
Anamnesis - no previous cardiac complaints. Smoker 25 years.
Physical examination. General condition of moderate severity, patient is
excited. Pulse - 94 per minute, rhythmic. Heart sounds are rhythmic; SI is
soft. BP - 140/70 mm Hg. Examination of the lungs and abdominal organs no pathological changes. Peripheral edema is absent.
ECG. In leads II, III, and AVF - elevation of the ST segment on 4 mm above
the isoline.
Troponin I - 1.20 ng / ml (0.04 ng / ml - norm).
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Acute coronary syndrome
STEMI
Acute stage
Posterior wall
Cardiogenic shock (BUT in normal circumstances BP should be lower than
90/60)
Tactics:
Hospitalization in PCI (Pre Cutaneous Intervention) center PCI
Thrombolytic therapy
(tenecteplase, Streptokinase and Metalisa)
(Shock therapy) Dobutamine and dopamine
Noradrenaline (vasopressin)
Oxygenation
Morphine
Aspirin (300mg) and Clopidogrel (600 mg)
Heparine or enoxiparine (I/V)
Situational task 6
Patient M., 53 years old, called the ambulance for complaints of
headache and pressing pain in the heart area. These complaints appeared
suddenly 20 minutes ago after severe stress. The patient has taken captopril
25 mg and nitroglycerin 0.5 mg, but his condition did not improve.
Anamnesis: hypertension in the last 3 years. The patient periodically took
antihypertensive drugs (i-ACE (lisinopril 20 mg)) with an increase of BP.
Physical examination: patient's condition is moderate severe, "fear of
death." Pulse - 90 / min, rhythmic. Heart auscultation - SI is soft, aortic
accentuation of SII. BP - 180/110 mm Hg. Respiratory rate - 18 / min. SpO2
- 90%. Examination of the lungs and abdominal organs revealed no
pathological changes. Peripheral edema is absent.
ECG. Sinus rhythm, heart rate 90 / min. Left axis deviation. Signs of left
ventricular hypertrophy (RV5 and RV6> RV4; SV1 + RV6> 35 mm). In the
chest leads (V1 - V6) - ST segment depression 2 mm below the isoline,
negative T wave.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS
Diagnosis:
Arterial hypertension 3rd stage, 3rd degree
Emergency hypertensive crises
Acute coronary syndrome
NSTEMI ?
Tactics:
Hospitalization and check troponin level
Nitroglycerine
Morphine (OS or I/V)
Oxygenation
Labetalol, metoprolol (Beta Blockers)
Aspirin 300 mg or clopidogrel 600 mg
Simvastatin, atorvastatin, rosuvastatin (Statin therapy)
Ramipril Enalepril (ACE inhibitors)
Situational task 7
Patient K., 72 years old, was admitted into the department of arrhythmias.
Complaints. Shortness of breath with mild physical exertion, frequent
dizziness, general weakness
Anamnesis myocardial infarction 2 years ago.
Physical examination: during the examination, the patient lost consciousness
several times with the appearance of clonic seizures. Pulse: 30 beats/ min.
rhythmic. BP: 140/60mmHg. Auscultation: the souds of the heart are soft,
but periodically a single S1 areintensified. Auscultation of the lungs – the
vesicular breathing. The liverpalpated on 3 cm belowe costal edge. Legs
edema
ECG: rhythem is non-sinus, regular, RR rate 30 bearts/min. PP rate – 75
beats/min P-P interval are the same, sometimes wave P is superimposed onto
T wave, ventriucalr complexes duration – 0.14 sec
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Ischemic heart disease
Post MI
Complete AV block
Morgagni Adams stroke Syndrome
Tactics:
Hospitalize in the ICU
Pacemaker placement
Atropine (subcutaneous???)
CPR if sudden cardiac death
Situational task 8
Patient M., 65 years old, an ambulance team was called for complaints of
sudden shortness of breath, pain in the chest, an episode of loss of
consciousness. This condition has developed acutely.
Anamnesis: a month ago patient had a fracture of the right tibia.
Immobilization was carried out by gypsum bandage.
Objectively: the condition is extremely severe, shortness of breath, RR - 25
/ minute, horizontal position, light diffuse cyanosis. There is no swelling of
the neck veins. Pulse - 112 / min, rhythmic, weakened ("filiform"). BP 80/60 mm Hg, Auscultation of the heart: S 1 - soft, accent of S II over a.
pulmonalis. Examination of the lungs and abdomen - without pathological
changes. Peripheral edema is absent.
ECG: sinus rhythm, heart rate 115 / min. Right axis deviation. Deep waves
QIII and SI. Incomplete block of the right branch of the bundle of His.
Troponin I - 1.0 ng / ml (N <0.5 ng / ml).
SaO2 - 89% (N> 95%).
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Pulmonary embolism
With shock
Tactics:
Hospitalization in the ICU
Thrombolytic therapy (tenecteplase, Streptokinase)
Morphine (for pain and shortness of breath
Noradrenaline and Adrenaline (for shock)
Oxygen therapy
Papaverine, Theophylline and Drotaverine (all I/V)
Heparin or amoxivarine (I/V)
Situational task 9
Patient K, 25 years old, felt a significant palpitations and weakness during
training in the gym. Such attacks arose a few times earlier and resolved
spontaneously without treatment.
Objectively: BP - 120/80 mm Hg. Heart rate - 180 beats / min., rhythmic,
satisfactory filling. Auscultation of the heart – sounds are not changed,
regular, tachycardia. Examination of other organs - no pathological changes.
ECG: the wave P is not found, QRS - 0.08 sec, RR intervals are identical,
heart rate - 180 beats / min.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Supraventricular paroxysmal tachycardia
Tactics:
Vagal maneuvers
If not effective:
Adenosine
Verapamil (Calcium channel blocker) Or Metoprolol (Beta blockers
Amiodarone (anti arrhythmic)
If none of the above worked:
Electrical cardio version
Situational task 10
Patient S., 65 years of age, who was on a hospital treatment for CAD, stable
angina, complains of palpitations, severe weakness, shortness of breath. The
palpitations arose suddenly 30 minutes ago at rest. Earlier such attacks arose
shortly, resolved spontaneously.
Objectively: patient's condition is grave. Skin of normal color. Pulse
rhythmic, heart rate 180/min. BP 80/40 mm Hg. Heart sounds are rhythmic,
SI is soft. Examination of the lungs and abdominal organs - no pathological
changes. Peripheral edema is absent.
ECG - heart rate 180 per min., wave P is absent, RR intervals are identical,
QRS complex 0.14 sec.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Ischemic heart disease coronary artery disease
Stable angina
Paroxysmal ventricular tachycardia
Arrhythmogenic shock
Tactics
Electrical cardioversion
Dopamine IV / Noradrenaline
Amiodarone Lidocaine or Propafenone
For prophylaxis:
Amiodarone or Propafenone or Sotalol
Situational task 11
Patient M., 28 years old.
Complaints: periodic heartbeat attacks accompanied by dizziness. Patient
twice lost consciousness for a few seconds. On previous ECGs the
prolongation of the QT interval to 0.52 sec.was fixed. Medication treatment
was not received.
During the next attack on ECG: rhythm is sinus, irregular. Frequent early (R
on T) ventricular extrasystoles. Frequent episodes of polymorphic (twisted,
Torsade de pointes) tachycardia of varying durations.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a group of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Prolonged QT interval
Ventricular extra systoles (5th class by Lown classification)
Ventricular tachycardia torsade de pointes
Syncope
Tactics
Magnesium sulfate IV
Isoptin (Calcium channel blocker) or Metoprolol (beta blockers)
Implantable cardioverter-defibrillator
Defibrillation for thermodynamically Unstable patient
Situational task 12
Patient K., aged 68, complains of palpitations, a feeling of interruptions in
the work of the heart during 12 hours, shortness of breath during exercise.
Anamnesis - pain behind the sternum during significant physical activity of
up to 5 minutes. Patient was treated from stable angina and hypertension.
Earlier such attacks arose shortly, resolved spontaneously. These
palpitations arose suddenly after physical overload.
Objectively. General condition of moderate severity. Skin of normal color.
Pulse arrhythmic, average Heart rate 120 /min. BP - 130/70 mm Hg. Heart
sounds are arrhythmic, SI is soft. Examination of the lungs and abdominal
organs - no pathological changes. Peripheral edema is absent.
ECG - heart rate 100-150 per min., wave P is absent, there are waves f,
different intervals RR, electrical alternation of the waves R.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Ischemic heart disease
Stable angina (second functional class of angina)
Myocardial sclerosis
Arterial hypertension
Atrial fibrillation
Tactics
Emergency care
Amiodarone IV,
Propafenone
Flecainide
Prophylaxis:
Anticoagulants (Warfarin 3-5 mg daily) or Rivaroxaban 20mg daily
Anti-arrhythmic: Amiodarone or Propafenone or Sotalol
Situational task 13
Complaints cannot be collected from the patient due to lack of
consciousness. It was discovered in a state of a lack of consciousness by a
police officer at night in the cabin of a lorry with a running engine. The
ambulance team is called.
Objectively: no consciousness. Pupils react to light extremely weakly. The
face is bright red. On the skin of the legs, the bladder with serous contents
(5x6 cm) resembles burning of the 2nd degree. Breathing is frequent,
periodically by the type of Cheyenne Stokes. Pulse 112 per minute frequent
extrasystole. Blood Pressure 60/35 mm. Tones of the heart are sharply
weakened. Tumor reflexes are high, uniform, sharp rigidity of muscles,
bilateral symptom of Marinesco.
erythrocytosis,
elevated
hemoglobin,
hematocrit
and
CBC:
carboxyhemoglobin levels were detected.
ECG: rhythm sinus, decrease of the wave R in all leads, interval S-T
displaced from the isoline in the chest, the wave T is two-phase.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a group of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Acute Carbone monoxide intoxication
Severe degree
Tactics
Extract the patient from incident site
Hospitalization
Oxygen therapy
Normobaric 100% oxygen
Hyperbaric oxygenation
Antidote therapy
Acizole 2-4 time daily
Situational task 14
The patient is hospitalized for community acquired pneumonia. Ceftriaxone
was assigned. After the second injection of ceftriaxone, the patient's
condition deteriorated suddenly. Complaints: sudden general weakness, a
feeling of dyspnea, the appearance of itching.
Objectively: the patient is pale, the skin is moist. BP - 60/20 mm. Hg. The
pulse on the peripheral arteries is not determined. Respiratory rate 25/min.
Oxygen saturation 86%.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Anaphylactic shock
Allergic reaction for Ceftriaxone
Tactics:
Stop using Ceftriaxone
Epinephrine IV
Dexamethasone
Noradrenaline or Dopamine
Suprastin or Tavagil IV (anti histamine)
Situational task 15
Patient H., female, 27 years old, was delivered to a therapeutic department.
Complaints: general weakness, fever, cough with rusty sputum. The
deterioration occurred 2 days ago after overcooling.
Objectively: the general condition is severe, the skin is pale. Body
temperature 38.2С, oxygen saturation 88%, respiration rate 25 / min. Pulse
is 120 bpm, rhythmic. BP 80/60 mm Hg. Auscultation: over the lower parts
of lungs - vesicular breathing is weakened, fine rales and crepitation are
heard. No other pathological changes were detected.
Chest X-ray: infiltration of pulmonary tissue of lower parts of both sides to
the level of the sixth rib.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming drug’s groups and representatives according to a modern algorithm.
ANSWERS:
Diagnosis:
Community acquired pneumonia
Bilateral
Septic shock 4th clinical group
Tactics
Hospitalization in the ICU
Antibiotic therapy:
Ceftriaxone or ceftazidime or cefepime
Levofloxacin (fluroquinolone)
Normal saline or lactate Rangel solution |(IV)
Dopamine or noradrenaline
Dexamethasone (IV) (steroids)
Enoxaparin (anti coagulants)
Situational task 16
Patient H. arrived at the hospital with complaints of pain in the epigastrium,
dizziness, palpitations, shortness of breath, nausea, flicker of flies in front of
the eyes, tinitus and a significant general weakness that developed after two-
time vomiting by the “coffee ground» and black diarrhea that began around
24 hours ago. The pain decreased slightly after vomiting.
The patient suffered a stomach ulcer for many years.
Objective examination: the patient is in the consciousness, the skin is
sharply pale, BP - 85/55 mm Hg., Pulse 100 / min, rhythmic, reduced
fullness. Heart sounds are rhythmic. Breathing is vesicular. The tongue is
clean and moist. The abdomen is moderately painful and tense locally in the
epigastrium. Mendel`s sign is positive. Hourly diuresis: 30 ml / h. Oxygen
saturation of art. blood is 95%.
At rectal examination: a black liquid faeces on a glove ("melena").
FGDS: acute ulcer of small curvature of the stomach in diameter of 2 cm,
with signs of ongoing bleeding.
Blood tests:
Indicator
Indicator Output
Reference values
12
RBC
2,85х10 /L
4.5*1012-5.5*1012/L
Hemoglobin
95 g/L
120-140 g/L
9
Platelets
240*10 /L
180*109-320*109/L
WBC
7,1х109/L
4.0*109 -9.0*109/L
ESR
20 mm/h
< 10 mm/h
Hematocrit
25
> 30
APTT sec
20
25,4-38,4
Fibrinogen g/l
4.5
2.0-4.0
H. pylori antigen was detected by PCR In the feces.
Central venous pressure – 4,0 sm Hg.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Peptic ulcer disease
Duodenal ulcer (Gastric ulcer???)
Complicated by GI bleeding, moderate degree
Tactics:
Hospitalization in the ICU or surgical department
FGDS for diagnosis and treatment purpose
Hemostatics:
Aminocapronic acid
Transmic acid
Ethamsilab sodium
Fluids
Normal saline
PPIs
Pantoprazole or Omeprazole
Situational task 17
Patient B., female, 38, complains of an attack of suffocation, which arose
after the inhalation of dyes. Inhalation of salbutamol in a dose of 100
micrograms did not lead to improve condition.
Anamnesis: during the last 3 years - attacks of suffocation and dry cough up
to
2-3 times per month, which appears due to inhalation of dyes and dust.
Patient does not receive permanent treatment. Periodically she takes
inhalations of salbutamol.
Objectively: diffuse cyanosis, respiratory rate 32 / min, oxygen saturation
78%,
pulse 110 beats /min., BP 140/80 mm Hg. Lungs auscultation - hard
vesicular breathing, a large number of whistling wheezes (wheezing) over
the entire surface of the lungs. The heart sounds are covered with
wheezing. Other physical data – without pathological changes.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a
group of drugs and a representative according to an existing algorithm.
ANSWERS:
Diagnosis:
Bronchial asthma
Moderate persistent
Acute asthma exacerbation
Tactics:
Hospitalization to the ICU or pulmonology department
Oxygen up to 95%
Gluccocorticosteroids (IV)
Dexamethasone
Prednisolone
SABA
Salbutamol
Inhaled corticosteroids
Budesonide
Anticoagulants
Enoxaparin
Theophylline
Fluids (IV) 1-2L daily
Situational task 18
The patient M., male, 64 years old, was examined by an ambulance team.
Patient is unconscious, 8-9 points according to Glasgow Coma Scale (GCS)
(Moderate, GCS 8 or 9–12).
Objectively: the skin and visible mucous membranes are pale with a
yellowish colour. The sclera’s are icteric. Pulse - 100 beats / min., rhythmic,
BP 110/80 mm Hg. Heart auscultation - S 1 is soft. Lungs auscultation vesicular breathing. The abdomen is enlarged at the expense of free fluid.
The lower edge of the liver is dense, painless, + 10 cm from the edge of the
ribs' arc.
Laboratory examination: a significant increase in the total bilirubin values
due to direct; and significant increase in ALT and AST values.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
Liver cirrhosis of unknown etiology
Class C according to child PUGH
Portal hypertension 2nd degree
Ascites
Hepatic encephalopathy 3rd degree
Tactics:
Hospitalization in the ICU
Diuretics
Furosemide
Spironolactone
Lactulose
Antibiotics
Ciprofloxacin
Rifaximin
Amino acids
Glutargine
Ornithine
Aspartate
Situational task 19
Patient A., 46 years old, was admitted to the emergency department
unconscious. It is known that he has diabetes mellitus for 14 years, received
insulin as the treatment for his disease.
The day before admission, the patient felt good. He had insulin injection in
the evening before; also, it is known that he had no dinner. The patient did
not wake up in the morning.
Objectively: no consciousness. The skin is warm and moist. The pupils are
dilated. The tone of the eyeballs is elevated. The pulse is 86 beats per minute,
rhythmic, average. BP 125/80 mm Hg. The heart tones are loud. During the
auscultation the breathing is vesicular. The tongue is wet and clean. The
abdomen is soft. Meningeal symptoms are negative.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
DM type 1
Hypoglycemic coma
Tactics:
Glucose 40% (20-80ml) fast
Glucagon 1mg IM
Adrenaline 0,18% 1ml IM
Prednisolone 3% 60mg or Hydrocortisone 100 mg IV
Glucose 10% (400ml IV)
Situational task 20
Patient D., 28 years old, during last month began to feel excessive thirst after
stress (drank up to 6-8 liters of fluid per day), had frequent urination as well
as weight loss (lost 10 kg per last month).
The patient was admitted to the hospital with general weakness, nausea,
vomiting with blood addition, pain in the epigastric area.
Objectively. The general condition of the patient is moderate. Weight 68 kg,
height 174 cm. A patient is conscious, answers the questions with delay. The
skin is dry; the patient has acetone smell from the mouth. Pulse rate: 94 per
minute, rhythmic. During the auscultation the breathing is vesicular. BP
105/65 mm Hg. The heart tones are muffled. The tongue is dry and red. The
abdomen is soft, painful in the epigastric and right subcostal area. The liver
is enlarged (+ 3 cm).The patient has no edema.
Task:
1. Formulate a preliminary diagnosis.
2. Identify patient management tactics and provide emergency care by
naming a groups of drugs and a representative according to an existing
algorithm.
ANSWERS:
Diagnosis:
DM type 1
Ketoacidosis first degree
Tactics:
Insulin 4-6 units IM every 2 hours
Normal saline 500-1000 mL (IV)
Potassium chloride 7.5% 20-40 ml (IV)
Thiosulfate sodium 30% 10ml (IV)