Approximate situational tasks (clinical cases)
Сase 1
Patient F., 43 years old, was admitted to the hospital with complaints of pain in the right half of the chest, cough with sputum, spontaneous fever, up to 39.4 ° C, chills, shortness of breath with slight exertion, general weakness. Three days ago, during the tooth extraction, he coughed violently (until vomiting), there was a heavy bleeding from the dental cavity. In the morning there was a chill, pain in the chest on the right, cough with profuse purulent sputum with an unpleasant smell, the body temperature increased to 39.4C.
The skin is pale. The right half of the chest lags behind in the act of breathing, shortening of percussion sound is determined from the angle of the scapula. The vesicular breathing in the place of shortening is weakened, there are single moist rales. The heart sounds are muffled. The pulse is 124 per minute; the blood pressure is 110/60 mm Hg.
The examination was scheduled: a general analysis of blood and urine, chest X-ray. The x-ray in the lower lobe on the right determines the infiltration of lung tissue with fuzzy contours.
Tasks and questions:
1. Highlight the main syndromes of the disease.
2. Make a diagnosis and justify it.
3. What factors contributed to the onset of the disease?
4. What microorganisms can be etiological factors of the disease in a similar situation?
5. Prescribe drugs for the treatment
Сase 2
A 53-year-old man came to the doctor with complaints of shortness of breath when going up to the 2nd floor, unproductive cough with the separation of a small amount of green sputum, general weakness, palpitations, sweating. Cough has been troubling for about 30 years. He has been smoking since he was 15. The last 10 years have been marked by the deterioration of the body’s condition. The shortness of breath has been troubling for 3 years, when going up to the second floor.
During the physical examination: breathing occurs at a frequency of 18 per minute. The chest is barrel-shaped. During the percussion of the lungs, the box sound is determined; the boundaries of the lungs are lowered to the 1st rib. The breath is weakened, the exhalation is prolonged, the scattered dry wheezes are more on the exhalation, the heart sounds at the top are weakened. The accent of the second tone is on the left of the sternum in the second intercostal space. The pulse rate is 100 beats per minute, the blood pressure is 140/90 mmHg.
Complete blood count: Hb 181 g / L, Le - 7.6 × 109/ L (e - 3, n - 1, s - 53, l - 35, m - 8), ESR 2 mm / hour. Sputum: color - green, 2-ply, Le - completely in sight, Er 0-1, ep. cells in a small number, macrophages 1-2 in sight. Acid resistant tuberculosis bacteria were not detected.
Spirography: FEV1 -51%, VC - 67.0%, FVC - 76%, FEV1/ FVC - 54%. There is a sharp decrease in the indicators of the function of external respiration in a mixed type. The bronchial obstruction is pronounced.
Tasks:
1 Make a diagnosis
2 Describe the treatment scheme.
3 Appoint the additional examination
4. Prescribe drugs for the treatment
Сase 3
The man is 60 years old. After emotional stress at work, intense compressive chest pains appeared with radiation to the neck and left arm; he had intensifying weakness and sweating. At home the condition did not improve; an ambulance crew was called.
From the anamnesis: pain in the region of the heart has been troubling for about three years. He is treated on an outpatient basis with nitrates. The last heartache happened six months ago.
Objectively: the skin is pale and sweaty. The respiratory organs are without pathology. Breathing occurs at a rate of 17 per minute. The boundaries of relative dullness of the heart are not changed. The blood pressure is 150/90 mm Hg. The heart rate is 100 beats per minute. The rhythm is correct and interrupted by extrasystoles; the tones are muffled. The tongue is clean and moist. During the palpation, the abdomen is soft and painless. The liver is not enlarged. There is no peripheral edema.
The ECG shows a pathological q wave, St segment elevation in the V1 - V3 leads and ventricular extrasystoles.
Tasks and questions:
1 Make a diagnosis and justify it.
2 What additional research is needed and for what purpose?
3 Make up the algorithm for providing emergency medical care at the prehospital stage
4 Determine the tactics of managing patients at the hospital stage.
Сase 4
The 64-year-old woman came to the dentist with a toothache. During the examination, the doctor noticed the lethargy, the patient’s drowsiness and indifference to what is happening. The patient complained of dizziness, the appearance of ‘fog’ before her eyes, a feeling of intense hunger. Soon she suddenly stopped responding to doctor’s questions.According to the accompanying son, the patient has been suffering from diabetes and getting insulin therapy for several years.
The examination shows: the patient is unconscious; the pupillary response to the light is preserved; she is overweight and has a hypersthenic body type; the skin is pale and moist; the tissue turgor is satisfactory; breathing occurs at a rate of 17 per minute; the pulse rate is 98 beats per minute; satisfactory filling and tension; the heart rhythm is correct; the tones are muffled; the blood pressure is 150/90 mm Hg; the blood sugar level is 2.8 mmol / l.
Tasks and questions:
1. What is the condition that complicates the course of diabetes, you can think of?
2. What are the causes of this complication?
3. Determine the tactics of hospital management of the patients?
Сase 5
Patient A., 55 years old, came to the dental clinic for tooth extraction. After the injection of lidocaine, the patient appeared: itching of the skin of the body, blisters on the skin, swelling of the eyelids, lips, tongue, barking cough, hoarseness, shortness of breath and, after that, stridor breathing.
Objectively: on the skin of the face, neck, body there are a lot of blisters of different sizes; there is swelling of the eyelids and narrowing of the eye slits; the tongue is increased in size.
Tasks and questions:
1. Determine the urgent condition of the patient.
2. What are the causes of this condition?
3. Make up and justify the algorithm for providing emergency medical care
Сase 6
The 35-year-old patient does not stop bleeding from the tooth extracted the day before.
From the anamnesis: long-term, difficult to stop bleeding, which occurs with minor injuries, has been observed since the childhood. With age, the tendency to bleed has decreased. Similar symptoms have been found in all maternal males.
Additional research: platelets - 220x109 / l, bleeding time according to Duke - 4 minutes, coagulation time according to Lee-White - 60 minutes. Factor VIII is absent.
Tasks and questions:
1. Highlight the main clinical and laboratory syndromes observed in this clinical case.
2. Make a diagnosis.
3. What is the mechanism of the development of symptoms observed in the patient?
4. Describe the treatment scheme.
Сase 7
Patient V., 70 years old, had a tooth filled the day before, when he celebrated his anniversary. Despite the fact that the patient did not feel well (a severe headache, general weakness), he went to the dentist, fearing that he would not have time to restore the seal within the warranty period for this seal. During dental procedures, headache and dizziness sharply increased; there was weakness in the upper and lower extremities on the left, visual impairment and dysarthria.
Objectively: there is a pale asymmetric face; the pulse rate is 78 beats per minute; the blood pressure is 100/70 mm Hg.
Tasks:
1. Make a diagnosis
2. Make up and justify the algorithm for providing emergency medical care
Сase 8
Patient M., 39 years old, had an asthma attack in the dental chair. From the anamnesis: asthma attacks and unproductive coughing are observed 1-2 times in the daytime and in the early morning hours (at 3-5 o’clock in the morning). These attacks have been bothering her for 2 years and they are more common in spring and summer. The attacks go away on their own 20-30 minutes after she gets out of bed and drinks warm water. Attacks have become more frequent for last week. During auscultation, a dry wheezing is heard in the lungs on exhalation.
Tasks and questions:
1. Make a preliminary diagnosis.
2. Make up the examination scheme.
3. What groups of drugs are used to treat this syndrome?
Сase 9
The 37 year-old patient complained of frequent irregular heartbeats, general weakness, dizziness and shortness of breath during dental procedures.
From the anamnesis: at the age of 18, the mitral heart disease was first discovered with a predominance of stenosis. He receives anti-relapse treatment systematically. In recent years he has begun to notice shortness of breath during physical exertion.
Objectively: the patient is in a serious condition. In the lungs there is vesicular breathing. The pulse rate is 138 beats per minute; pulse palpation of the radial artery determines pulse waves of various sizes and tensions. The heart rate is arrhythmic. The blood pressure is 90/50 mm Hg.
Tasks:
1. Determine the emergency condition that the patient has developed.
2. Make a diagnosis, taking into account the results of the ECG examination of this patient: the absence of the P wave, the appearance of small waves f, various distances RR.
3. Make up and justify the algorithm for providing emergency medical care.
Сase 10
During the entire time after the intramuscular injection of penicillin, the patient complained of restlessness, chest tightness, weakness, dizziness and nausea. The blood pressure is 80/40 mm Hg. The pulse rate is 120 beats per minute and it has a weak filling and tension.
Tasks:
1. Make a diagnosis and justify it.
2. Make up the algorithm for providing emergency medical care.
Сase 11
The 17-year-old patient was admitted to the intensive care unit in a coma. According to relatives, the patient complained of weakness, drowsiness, and thirst for the last 7-10 days and lost 10 kg in a month.
The examination shows: the patient is in a coma; breathing occurs at a frequency of 32 per minute and it is deep noisy; you can smell acetone in the exhaled air. The tone of the eyeballs is reduced; the tone of the muscles is reduced. The pulse rate is 120 per minute. The blood pressure is 65/40 mm Hg.
In the course of laboratory research, it was revealed: hyperglycemia (26 mmol / L), hypokalemia (3.0 mmol / L), pH - 6.9; acetonuria.
Tasks:
1. Formulate a presumptive clinical diagnosis
2. Make up the examination scheme.
3. Determine the necessary treatment measures during the first 1-3 hours of patient management
Сase 12
The 24-year-old man was delivered a day after the onset of the disease with complaints of general weakness, vomiting the color of coffee grounds. He considers himself sick from the army when he began to notice “hungry” pains in the epigastrium, which periodically occur in spring and autumn. He was treated on his own. There was deterioration in the last two weeks, when epigastric pain appeared, which decreased after taking almagel. Two days ago he noticed a tarry stool.
Objectively: the general condition is satisfactory. The skin and mucous membranes are pale pink; the pulse rate is 96 per minute and rhythmic; the blood pressure is 110/70 mm Hg. The abdomen is not swollen; on palpation there is slight pain in the epigastrium and on the right. Peristalsis is good. The patient has a dark-colored stool. In the blood: Er 3.5 x 10 / L, HB - 100 g / L.
Tasks and questions:
1. Make a diagnosis.
2. What complication is possible in the patient?
3. What necessary instrumental and laboratory examination methods should be performed?
4. Make up the algorithm of your actions.
Сase 13
Patient K., 56 years old, consulted the dentist. During the examination, the dentist noticed the emotional excitement of the patient and the patient also tried to rub the area of the sternum with his hand. The following complaints were identified: heaviness behind the sternum, radiating to the left shoulder, a feeling of lack of air. These symptoms appeared just a few minutes before the start of the dentist's appointment. From anamnesis it is known: for the last 2 years she has noticed short-term compressing, pressing pain behind the sternum when going up to the 3rd floor, walking a distance of 250 m, passing after a short rest. She denies other diseases.
On examination: the condition is relatively satisfactory. The height is 170 cm, the weight is 94 kg. The pulse rate is 88 beats per minute; the blood pressure is 140/90 mm Hg on the both hands. The abdomen is soft and painless in all departments.
In a biochemical blood test: the blood sugar level is 6.1 mmol / L, total cholesterol is 7.5 mmol / L. ECG - sinus rhythm, the deviation of the electrical axis of the heart to the left, violation of the processes of repolarization in the myocardium.
Tasks:
1. Formulate a clinical diagnosis.
2. Identify the emergency condition that the patient has developed.
3. Make and justify the algorithm for emergency care and further tactics of patient management.
Сase 14
The 40-year-old woman went to the dentist in connection with a toothache. In the process of dental manipulation, an attack of expiratory suffocation developed. According to the patient, she has noticed such attacks 2-3 times a month for 5 years. These attacks are removed by inhalation of salbutamol. The skin is physiological in color. In the lungs, there is difficulty breathing, dry wheezing and wheezing, often on the exhalation. Breathing occurs at a frequency of 20 per minute. The blood pressure is130/90 mm Hg, the pulse rate is 92 beats per minute. The abdomen is painless on palpation. The liver is not palpable.
Tasks:
1. Make a preliminary diagnosis, justify it.
2. Make up the examination scheme.
3. Describe the treatment scheme.
4. Provide the emergency care.
Сase 15
In the dentist's chair, the patient suddenly became agitated, the patient screamed, lost consciousness, turned pale, there were generalized tonic contractions of the muscles (arms bent, head thrown back, torso extended, legs unbent and tense). After a minute, the muscle tension abruptly subsided, muscle relaxation began, and then the muscles of the torso and extremities were strained again.
Objectively: bloody foam is released from the mouth.
Tasks:
1. Determine the emergency condition that the patient has developed
2. Make up and justify the algorithm of the examination and emergency care
Сase 16
The dentist is invited to consult the 21–year-old patient in the hematology department, who complains of fatigue, weight loss, subfebrile fever, a tendency to subcutaneous hemorrhage, severe pain in the mouth and pharynx. Because of the pain when swallowing, food and liquid intake is difficult. There is a lack of taste in the food, although the appetite remains.
Objectively: Local status: the mucous membranes of the mouth and pharynx are hyperemic; there is bleed when touched, the gums are ulcerated, the lingual surface of the gums is hyperplastic, the tongue is superimposed; there is purulent plaque on the tonsils.
On the limbs there are multiple small subcutaneous hemorrhages. The temperature is 37.3 ̊ С. The pulse rate is 88 beats per minute and has satisfactory qualities. The blood pressure is 120/80 mm Hg, respiratory rate of 18 per min. Blood test: Er 3.2x1012 / L, Hb 92 g / L, Tr 90x109 / L, white blood cells 30x109 / L, basophils - 0%, eosinophils -1%, blast cells - 80%, myelocytes - 1%, segmented neutrophils - 5%, lymphocytes -13%, monocytes - 0%, ESR - 42 mm / hour.
Tasks and questions:
1. What clinical and laboratory syndromes does the disease exhibit?
2. Make your preliminary diagnosis.
3. What additional research is needed?
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выпускников по специальности «Стоматология»
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3. Острые и хронические лейкозы: миелолейкозы, лимфолейкозы, эритремия. Критерии диагностики. Дифференциальная диагностика. Лечение.
4. Агранулоцитоз. Лечебная тактика врача-стоматолога.
5. Ишемическая болезнь сердца. Классификация ВОЗ. Клиника, диагностика, лечение стенокардии. Тактика врача-стоматолога при возникновении приступа стенокардии в стоматологическом кресле.
6. Острый инфаркт миокарда. Клиника. ЭКГ признаки. Тактика врача-стоматолога при подозрении на развитие инфаркта миокарда в стоматологическом кресле.
Лечение.
7. Острые пневмонии. Классификация, особенности этиологии внебольничных и нозокомиальных пневмоний. Значение одонтогенной инфекции. Лечение пневмоний. Диагностика осложнений пневмоний, неотложные мероприятия.
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9. Язвенная болезнь желудка и 12-перстной кишки. Значение хеликобактерной, одонтогенной инфекции в развитии язвенной болезни. Диагностика. Лечение. Диагностика и лечение неотложных состояний, связанных с осложнениями язвенной болезни.
10. Хронические гепатиты, цирроз печени. Классификация. Диагностика, основные лабораторные синдромы поражения печени. Лечение. Особенности оказания стоматологической помощи. Диагностика и лечение неотложных состояний, связанных с циррозом печени.
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12. Инфекционный эндокардит. Этиология, значение заболеваний полости рта. Клинические проявления (по стадиям). Лечение. Особенности оказания стоматологической помощи в рамках профилактики инфекционного эндокардита.
13. Гипертонические кризы. Диагностика. Тактика врача-стоматолога при возникновении криза в стоматологическом кресле.
14. Аритмии и блокады сердца. ЭКГ признаки. Неотложные мероприятия при возникновении пароксизмальных аритмий в стоматологическом кресле.
15. Дифференциальная диагностика при шоках различного генеза (анафилактический, болевой, септический и др.). Этиология. Клиника. Неотложная помощь.
Тактика врача-стоматолога при развитии шока в стоматологическом кресле.
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17. Осложнения острого гломерулонефрита. Неотложная помощь.
18. Гипергликемическая кетоацидотическая и гипогликемическая комы. Дифференциальный диагноз. Тактика врача-стоматолога при развитии комы в стоматологическом кресле. Профилактика.
19. Тиреотоксический криз. Неотложные мероприятия.
20. Респираторный дистресс-синдром и отек легких. Этиология. Диагностика. Лечение.
21. Диагностика и неотложная помощь при ТЭЛА.
22. Дифференциальная диагностика при болях в груди. Тактика врача-стоматолога при возникновении боли в области сердца.
23. Дифференциальная диагностика при синкопальных состояниях. Неотложная помощь.
24. Дифференциальная диагностика при судорогах. Неотложная помощь.
25. Дифференциальная диагностика при лихорадочном синдроме. Неотложная помощь.
26. Дифференциальная диагностика анемий. Лечение анемий.
27. Внезапная смерть. Диагностика. Алгоритм проведения реанимационных мероприятий на догоспитальном этапе.
28. Дифференциальная диагностика при абдоминальном синдроме. Тактика врача-стоматолога при абдоминальном синдроме.