Zaporozhye State Medical University

Author: Andrii Bilai

Case outline

You are a doctor of the admission department.

Your new patient is a 55 year old man, Mykola Savin.

He was delivered to the Regional Clinical Hospital on 13.11.13, at 5:20 with complaints of aching lumbar pains behind the sternum, a feeling of numbness in the fingers of the left arm, heaviness in the right Iliac region, vomiting, loose stools. Deterioration of health at 01:00, when the lumbar pains behind the sternum appeared, gradually increasing in intensity, the pains made the patient awaiken, there was a feeling of numbness in the fingers of the left hand. Also, the patient noted pain in the epigastric region and heaviness in the lumbar region on the right, cramps when urinating. In the evening before the admission he drank 150-160 ml of vodka, and 2 days before admission there were the following manifestations: nausea, a single vomiting of dark color, loose stool up to 3 times a day.

According to his wife’s story, Mykola has been working at Zaporizhstal for the last 36 years. During the last medical occupational examinations, a high blood pressure was diagnosed, and a planned hospitalization was recommended, which is still only in the plans.

During the last examination, the ultrasonography was made, and calculus was found, he was recommended to visit the urologist, but has not consulted the doctor at the polyclinic yet.

From the anamnesis of life:

HIV, hepatitis denies, surgical interventions were not made.

On examination:

T 36.9 ° C, BP ​​190 and 120 mm. Hg; Art., Heart rate = Ps 60 per min. Heart sounds are muffled, rhythmic. Respiratory rate is 18 sighs per minute. In the lungs, breathing is hard, inhaling: exhalation 1: 1. The abdomen is soft, slightly painful, the peristalsis is audible. Costovertebral angle tenderness is weakly positive on the right. The stool is liquid - 3-fold. Diuresis – cramps while urination.

The antihypertensive therapy was delivered to the patient. Results of examination 6:00: AD 150 and 100 mm. Hg; Art.

Choice 1 Consultation of the surgeon (E) / Consultation of a gastroenterologist (P) / ECG, laboratory tests, ECHO-CS / urological consultation (G)

On examination: T 36.9 ° C, ABP 190 and 120 mm. Hg. St., Heart rate = Ps 60 per min. Respiratory rate is 18 sighs per minute. The patient’s condition is of moderate severity. Skin and visible mucous are pale pink. Heart sounds are muffled, rhythmic. In the lungs, breathing is hard, inhaling: exhalation 1: 1. The abdomen is soft, slightly painful in epimesogastrium, peristalsis is audible. Costovertebral angle tenderness is weakly positive on the right. 

Choice 2 Computer tomography of the abdominal cavity / Ultrasound examination of the urinary track system (G) / Laparoscopy (E) / Dynamic observation (P)

The laparoscopy was performed, and inflammatory changes of the appendix were found.

Choice 3 Sils-appendectomy (P) / Appendectomy of the laparotomy access appendix (G) / Laparoscopic appendectomy and abdominal drainage (E)

Learning Objectives

• Anatomico-physiological data.
• Causes of development of acute abdominal syndrome.
• Appendicitis: Clinical manifestations, diagnostics and differential diagnostics, complications, therapeutic tactics.

Errors covered

• Fixation and Playing the odds
• Poor teamworking
• Insufficient skills
• Bravado/Timidity

Author: Oleksandr Voloshyn

Case outline

The patient of 64 years old comes to the general practitioner with complains of severe pain in the stomach, with nausea and urge to vomiting, loose stools, asthenia and distress.

From the anamnesis of disease:

Over a long period of time the patient has been followed-up by the gastroenterologist with a chronic gastroduodenitis, associated with HelicobacterPylori, 2 years ago Eradication therapy for Helicobacter pylori infection was received. 40 minutes before the reference to a doctor deterioration occurred, and the abovementioned complaints occurred.         

From the anamnesis of life:

The patient denies tuberculosis, diabetes, skin and venereal diseases, diabetes.

It’s known that the patient has been engaged in archeology for 30 years, is still working at the present moment, labour conditions are not satisfactory, nutrition is not regular, regularly goes abroad, the last business trip was 1,5 month ago to the Middle Eastern countries.  The patient remembered several cases of acute enteric infection among his colleagues. 

He is also followed-up by the private cardiologist with the diagnosis Coronary heart disease: ischaemic heart disease, postinfarction cardiosclerosis (heart attack in 2009), postinfarction aneurysm of the left heart ventricle. 6 years ago coronary artery bypass grafting in the basin of the right coronary artery, of the left circumflex coronary artery and Dor plastics of the left ventricle were done.  

After the heart surgery the patient noted occasional rhythm disruptions, and 2 years later Frederick Syndrome developed. The patient is a heavy smoker and suffers from chronic obstructive pulmonary disease (the diagnose was made 8 years ago) and chronic cor pulmonale with heart failure 2А II ФК. The patient also complains on increase in arterial blood pressure, the patient regulates it with permanent taking of Lisinopril and bisopronol.

At the age of 18 he had an appendectomy, and at the age of 40 the patient was operated because of peritoneal adhesions and mechanical intestinal obstruction.

In 2015 a procedure of stenting of the left common iliac artery was made because of the atherosclerotic vascular disease of the lower extremities with the clinical manifestations of intermittent lameness while walking less than 70m.  Stenosis of the left renal artery up to 65 % was found during the angiography, the patient has refused to receive endovascular correction.

Choice 1. Send the patient to the general surgeon (G) (2 hours and 30 min) / anaesthetize, make antispasmodic injection and transfer the patient to the surgical department (G) / multislice computed tomography of the abdominal cavity organs (G) (5 hours) / Diagnostic laparoscopy (G) / Urgent laparotomy, attempt to conduct thrombectomy from the superior mesenteric artery (G)

Choice 2. Continue diagnostics and start conservative treatment (P) (6 hours) / anaesthetize, transfer the patient to the surgical department (G).  

Choice 3. Stop the physical examination and send the patient to the inpatient surgery department (E) / conduct angiography of the aorta abdominal region and all its branches (E) (1 hour and 20 min) / selective thrombolysis Actilise 100 mg (E).  

Learning Objectives

• Anatomical and physiological peculiarities of the aorta and its visceral branches;
• Mesenterial thrombosis: ethiology and risk factors;
• Aspects, diagnostics and differential diagnostics of the Mesenterial thrombosis
• Peculiarities of surgical treatment and thrombotic therapy in patients with thrombosis

Errors covered

• Fixation
• Poor teamworking
• Playing the odds

Author: Oleksii Kapshytar

Case outline

You are an ambulance doctor.

On 14.02.2017 at 15.00 the ambulance team came after the call made to the Central substation at 14:50 to the patient Prokhir Shaliapin, born in 1943 (74 years old). During the examination it was discovered that the patient has been suffering from ischemic heart disease for a long time: exertional angina, hypertensive disease of the 2^nd type. The patient had appendectomy in the past. The patient suffers from periodical epigastric burnings (he stops the manifestations with baking soda). Prokhir has been smoking since 14. Dysuric manifestations has been disturbing the last 8 years.   

The last meal was at 12:00 (smoked sausage with bread), the severe acute and squeezing pain in epigastric region appeared, nausea, repeated vomiting with gastric material, liquid stool as well.

Results of an examination:

The condition is satisfactory, conscious, mentally competent. The skin is pale pink, Arterial blood pressure -   160/90 mm. Hg; St., Heart rate = Ps 92 per 1 min. The respiratory rate is 20 sighs per min. The tongue is moist, the abdomen is not swollen and soft, slightly painful in the epigastrium, there are no peritoneal signs, peristalsis audible. Costovertebral angle tenderness is slightly positive on the right, urinary difficulty.

Choice 1 – Surgeon consultation (E) / Introduction of antispasmodic agent/ electrocardiogram (P) / Consultation of Infectious Disease Physician (G). The condition is satisfactory, conscious, mentally competent. The skin is pale pink, AP -   160/90 mm. Hg; St., Heart rate = Ps 92 per 1 min. The respiratory rate is 20 sighs per min. The tongue is moist, the abdomen is not swollen and soft, slightly painful in the epigastrium, there are no peritoneal signs, peristalsis audible. Costovertebral angle tenderness is slightly positive on the right, urinary difficulty.

Choice 2 – Consultation of cardiologist / echocardioskopy, multislice computed tomography / refusal of hospitalization (P) / explanation about necessity of consultation / abdominal x-ray / abdominal ultrasound examination (G) / examination by the responsible surgeon (E)

You are a duty medical officer invited to the hospital admissions – define the diagnostic tactics and treatment.

Choice 3 – continue the treatment prescribed by the cardiologist/ Infectious Disease Physician / troponin test (P) / abdominal ultrasound examination (G) / hospitalization to the surgical department / the Schwartz Test / diagnostic videolaparoscopy (E)

The Schwartz test was made: taking into account the presence of the scar on the anterior abdominal wall (result of the appendectomy). The patient received barium with the following control of its passage along the intestinal canal. The condition is with negative dynamics, the abdomen is slightly swollen, tachycardia increased.

Diagnostic videolaparoscopy: small intestine loops are of cherry colour, they are swollen, hemorrhagic effusion in the abdominal cavity, mesentery is oedematous with blood effusion areas. Acute intestinal obstruction is suspected. Diagnostic examination was stopped due to intense swelling of the intestine and high probability of gut wall hurt.

Choice 4 – continue the treatment prescribed by the cardiologist / of the Infectious Disease Physician / angiography of the coronary arteries (P) / consultation of a general practitioner / control of tests results (G) / consultation of surgeon/ surgical intervention (E).

During examination a commissure was found at a root of mesentery. This commissure goes from a head of blind colon to the root of mesentery and caused the 180° intestinal loop malrotation.  Enteropathy is  subtotal. After the commissure dissection and procaine block of the root of mesentery the intestinal peristalsis, pulse of vessels and abdominal membrane glaze were recovered. Intestinal tract is considered to be viable. After 14 days the patient was discharged from the hospital in satisfactory health condition.

Learning Objectives

• Anatomico-physiological data;
• Reasons of the acute intestinal obstruction development;
• Classification, stages of the acute intestinal obstruction;
• Acute intestinal obstruction: clinical manifestations, diagnostics and differential diagnostics, complications, surgical tactics.

Errors covered

• Fixation, Bravado, Ignorance;
• Playing the odds, Insufficient skills;
• Sloth;
• Poor teamworking.

Author: Andrii Bilai

Case outline

You are an ambulance doctor.

Patient: Male 47 years old, Eduard Ivanov.

20.01.17 at 3:40 an ambulance was called.

The patient notes complaints of persistent pain in the right upper quadrant with irradiation in the right shoulder blade and lower back, vomiting with an admixture of bile. Deterioration of health at 01:00, when the pain in the right hypochondrium, nausea, the urge to vomit from which the patient woke up appeared, there was a feeling of bitterness and burning in the mouth. The day before in the evening, he ate fatty foods and oriental dishes, and 2 days before the arrival he suffered from heartburn, weakness, heaviness in epigastrium.

According to his wife, Edward has been working in a restaurant of Japanese food for 15 years. During the last occupational examination, Edward was diagnosed with concussions of the gallbladder on ultrasound, he was recommended an observation by a gastroenterologist, but he has not consulted a doctor at the polyclinic yet. Periodically, he noted pain attacks in the right hypochondrium, which were stopped by taking antispasmodics and following a diet: Table №5.

From the anamnesis of disease:

Repeatedly passed a course of ulcer therapy in occasion of a chronic ulcer 12 p.c. However, he has not followed the recommendations for taking acid-lowering medications (Pantoprazole, De-nol) and the corresponding diet. Drugs were taken from time to time, when he noticed the appearance of the discomfort in the epigastrium and the appearance of heartburn.

He also had a history of inpatient treatment for ischemic heart disease: diffuse cardio sclerosis, atrial fibrillation.

From the anamnesis of life:

The patient denies tuberculosis, hepatitis, venereal diseases, diabetes mellitus denies, no allergies to medications. Accepts iron preparations because iron deficiency anemia.

Surgical interventions:  20 years ago, hernia repair was performed with the plastics of its own tissues.

He is followed by the urologist at the place of residence concerning the ICD. There is a stone in the right kidney.

On examination: T 37.7 ° C, ABP 140 and 80 mm. Gt; The heart rate is PS 92 beats per minute. Heart sounds are clear, rhythmic. The respiratory rate is 18 per minute. In the lungs, breath is vesicular, inhaling: exhalation 1: 1. The abdomen is mild, moderately painful in all parts, more in the right upper quadrant, the peristalsis audible. Costovertebral angle tenderness is weakly positive.

Choice 1 – Anesthetize and transport to the university clinic (E) / anesthetize and leave under the supervision of relatives / send the patient to the clinic for gastroenterologist’s examination (P) / anesthetize and transport to the therapeutic department (G)

You are a doctor in the hospital.

At the admission department, an objective examination was conducted.

On examination: T 37.8 ° C, AP 150 and 90 mm. Hg. The heart rate equal to PS 102 beats per minute. Heart sounds are muffled, rhythmic. The respiratory rate is 22 per minute. In the lungs, the breath is vesicular. The abdomen is mild, moderately painful in all parts, mostly in the right parts, irradiuret in the lower back, peristalsis is audible. The patient is injected with an antispasmodic, some improvement is visible.

Choice 2 – Laboratory tests (P) / additional physical examination (G) / instrumental examination methods (E)

You are a doctor in the hospital. Select the instrumental survey.

Choice 3 – Ultrasound of the abdominal cavity organs and the urinary track system (P) / fiberoptic esophagogastroduodenoscopy (G) / roentgenoscopy of the thoracic organs and the abdominal cavity organs (E)

Roentgenoscopy of the thoracic organs and the abdominal cavity organs was performed.

Lungs without focal and infiltrative darkening. The hypostasis is on both sides of the diaphragm is. The roots are rectangular. The diaphragm is mobile. In the sinus on the right and above the diaphragm, under the interlobar fissure, the effusion is found. The heart is widened to the left by the left ventricle, the aorta is sclerosed, unfolded.

In the abdominal cavity there is an expressed increase of pneumatisation of the intestine on the right in the epi-mesogastric region, and the stomach is distended with a liquid level.

Choice 4 – Consultation of the therapist (P) / Gastroenterologist consultation (G) / Surgeon consultation (E)

The patient was examined by the surgeon of the department, data on complaints, anamnesis of life and the disease were collected, a physical examination of the patient was conducted, instrumental studies were prescribed.

On examination: T 37.7 ° C, AP 140 and 90 mm. Hg; St., Heart rate = Ps 92 per 1 min. Heart sounds are muffled, rhythmic. The respiratory rate is 22 per minute. In the lungs, the breath is vesicular. The abdomen is mild, moderately painful in all parts, predominantly in the right divisions, radiates into the lower back, peristalsis audible.

Laparoscopy of the abdominal cavity is recommended. However, at the moment, the laparoscopic stand is busy because of an urgent surgery for an acute gangrenous cholecystitis.

Choice 5 – Ultrasound of the abdominal cavity organs and the urinary track system (P) / abdominal ultrasound examination and puncture of fluid clusters (G) / Laparocentesis (E)

Exudate was obtained from the abdominal cavity.

Choice 6 – Conservative therapy with endoscopic injection of hemostatic drugs (P) / Neymark test (G) / Laparotomy (E)

When examining the abdominal organs in the right upper quadrant, a small amount of serous effusion with fibrin is found. The loops of the small intestine are swollen. In the gallbladder, various calculi are palpable. On the back wall 12 p.c. the covered perforated ulcer with a fibrinous pellicle is determined.

Choice 7 – Gastrectomy by Billrot-2 (P) / Stem vagotomy, excision and suturing of the ulcerative defect (G) / Selective vagotomy, excision and suturing of the ulcerative defect (E)

The operation was performed: laparoscopy (laparotomy), selective proximal vagotomy, excision of the ulcer, duodenoplasty, sanitation and drainage of the abdominal cavity. Conducting a probe for enteral feeding. The patient was discharged on 10 day in a satisfactory condition.

Learning Objectives

• Anatomico-physiological data;
• The reasons for the development of ulcer diseases;
• Complications of ulcer diseases;
• Perforated ulcer: Clinical manifestations, diagnosis and differential diagnosis, complications, therapeutic tactics.

Errors covered

• Fixation and loss of perspective, poor triage
• Insufficient skills, Bravado/Timidity
• Poor communication
• Poor teamworking

Author: Oleksandr Voloshyn

Case outline

A patient – Mykola Huryliov - 66 years old has come to the Regional Hospital admission department with the complains of the general weakness, ailment, temperature rise, pain in the chest, and discomfort between scapula and lower back.

From the anamnesis of disease:

About one month ago the patient was treated in the surgical department of the Central Regional Hospital because of bullouse form of rose of the left lower extremity. The patient was discharged from the hospital 10 days ago with slight positive changes. And 7 hours ago because of deterioration of general health condition the patient referred to a doctor in the hospital admissions (temperature rise, pain in the chest and lower back).   

From the anamnesis of life:

About 10 years ago the patient suffered from an injection drug use (injections were made into the great vessels of the lower and upper extremities). According to the evidence of relatives and the patient himself he has been in remission for 10 years. Patient has been suffering from high blood pressure for a long time; the patient doesn’t receive the required systematic treatment. The patient has been suffering from Hepatitis В and Hepatitis С for about 15 years, from Diabetes of the 2^nd type for 5 years. 7 years ago the patient was operated because of the perforated gastric ulcer.

Results of an examination:

A thin man, 190 sm high, significant kyphoscoliosis and koilosternia are noted. The general health condition of the patient is severe, the state is confusional, the man is a bit retarded; he answers to questions not clearly with significant inspiratory dyspnea. The skin and visible mucous membrane are pale. Body temperature is 37,0°. Arterial Blood Pressure is 100/50 mm.Hg on the left arm and 120/60 mm. Hg on the right arm. Respiratory rate is 25 sighs per min. Heart rate is 79 beats per min. The respiration is harsh; the breath sounds are abruptly decreased in the lower parts. Upon auscultation the rasping systolic murmur in the second intercostal space on the right from the chest are heard.

Choice 1. Do Duplex ultrasound of lower extremity veins / multislice computed tomography of the thoracic organs (E) / 100000 Da of Heparin intravenous by stream infusion through bolus, fiberoptic gastroduodenoscopy urgently (E)

You have introduced 100000 Da of Heparin intravenous by stream infusion through bolus and conducted fiberoptic gastroduodenoscopy urgently. Results of fiberoptic gastroduodenoscopy: Chronic ulcer of the stomach of 7 mm. Hemorrhage Forest 2C. Cicatricial ulcerative deformation of the duodenal cap. Slight erosion. / Heparinotherapy in the department of the intensive care, anti-ulcer therapy (E)

From the second day of the heparin therapy the patient’s health improved. The result of the control multislice computed tomography after 5 days: Miller index reduced, and now it is 10. On the 7^th day of the management the patient was transferred to the ward of the cardiac surgery department. The therapy was changed to indirect-acting anticoagulants, and the patient was discharged on the 12^th day of the treatment.

Choice 2. Continue diagnostics and appoint laboratory follow-up examination (G).

While waiting for the results of treatment and conducting examinations and tests the condition of the patient deteriorated greatly, the severe pains in the chest, respiratory difficulty, fear of death appeared; the patient became pale. Abrupt hemodynamic deterioration is present, blood pressure is 80/20 mm.Hg., heart rate is 112 beats per min., the respiratory rate is 33 sighs per minute.

Auscultation: the appearance of systolic gallop rhythm, increase of the 2^nd  tone in the 2^nd  hypochondrium on the left of the thorax. / Selective thrombolysis Actilise 100 mg in the emergency department (P)

During the thrombolysis a massive gastrocardiac hemorrhage  started. And the patient died. 

Choice 3. Transfer the patient to the cardiologic dispensary to treat the infective endocarditis or pneumonia (P) / Adrenaline 1,0 intravenous by stream infusion, Infusion detoxication and antibacterial therapy (P).    

You made infusions of:

Adrenaline 1,0 intravenous by stream infusion

Infusion detoxication – Rheosorbilact 400,0 intravenous by drop infusion

Antibacterial therapy – Levofloxacin 1000 mg intravenous by stream infusion.

During the treatment the condition of the patient abruptly deteriorated, the manifestations of the respiratory distress increased, inspiratory dyspnea appeared, sharp pains in the thorax appeared. The attempt of intubation failed. The cardiac arrest emerged, the doctors start closed-chest massage and expired air ventilation. Resuscitation procedures are not sufficient, and the patient dies in 45 minutes.

Learning Objectives

• Thromboembolia of the pulmonary artery: etiology, risk factors;
• Differential diagnosis of the thromboembolia of the pulmonary artery;
• Peculiarities of a thrombolytic and anticoagulantic therapy.

Errors covered

• Fixation / loss of perspective;
• Playing the odds;
• Insufficient skills;
• Bravado.

Author: Oleksii Kapshytar

Case outline

You are an ambulance doctor.

Your new patient is a woman of 47 years old, Zoia Strybok.

On 23.03.17 (12 o’clock) the emergency team came after the patient’s call. The patient – Zoia Strybok, born in 1970 (47 years old) complains of the chills, cough, temperature of 39⁰ С, pain in lower back, dry mouth, nausea, general weakness, dizziness.

The patient says that all these manifestations appeared on 20.03.17, can’t find any reasons for them. On her own accord she took Aspirin, Paracetamol, and the hyperthermia was decreased for short period of time. She hasn’t consulted a doctor. Today she was going to visit a general practitioner.

The patient has cold-related diseases 3 or 4 times a year. When she was in senior classes of the middle school she had severe acute pyelonephritis, and after that she has been followed by the doctor with chronic pyelonephritis.

Results of an examination:

The condition is of intermediate severity, the patient is conscious and mentally competent. The skin is pale pink. AP 140/90 mm. Hg; St., Heart rate = Ps is 92 per 1 min. The breath over the whole lungs surface is harsh, dry rales in the lower right part are heard, Respiratory rate is 20 sighs per min. The tongue is dryish, not coated, the abdomen is not distended, a fresh scar along the middle line, without any peculiarities, the patient feels epigastric pain, pain in the right hypochondrium, there are no peritoneal syndromes, peristalsis is audible. Tinel’s symptom is weakly positive on the right. The patient also mentions about pollakiuria.

Choice 1 Consultation of the surgeon (E) / Consultation of the therapeutist (G) / Consultation of the urologist (P) the condition is of intermediate severity, the patient is conscious and mentally competent. The skin is pale pink. AP 140/90 mm. Hg; St., Heart rate = Ps 92 per 1 min. The breath over the whole lungs surface is harsh, dry rales in the lower right part are heard, Respiratory rate is 20 sighs per min. The tongue is dryish, not coated, the abdomen is not distended, soft, a fresh scar along the middle line, without any peculiarities, the patient feels epigastric pain, pain in the right hypochondrium, there are no peritoneal syndromes, peristalsis is present. Tinel’s symptom is weakly positive on the right. The patient also mentions about pollakiuria.

Choice 2 Procalcitonin, С-reactive protein / abdominal plain radiography / samples for analysis (G) / abdominal ultrasound (E) / sputum examination, plain radiography of thoracic organs (P)

In subhepatic space a round shape formation of 60х40 мм is found, the formation is inhomogeneous echostructure, boundaries are distinct and plain.  The capsule is easily defined.

Choice 3 Fiberoptic esophagogastroduodenoscopy (P) / Computed tomography (G) / diagnostic and treatment laparoscopy (E)

Learning Objectives

• Anatomico-physiological data;
• Reasons of sepsis development;
• Sepsis: clinical manifestations, diagnostics and differential diagnosis, complications, surgical management.

Errors covered

• Fixation and loss of perspective;
• Playing the odds;
• Ignorance;
• Poor teamworking;
• Insufficient skills;
• Bravado.