Indicate the most probable diagnosis and examination methods which may confirm
your diagnosis.
3. A 48 y.o patient with a history of ulcer for 16 years having intense pain
in sobstvennoepigastralnoy area, which then radiate in the back. Was single
vomiting. Objectively: the general state of a heavy, tongue dry, mild abdominal
distension in the upper half and moderately DEFENSE muscles in the epigastric
region. Symptom Spizharnov, Orlanki negative. BP 120/70 mm of Hg, pulse 112
per minute, body temperature 37,9 º C, leukocytosis 19,2 • 106 band neutrophils -
17. Suspected perforated ulcer on the posterior wall of the twelve duodenum.
Conduct differential diagnostics. On the basis of what methods of inspection it is
possible to verify the diagnosis indicated.
6.A 38 years old patient suffers from ulcer for last 12 years. There were
repeatedly the attacks of acute pancreatitis. After eating big amount of food he felt
intensive pains in the epigastral region. There was single vomiting. With the
inspection is determined the pain and the moderately expressed shielding muscle
tension before the epigastric region. The symptom Of Spijarnov is negative. Free
gas in the abdominal cavity is not revealed with the survey roentgenography. In
gastroduodenoscopy established “deep” ulcer of the rear wall of the pyloric
division of stomach. It is hospitalized beside the surgical department with the
diagnosis of acute pancreatitis, stomach ulcer. The conservative therapy of acute
pancreatitis before the flow of 4 hours was ineffective. Remains abdominal pain,
arose the symptoms of the irritation of peritoneum predominantly before right half
of stomach, temperature of the body of 38 ºC, leukocytosis 18,4·106, the stab
neutrophils - 19. to patient is produced the abdominal section, during which is
revealed a small quantity of stomach contents before by right the flank of stomach.
Stomach contents enter the abdominal cavity through foramen of
gastroepiploicum.
What clinical form of perforated ulcer in patient? What was the basic reason
for the late establishment of diagnosis? What operational interference have to be
done to patient?
7.the patient of 32 years is operated for perforated ulcer of the front wall of
duodenum. The operation of the taking in of perforated ulcer is produced. Down
the third day of postoperative period the abdominal pains arose. On the drainages
from the abdominal cavity are noted the isolations of stomach contents with the
admixture of the hemolyized blood of the nature “coffee sediment”. Is noted the
isolation of the analogous down intestinal contents nature “coffee sediment” during
sounding of stomach. Arose suspicion down the physical incompatibility of the
seams of the taken in perforated ulcer of duodenum that stomachic hemorrhage. In
connection with this it is executed pressing re laprotomy. The seams of the taken in
perforated ulcer are well-off. Stomach contents was “coffee sediment” enters the
free abdominal cavity through foramen of gastroepiploicum.
What pathology should be suspected? What actions should be carried out for
establishing the diagnosis? What volume of operational interference should be
carried out depending on the advanced diagnosis?
8.The patient of 64 years old is hospitalized in the surgical department with
the diagnosis of ulcer of the duodenum, complicated with hemorrhage. State of the
patient of the average degree of gravity. BP 110/80 mm of Hg, pulse of 100 beats
in 1 min. stomach soft, painless, the symptoms of the irritation of peritoneum are
negative. With fibrogastroscopy it is discovered the ulcer of the rear wall of the
bulb of the duodenum, from walls of which reliable capillary hemorrhage.
Determine the most optimum therapeutic tactics in this patient.
17.Patient against the age of 14 years complains the abdominal pain without
the clear localization, the vomitings, the liquid chair. It is ill before the flow of 12
hours. First pain arose in the epigastral region. Through 4 hours it is noted the
migration of pain beside the right epigastral division and propagations down entire
abdominal cavity. The language moist, stomach am not inflated with the
inspection, limitedly participates before the report of respiration. The symptoms of
the irritation of peritoneum are expressed illegibly. Temperature of the body of
37,6 ºC, the pulse of 90 beats beside min., BP 120/70 mm Hg, leukocytosis
12,4·109, the stab neutrophils - 9. with the survey roentgenography of stomach are
determined moderate [aeroenteriyu], free gas before the abdominal cavity it is not
established.
You will establish and base preliminary diagnosis. You will determine
further diagnostic and treating tactics.
18.In patient after drop based on the height the moderate abdominal pain
arose, there was single vomiting. The skins of usual color, language moist, the
stomach is moderately inflated with the inspection, during the palpation the pain
before its left half is determined, the symptoms of the irritation of peritoneum are
doubtful. Temperature of the body of 37,2 ºC, the pulse of 94 beats beside min., BP
120/70 mm Hg, leukocytosis 14,3·109, the stab neutrophils - 11. With the survey
roentgenography of stomach it is established moderate [aeroenterografiyu], free
gas before the abdominal cavity it is not established.
Indicate preliminary diagnosis. You will determine further diagnostic and
treating tactics in this victim.
19.In sick 57 years, that suffers cirrhosis of the liver as a result of the
chronic alcoholic intoxication, arose the moderate abdominal pain. The skins are
moderately icteric with the inspection of sclera. Stomach is increased before the
sizes due to ascites. Temperature of the body of 38,2 ºC the pulse of 104 beats
beside min., BP 110/60 mm Hg, leukocytosis 17,3·109, the stab neutrophils - 14.
with an ultrasonic study of the organs of abdominal cavity are determined the signs
of cirrhosis of the liver, significant amount of liquid in the free abdominal cavity.
You will establish preliminary diagnosis. You will determine the additional
methods of inspection for affirming this diagnosis.
20.The patient of 32 years, who suffers ulcer of duodenum, felt pain in the
epigastral region, whose intensity decreased 3 hours after appearance. By 3 days of
patient it began to complain the pain before by right subcostal area, the nausea, an
increase in the temperature of body to 38,0 ºC. During the palpation before as far
as right the subcostal area is determined the positive symptom of [Shchetkina]-
Blumberg. Pulse of 102 beats beside min., BP 112/70 mm Hg, leukocytosis
18,2·109, the stab neutrophils - 16.
Place the preliminary diagnosis of pathologic state and the possible reasons
for its appearance. You will determine the additional methods of inspection for
affirming this diagnosis and therapeutic tactics.
21.In the patient of 68 years, by the suffering gallstone disease, arose the
assault of acute cholecystitis. First conservative therapy with the application of
spasmolytics was effective. However, down 3 days from the beginning of disease
again arose pain before by right subcostal area, an increase in the temperature of
body to 38,1 ºC. During the palpation before as far as right the subcostal area is
determined infiltration. Pulse of 98 beats beside min., BP 130/80 mm Hg,
leukocytosis 17,4·109, the stab neutrophils - 15. With THE UZIS the presence of
[konkreagentov] beside cavity of gall bladder, edema of its wall with the
[podvoynymi] outlines.
You will establish diagnosis. You will determine therapeutic tactics.
24.In sick 37 years in 5 weeks from the beginning of the assault of acute
pancreatitis arose local pain before the left subcostal area, fever, temperature of the
body of 38,7 ºC. During the palpation the symptoms of the irritation of peritoneum
are absent. Before the left subcostal area moderately unhealthy infiltration is
determined. Pulse of 114 beats beside min., BP 120/70 mm Hg Of [lekotsitoz]
19,7·109, the stab neutrophils - 21. With THE UZIS in the section of the tail of the
pancreas is present liquid formation with its surrounding capsule.
You will establish diagnosis and you will determine therapeutic tactics in
this patient.