Colleagues, real and virtual, present and future. In the holidays, offering fun!!! To arrange a challenge game to interesting cases from pubmeda, NEJM. Collect case studies from NEJM, the answers are direct links (I hope the copyright is not broken, because I really want beautiful, beautiful discussion and with beautiful pictures:) the Winner, who guessed right more all cases, will give the e-book, purchased personally by me:
1) 36-year-old somatically healthy pregnant (3яя pregnancy, childbirth 2nd coming) in the 37th week of pregnancy was admitted with early labor. Over the past weeks worries gradually progressive shortness of breath with obvious negative dynamics for the last day. The patient in orthopnea, chest pain denies, complains of cough with scanty mucous sputum with a pinkish tinge, increasing swelling of the lower extremities and the appearance of low-grade fever. Upon inspection of the heart rate 120 / min, respiratory rate 18 / min, BP 108/70 mm Hg.St., temperature 38 °C, ѕРО2 91% (at 3 l / min of oxygen via nasal cannula). Auscultation multiple areas of crepitate. Oak: leukocytosis is 12 000 per µl with no left shift, HB 100 g/l, platelets 150 x 10в9/ L. D-dimer 4999, CCJ, ALT, AST-normal. OAM – 50 cells in field of view, no protein, nitrite +. Radiographs of her chest
Diagnosis and management tactics.2) a 54-year-old man was hospitalized because of an acute unilateral loss of vision. A year ago she was diagnosed with Hodgkin’s lymphoma with a lesion of the l/u neck and mediastinum (conducted polychemotherapy(PCT): – doxorubicin, bleomycin, vinblastine and dacarbazine, mechlorethamine, procarbazine and prednisolone, PCTs were completed within 4 months before the appearance of symptoms ocularly, subsequent radiation therapy (RT) of the neck and mediastinum). On the morning before admission the patient noted a decrease in Central vision in the left eye and went to the optometrist: peripheral vision in the left eye and the vision in his right eye was saved, there was headache, pain in the eyes or neck, flashing lights or other visual symptoms. On examination, the visual acuity in the left eye was 20/400. The fundus examination of the left eye revealed a pale, swollen optic nerve with a small bright hemorrhages. ESR 56. It is known that PCTs and RADIOTHERAPY with good effect: complete regression of lymphadenopathy. However, chemotherapy was complicated by ongoing pancytopenia and recurrent infections (which continued after the completion PCTs) and peripheral neiropatia with numbness and paresthesias in the extremities and by decreased sensitivity. In addition, once was genital herpes with a primary lesion of the penis. Five months before eye symptoms on the body appeared a macular rash, presumably to filgrastim (filgrastim neutrophilic dermatitis). Two months before admission there were two episode of vertigo with nausea, vomiting and unsteady gait. The patient lost 20 kg since diagnosis of Hodgkin’s lymphoma. 10 years ago, the patient has already been to a neurologist where he was diagnosed with Guillain –Bar. Then there was a progressive loss of sensitivity and decreased reflexes, no muscle weakness. HIV was negative. IVIG was introduced with quick effect. The patient also had chronic back pain, a compression fracture of Th 11 and 12. In the history of appendectomy, arthroscopy of the shoulder about the injury and fracture to the lower limb. Married, office worker, quit Smoking about 10 years ago. Examination of 36.3 ° GARDEN 90/55 mm Hg.St., 71 HEART RATE, RESPIRATORY RATE 20. Testing of the visual field showed Central scotoma and the deterioration of color vision. The pupils to light react symmetrically to movements of the eyes b/o Left upper eyelid was slightly lowered. Roth spots or hemorrhages into the retina were observed. Peripheral retinal vessels b/o In the Romberg unstable. Spotted rash on forehead, chest and upper back. Biochemistry, electrolytes, chest x-ray,hemostasis, troponin is normal. Lumbar puncture – no m/o Required further examination? The diagnostic concept?3) 77-year-old man with moderate COPD were hospitalized with penuriously acute renal failure and unclear signs of progressive pulmonary edema. In the past 30 years and smokes about AG gets lisinopril, a year and a half ago he was diagnosed with rheumatoid arthritis, treatment with indomethacin and hydroxychloroquine with good clinical effect. For 6 six days before the patient was admitted to another hospital with acute-onset shortness of breath without fever. Chest x-ray showed numerous diffuse pulmonary dimming and minimal pleural effusion on the right. Set pulmonary edema and started therapy with furosemide, nitroglycerin, insufflate oxygen. Treatment with indomethacin, hydroxychloroquine and lisinopril were continued. On the second day was joined by a fever, started therapy with amoksiklava added m-cholinolytic inhalation. ECHO – left ventricular hypertrophy and mild pulmonary hypertension. Renal ultrasound normal. Added dopamine. When saving a fever and increasing shortness of breath re-x-ray: negative.
Tank blood cultures/urine no growth. The patient was transferred to multiprofile hospitals. Upon receipt of 39.6 ° C, heart rate 112, respiratory rate 50. HELL 145/85 mm Hg. Atmospheric PO2 on воздухе75%. Leukocytes 10,5 10 9 (neutrophils 91%), Platelets 519 thousand in ál, culture of blood and urine is feces no parasites, creatinine of about 700 mmol/l, potassium of 4.7. Presumptive diagnosis? The Genesis of acute kidney injury?4) a 67-year-old woman reported progressive shortness of breath for several months, three years after aortic valve replacement for aortic insufficiency presumably atherosclerotic origin, whereas other signs of atherosclerosis have been identified. The patient was in whole, somatically healthy, in addition to fairly frequent migraine headaches. During the inspection, BP 170/95 mm Hg ECHO showed a normal prosthetic aortic valve and marked thickening with severe mitral, pulmonary and tricuspid. When carrying out invasive procedures: pressure in the right atrium increased, coronary artery. Executed the replacement of three damaged valves. Performed histological examination confirmed the cause of the lesions of the valves, has also been revised preparations of the aortic valve. What could be the reason?
b)But somewhat similar picture but completely different situation. What is it?
5) a 25-year-old patient, primipara parvovirinae, 16 weeks, about a week ago returned from India, where it remained for 3 weeks. Somatic anamnesis without features. Complaints of severe nausea and vomiting for 2 days, weakness, chills, arthralgia, muscle pain, fevers to 39.6 C. Objectively: conjunctival injection of both eyes, slight pale skin and mucous membranes, AD 116 and 70 mm Hg, heart rate 140/min, the sections scarlatiniform rash (palms, knees, feet). Laboratory parameters HB 7.5 g/DL, leucocytes – of 9.2 × 10 9/l, platelets 130 × 10 9/l was seen by infectious diseases, suspected and confirmed diagnosis of Dengue. Started infuzionna therapy and NSAIDs. On the trail.the day opened with profuse uterine bleeding, diagnosed with fetal death, аbrasio cavi uteri. The sharp deterioration of within the next 48 hours: the growing pallor of the skin, the appearance of fever to 40.2 C, swelling of the face, extremities, stupor. HB of 6.9 g/DL, platelets 9 × 10в9/l, ALT 312, AST 1246 U/l, LDH more than 2000. Bilateral hydrothorax, ascites, common ekhimozy. The diagnostic concept, method, and tactics of further examination?