CLINICAL CASE 1

At the 68-year-old hypertensive patient on the 5th day after gastrectomy, the clinical condition
suddenly worsens. At the patien appeared severe dyspnea, tachypnea (> 32 breaths / minute),
with central and peripherial cyanosis, hypotension (T / A 80/60 mm Hg), tachycardia (110 beats /
minute), with rhythmic cardiac tones, right ventricular gallop and chest pain. Patient is suffering
from obesity, gastrectomy was made for gastric carcinoma.

1. Arrange the presumptive diagnosis.

2. Сonfirm presumptive diagnosis based on the history of the disease, patient complaints,
results of the objective exam, presented in the statement of this clinical case.
3. With what pathology entities must be performed differential diagnosis?
4. What are the peculiarities of clinical examination and what additional maneuvers will be
performed to confirm the diagnosis?
5. Write the laboratory investigations that may be useful in determining the final diagnosis.
6. What type of imaging methods of investigation could confirm the final diagnosis?
7. Describe the expected results from the laboratory and instrumental investigations. Please,
formulate definitive diagnosis.
8. Develop the programm of treatment (management) for this clinical case.
9. What are the principles of medicamentous treatment in this disease? Describe surgical
management depending on the clinical evolution and disease severity.
10. Prescribe the recipe of some medication which are used in the treatment of this
pathology.

1. pulmonary embolism
2. The sudden onset of severe dyspnea, tachypnea, cyanosis, hypotension, tachycardia, chest
pain, and right ventricular gallop makes the diagnosis of pulmonary embolism highly
suspect, especially in patients with a history of gastrectomy and obesity.
3. Differential diagnosis should be made with MI, pneumonia, pneumothorax, ARDS,
exacerbation of COPD.
4. Additional procedures may include ABG measurements, ECG, CXR, CT, pulmonary
angiography.
5. Laboratory tests: D-dimer, arterial blood gas analysis, troponin levels.
6. CT, pulmonary angiography, and ventilator perfusion scans.
7. hypoxemia, respiratory alkalosis, right ventricular strain, and pulmonary artery occlusion
may be informed from the tests.
8. Treatment of PE - anticoagulant therapy with heparin / low molecular weight heparin
followed by long-term oral anticoagulants for 6 months.
9. Surgical management depends on the clinical evolution and severity of the disease.
 CAZ CLINIC 2

Patient M.V., aged 70 years, was presented in the emergency department with severe
periombilical pain, vomiting, flatulence. From the history of the disease it is apparent that the
patient is under cardiology treatment with blockers of the conversion enzyme of generation II
during 8 years. For 4 days before presenting in emergency service the patient presented 5
diarrheic stools, diffuse abdominal pain, that was explained as an acute enterocolitis.
Subsequently, 24 hours before admission, the patient presented bilious vomiting and then with
fecaloid content, absence of bowel movements, abdominal pain. At the hospitalization day the
patient is in severe general condition, skin is pale, abdomen is ditanded and assimmetric, at
palpation is painfull in the mesogastral region. Rectal exam: rectal ampula is empty, the walls
are of elastic consistence, traces of blood on the gloves. Blood pressure 130/70 mm col.Hg, pulse
- 70 Beats per minute, rhythmic. On the plasement of naso-gastric tube it was exteriorised about
800 ml of fecaloid fluid. Simple abdominal radiography: a n air-fluid levels in the upper
abdominal quadrants.

1. Arrange the presumptive diagnosis.

2. Сonfirm presumptive diagnosis based on the history of the disease, patient complaints,
results of the objective exam, presented in the statement of this clinical case.
3. With what pathology entities must be performed differential diagnosis?
4. What are the peculiarities of clinical examination and what additional maneuvers will be
performed to confirm the diagnosis?
5. Write the laboratory investigations that may be useful in determining the final diagnosis.
6. What type of imaging methods of investigation could confirm the final diagnosis?
7. Describe the expected results from the laboratory and instrumental investigations. Please,
formulate definitive diagnosis.
8. Develop the programm of treatment (management) for this clinical case.
9. What are the principles of medicamentous treatment in this disease? Describe surgical
management depending on the clinical evolution and disease severity.
10. Prescribe the recipe of some medication which are used in the treatment of this
pathology.
1. acute intestinal obstruction.
2. patient's history of chronic use of enzyme inhibitors and recent symptoms of diarrhea and
diffuse abdominal pain followed by vomiting and absence of bowel movements, physical
examination findings of abdominal distension, tenderness, and empty rectal ampulla support
the diagnosis of intestinal obstruction.
3. DDx with acute colitis, acute pancreatitis, acute cholecystitis, and mesenteric ischemia.
4. Additional maneuvers may include abdominal ultrasound, computed tomography scan, and
possibly exploratory laparotomy.
5. Laboratory investigations: CBC, electrolyte levels, ABG, serum lactate levels.
6. Imaging methods: x-ray, CT, barium enema, upper GI endoscopy.
7. The expected results may show evidence of metabolic acidosis, elevated WBC, and
radiographic evidence of intestinal distension and air-fluid levels, supporting the diagnosis
of acute intestinal obstruction.
8. Treatment for acute IO may include nasogastric tube decompression, bowel rest, IV fluid,
electrolyte correction, and pain management.
9. medicamentous treatment: antiemetics, prokinetic agents to promote motility. Surgical
management depends on the degree and duration of bowel obstruction, as well as the
patient's comorbidities