Question

Patient J., a 65-year-old man, has complaints of dyspnea, palpitation, fatigue during ordinary physical activity.

History: at the age of 59 the patient had myocardial infarction. For the past year he started to feel dyspnea, palpitations during intense physical activity at first, but lately it bothers him even during ordinary physical activity. He decided to make an appointment with his local GP because of that.

Anamnesis vitae: grew and developed normally. Past surgical history is unremarkable. The family history is significant for ischemic heart disease. He denies illicit drug use. Drinks in moderate amounts occasionally. The patient denies smoking.

Upon examination: satisfactory condition. The patient appears appropriate for his stated age, and is alert and oriented to person, place, and time. Skin is found to be pale, without edema present. BMI is 29,35 kg/m 2. Temperature is 36.8 C. Auscultation of the lungs: vesicular lung sound, fine crackles over posterior lung bases. Respiratory rate is 18 per minute. Cardiac sounds are rhythmic, no murmurs, the heart rate is regular, 76 beats / min. BP 125/95 mm Hg. The abdomen is soft without palpable masses or organomegaly. No signs of peritoneal irritation. Peripheral arterial pulses are normal.

Blood analysis: hemoglobin 15,4 g / dL, RBC - 5.1 × 1012 / L, WBC - 6.9 × 109/ L, ESR - 9 mm / h

Biochemical profile: urea – 5,6 mmol/L, creatinine – 0,92 mg/dL, total protein – 7,2 g/dL, cholesterol – 301 mg/dL ,HDL – 30 mg/dL, TG – 89 mg/dL, LDL -185 mg/dL, AST – 22 U/L, ALT – 22 U/L, glucose - 5,8 mmol/L

Urinalysis: normal.

Echocardiography: LV size is 63 mm. Average thickness of the left ventricle is 10 mm. EF is 50%. Akinesia is seen in the region of the old MI.

Questions.

1. Formulate a preliminary diagnosis, justify your answer.

2. List the necessary additional examination methods to clarify the diagnosis, justify your choice.

3. Assign treatment by specifying the groups of drugs, with an example of a drug and its prescribing scheme.

4. With what diseases it is necessary to conduct a differential diagnosis. List the main diseases and a list of distinctive clinical and laboratory indicators​

Answer 1

Question:

Patient J., a 65-year-old man, has complaints of dyspnea, palpitation, fatigue during ordinary physical activity.

History: at the age of 59 the patient had myocardial infarction. For the past year he started to feel dyspnea, palpitations during intense physical activity at first, but lately it bothers him even during ordinary physical activity. He decided to make an appointment with his local GP because of that.

Anamnesis vitae: grew and developed normally. Past surgical history is unremarkable. The family history is significant for ischemic heart disease. He denies illicit drug use. Drinks in moderate amounts occasionally. The patient denies smoking.

Upon examination: satisfactory condition. The patient appears appropriate for his stated age, and is alert and oriented to person, place, and time. Skin is found to be pale, without edema present. BMI is 29,35 kg/m 2. Temperature is 36.8 C. Auscultation of the lungs: vesicular lung sound, fine crackles over posterior lung bases. Respiratory rate is 18 per minute. Cardiac sounds are rhythmic, no murmurs, the heart rate is regular, 76 beats / min. BP 125/95 mm Hg. The abdomen is soft without palpable masses or organomegaly. No signs of peritoneal irritation. Peripheral arterial pulses are normal.

Blood analysis: hemoglobin 15,4 g / dL, RBC - 5.1 × 1012 / L, WBC - 6.9 × 109/ L, ESR - 9 mm / h

Biochemical profile: urea – 5,6 mmol/L, creatinine – 0,92 mg/dL, total protein – 7,2 g/dL, cholesterol – 301 mg/dL ,HDL – 30 mg/dL, TG – 89 mg/dL, LDL -185 mg/dL, AST – 22 U/L, ALT – 22 U/L, glucose - 5,8 mmol/L

Urinalysis: normal.

Echocardiography: LV size is 63 mm. Average thickness of the left ventricle is 10 mm. EF is 50%. Akinesia is seen in the region of the old MI.

Questions.

1. Formulate a preliminary diagnosis, justify your answer.

2. List the necessary additional examination methods to clarify the diagnosis, justify your choice.

3. Assign treatment by specifying the groups of drugs, with an example of a drug and its prescribing scheme.

4. With what diseases it is necessary to conduct a differential diagnosis. List the main diseases and a list of distinctive clinical and laboratory indicators​

Answer:

1.

Chronic heart failure can present with worsening dyspnea and hypoxemia, and restrictive changes on PFTs are consistent with CHF. However, historical and examination findings supportive of a diagnosis of CHF, including orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, extra heart sounds, and peripheral edema, were all notably absent. Digital clubbing is uncommon in patients with CHF. Alveolar and interstitial infiltrates may be seen on radiographs in patients with CHF, but cardiomegaly and pleural effusions are commonly present. Both constrictive bronchiolitis and chronic obstructive pulmonary disease often present with progressive dyspnea and low Dlco, as found in this patient, but both typically cause obstructive, not restrictive, changes on PFTs, making these 2 diagnoses unlikely. Interstitial lung disease encompasses a number of diseases that present as worsening dyspnea and dry cough. Physical examination reveals dry bilateral crackles on chest auscultation and clubbing of the fingers secondary to chronic hypoxia. Chest imaging classically shows bilateral interstitial infiltrates. Interstitial lung disease presents as a restrictive pattern on PFTs, and arterial blood gas values usually reveal profound hypoxia and increased alveolar-arterial gradient. Our patient's history of progressive dyspnea, dry crackles, and digital clubbing on examination, as well as restrictive changes on PFTs, diminished Dlco, and chest infiltrates, made ILD the most likely diagnosis. Acute eosinophilic pneumonia may cause restrictive changes on PFTs and radiographic changes similar to those seen in this patient. However, AEP presents as an acute febrile illness with associated dyspnea and cough of less than 3-weeks duration.

Because ILD has many causes, we thought further testing was necessary in this patient to confirm and better characterize the disease.

2.The physical examination continues the diagnostic process, adding information obtained by inspection, palpation, percussion, and auscultation.

3. Anaesthetics, preoperative medicines and medical gases.

Medicines for pain and palliative care.

Antiallergics and medicines used in anaphylaxis.

Antidotes and other substances used in poisonings.

Anticonvulsants/antiepileptics.

Anti-infective medicines.

Antimigraine medicines.

Immunomodulators and antineoplastics.

4. For example, many infections cause fever, headaches, and fatigue. Many mental health disorders cause sadness, anxiety, and sleep problems. A differential diagnosis looks at the possible disorders that could be causing your symptoms.

Mark me as brainllist.