Bukovinian State Medical University

Author: Serhii Sazhyn

Case outline

You are a doctor of the admission department. When you come on duty nurse informed that three patients waiting for doctor.

In the first stage students are invited to evaluate and establish the priority of emergency aid.

1. Oksana, female, 34 y.o., with complaints on severe headache in right temporal area, nausea. The pain occurred evening yesterday. Despite to took painkiller drugs pain intensity increased. Patient told that similar symptoms she had before.

2. Oleksii, male, 62 y.o., informed you about discomfort in left part of the thorax this morning and decided to come for consultation in hospital. Suddenly he felt worst the pain was stronger. Till he waiting in queue he suddenly felt worse himself, the pain intensified. Physical examination: in consciousness. Overweight. Skin is pale. Vesicular breathing during lung auscultation, 18 breath/min. Tones of the heart are rhythmic, a bit muffled. Heart rate - 94/min, BP - 140/90 mm Hg. Abdomen and other internal organs without pathology. You gave one tablet of Nitroglycerin and asked him to wait 5-10 minutes in patients' room.

3. Maskym, 45 y.o, male. Complaints about dry cough more at night, shortness of breath, increased body temperature up to 37.1^oC. You have suspected respiratory infection and asked nurse to check body temperature of the patient.

Who of the patients most requires attention?

Choice 1. You examined Oksana, got more information about history of the disease and life. You suspected migraine headache and calmed down the patient that this condition is not danger for her life. You invited her to contact a neurologist as soon as possible.

Choice 2. The nurse reported that the general condition of patient with heart pain has improved after taking nitroglycerin. You have recommended an ECG and sign up for a cardiologist consultation. Also you have given advice about emergency treatment of angina attack.

Choice 3. You decided to continue examination of the patient with dry cough. The body temperature is 36.9oC, skin is pale. Heart rate 96/min. Respiratory rate 28/min. You have heard hoarse breathing with dry and moist rales during lung auscultation. During conversation patient has told that dry cough occurred few month ago after respiratory infection, symptoms have intensified in recent days. 

The second stage involves the ability to carry out tactic of diagnostic and further monitoring of bronchial asthma.

Learning outcome for VP case

• providing emergency care in patient with asthma attack
• clinical symptoms and syndromes in bronchial asthma.
• peculiarities of asthma in adults, depending on the severity and level control.
• laboratory and instrumental investigation in asthma.
• Differential diagnosis of asthma and bronchial obstruction syndrome.

Medical error

• mis-triage,
• ignorance,
• system error;
• poor team working,
• fixation.

Author: Mykola Garas

Case outline

 You are a doctor-intern of a municipal policlinic. At the reception, boy A., 22 years old, a 3rd year student at a medical university, is unmarried, complains about a sudden deterioration in the state of the day before yesterday, on Saturday, while staying in relatives in the village, when there was nausea, multiple vomiting and diluted stools, increase body temperature up to 38˚С. These complaints relate to the food factor - the consumption of malnutrition. After the vomiting, the condition improved somewhat, nausea decreased, but continued to disturb the apparent general weakness, dizziness, fever to 37.3˚C, abdominal discomfort, which prevented the preparation for examinations in surgery and pediatrics, which took place these days, so decided to apply for medical assistance for examining and receiving a certificate of temporary disability. In the history of the patient - vaccinated by the calendar, chronic gastritis, chronic cholecystopancreatitis with periodic exacerbations. Congenital far-sighted astigmatism, since childhood, uses glasses. Grandmother along the maternal line and the mother of the boy suffer from peptic ulcer disease.

Examination: body temperature (axillary) 36,7˚С, skin and visible mucous membranes are pale, dry, clean, limbs with a touch of warm, tissue turgor satisfactory. The guy, when viewed in the mind, is adequate, the meningeal signs are negative, the pupils react to the light symmetrically, somewhat expanded. Above the lungs is percussion - clear sound, breathing is carried out equally on both sides, the frequency of respiratory movements is 18 / min, cardiac activity is rhythmic, tons of noisy, heart rate 88 / min. The tongue is a white-cheek stratification. In the ziva - a slight hyperemia of the back wall of the pharynx. Percussion over the stomach timpanic sound. Slight pain in palpation in the epigastrium. The Shchotkin-Blumberg symptom and the fluctuation symptom are negative. When auscultation of the abdomen is heard, intestinal noises are heard at a frequency of 10 / min. The percutaneous border of the liver according to Kurlov is 9/8/7 cm. The lower edge of the liver by linea medioclavicularis dextra 1 cm below the right edging arc. Symptoms Ker, Ortner are questionable. The spleen is not palpable.

Choices are denoted Excellent (E) / Good (G) / Poor (P)

Choice 1. Recommendation of a general and biochemical blood test and a re-examination of the next day (E), consultation of the gastroenterologist (G), recommendation  to prescribe sorbents and re-review when ineffective or degraded (P).

The next day, Andrei complaints of increase dizziness, general weakness and liquid stool three times. The guy is in consciousness, adequate, the meningeal signs are negative, the pupils react to the light symmetrically, asymmetry of the eye gaps. CBC- RBC - 4.0 T/l, Gb - 120 g/l, ESR - 4 mm/h, WBS -12.5 G/l, bands n.  - 6%, segments n. - 76%, eos. -1%, lymph. - 16%, mon. - 1%. Serum test - total protein - 73.8 g/l, urea - 3.6 mmol/l, creatinine - 67.6 μmol/l, bilirubin total - 13.6 μmol/l, bilirubin direct - 1.8 μmol/l, ALT - 0.4 μmol/l, AST - 0.2 μmol/l.

Choice 2. Consultation of a neurologist (E), consultation of the gastroenterologist (G), recommendation  to prescribe sorbents and re-review when ineffective or degraded (P).

The guy complaints of periodic dizziness, voicelessness, diarrhea. Eye gaps are asymmetric due to some omission of the right upper eyelid. Periodically there is a fine-skinned horizontal unstable nystagmus. The pupils are expanded, more than right pupil, a photo-reaction is common. The facial folds are contoured indiscriminately.

Choice 3. Direction of the patient to the hospital (E), consultation of an ophthalmologist (P), consultation of the gastroenterologist (G)

Doctors suspected diagnosis of botulism

Choice 4. Prescription of infusion rehydration therapy and fluoroquinolones oral (P), prescription of infusion rehydration therapy, sorbents and fluoroquinolones oral (P), prescription of infusion rehydration therapy and polyvalent antibotulinic antitoxin (E)

Learning Objectives

• Leading clinical symptoms and syndromes, differential diagnosis of acute intestinal infections.
• Differential diagnosis of AEI among themselves and with diseases of the gastrointestinal tract infectious origin.
• Clinical management of patients with AEI.
• Emergency conditions in acute intestinal infections.

Errors covered

• Fixation
• Playing the odds
• Bravado
• Poor communication.

Author: Victoria Khilchevska

Case outline

You are a young physician-therapist at the city clinic, leading an urgent reception of patients. A 47-year-old man, Alexander, appealed to you with complaints of pain in the epigastric area, right hypochondrium, nausea, heartburn, shortness of breath. I felt bad in the morning at work while working for a computer. Alexander works as a web-programmer in a large computer corporation who is not married, which explains a rigid inflammatory character and a reluctance to maintain long-term relationships. On the eve of her husband informed about the contraction at work, all evening he felt anxiety, depressed mood, sleep badly at night, in the morning he ate a lot and with appetite. Earlier, such symptoms were not observed, in the history - chronic noncalculous cholecystocholangitis. From bad habits - smoking for 10 years to 10-12 cigarettes per day. Alcohol does not abuse. Power is irregular, often uses fast food.

Over the past 2 years, it has noticed an increase in weight by 20 kg. Over the past 5 years, the patient registered high blood pressure (up to 160/95 mm Hg), antihypertensive drugs were taken irregularly. Arterial pressure in normal conditions 130/80 mm Hg.

In an objective examination, the patient's condition is closer to moderate severity. Consciousness is clear. Temperature 37.0С. When viewed slightly excited, the skin is clean, pale, but clinically not anemic. Visible mucous membranes of pale pink color, subcurrent sclera. Thyroid gland is not enlarged. Peripheral lymph nodes are not palpable. No peripheral edema.

Choices are denoted Excellent (E) / Good (G) / Poor (P)

Choice 1. Assign antisecretory, anti-emetic, antispasmodic remedy and release home (P). Refer for consultation to a gastroenterologist (G). Continue patient examination and examination (E).

While you were analyzing the blood parameters, the patient complained of an increase in pain in the upper abdomen, nausea, sour taste in the mouth, unpleasant sensations in the area of ​​the heart. The man looks pale, there is sweating, anxiety, a slight shortness of breath at rest. AT - 115/75 mmHg, heart rate 60 beats / min, WB 22 / min, capillary filling 2 s, SaO2 96%. He explains his anxiety to the unresolved problems at work. You offer Alexander hospitalization in the gastroenterological department for a more detailed examination, but he categorically refuses and requests you to prescribe him treatment for pain in the stomach and to let go home.

Choice 2. Perform an chest X-ray, ECG (G), repeated determination of troponin levels in blood after 4-6 hours and studying the level of KFK, KFK-MB, LDH (E), direction to the ultrasound of the abdominal cavity and EGDFS (P)

Choice 3. Urgent tactics of thrombolysis (E), carrying out a coronary artery with the decision on the issue of revascularization of the myocardium (G), conducting Echo-Cardiography with Determination of Ejection Fraction (P).

Learning outcome for VP case:

• Leading clinical symptoms and syndromes myocardial infarction.
• Differential diagnosis of infarction of myocardium and previous clinical diagnosis. Laboratory and instrumental datas of myocardial infarction.
• Clinical management of patient
•  Treatment and emergency for complications of myocardial infarction
•  Preventing complications.

Medical error

• Ignorance,
• poor triage,
• poor communication

Author: Natalia Bogutska

Case outline

You are doctor intern in the office of a general practitioner of family medicine on an independent reception of patients. A 33 year old Olena Hayduk without a preliminary record came to your reception because she was advised to be consulted due to her lab tests. The pediatrician advised her to contact her family doctor without delay. A woman gives you a piece of paper with the blood test result printed on the automatic blood analyzer.

You assess the CBC analysis.

From the anamnesis:

Patient reports that she has three children, the elderly boy has recently undergone an operation to replace the aortic valve, he is constantly receiving warfarin, the rest of the children are healthy, all are vaccinated. She was married, she has never been ill and has never been hospitalized before, except for the appendectomy that was about 20 years ago. Allergies have never happened. No medication are used by her, except for zolmigren for headache and aspirin because of menalgia occasionally. She is vegetarian for 5 years. Does not smoke, alcohol consumes occasionally, several times a year, does not use narcotic drugs. Two weeks ago she was treated with a dentist - he made several dental fillings. The patient's parents are alive, the father is ill with type II diabetes, there are no other significant illnesses in the family.

Examination:

Objectively (lying): a white woman 33 years old, with asthenic body building, weight 52 kg, height 169 cm, T axillary 35,8°C, RR 28 per min, HR 112 per min, blood pressure 100/55 mm Hg, skin is dry, skin and mucous membranes are very pale. Treated dental caries, tonsils are not enlarged, single submandibular lymph node is painless and enlarged up to 1 cm, apical heart impulse displaced to the left, tones of the heart are slightly weakened, at the apex - aortic systolic murmur of the II degree, vesicular breathing, the liver is not palpable, the skin is swollen on the lower limbs up to ankles. Abdomen is soft, sensitive to palpation in the epigastrium. Neurologically - without pathological changes. Menstrual discharge for 7th day.

You report your findings to the patient, but she calms you: changes in her heart have been found on the ultrasound of the heart during pregnancy, these changes are the same as her eldest son’s, but she has been repeatedly examined and told that she does not need treatment. Due to medical documentation, the last time she was examined by doctor two years ago, she was diagnosed having the bicuspid aortic valve.

Suddenly a woman begins to cry and apologize for this: a month ago her husband-soldier was killed in the combat zone, she is very "nervous", she does not sleep at night almost at all, she can fall asleep only sitting, she's afraid of who her children will remain with if she gets any sickness, so she decided to check her health status.

This is a clinical case of the management of severe chronic iron deficiency anemia of mixed genesis in a patient with premenopausal menorrhagia and the upper gastrointestinal bleeding as well as heart failure due to volume overload (cardiogenic pulmonary edema) during infusion of crystalloids and packed red blood cells.

The clinical case of the management of severe chronic iron deficiency anemia of mixed genesis in a young patient Hayduk Olena (who has 3 children) with premenopausal menorrhagia is offered for students’ consideration. In addition, bleeding from the upper gastrointestinal tract is present in this patient. Also, heart failure (cardiogenic pulmonary edema) develops and progresses due to volume overload (i/v infusion of crystalloids and packed RBC with regard to bleeding).

At first, students should pay attention to the expressed anemic syndrome according to clinical signs (it should be assessed that this is a severe anemic syndrome), as well students should carry out age-specific and gender dependent analysis of the possible causes of the development of this anemic syndrome. Students should be aware that the patient's complete blood count test does not belong to her (a system error is an error in handing out analyzes to patients), and the degree of anemia is not clinically relevant to the analysis. Anamnestic data, anemic syndrome, detected heart murmur should encourage students to make the most appropriate choice - to set up an complete blood test, an ECG, and continue to collect anamnesis. If students are concentrated on the psychological state of the patient, which is exacerbated by a severe anemic syndrome, or on an existing diagnosis of the bicuspid aortic valve, then they can choose false steps with a loss of time. The choice of the immediate appointment of amoxicillin orally due to the risk of bacterial endocarditis (fixation, inadequate skills, choice of a more probable diagnosis – playing odds) is incorrect, since neither clinical nor anamnestic data are in favor of a probable bacterial endocarditis.

Choice 1. Complete blood test, an ECG, and continue to collect anamnesis (E) / oral ferrotherapy and direct the patient to psychological support social group (G) / ultrasound of the heart and counseling a psychiatrist (P)/ sedative herbage, a re-examination with a doctor-curator and a consultation of a cardiologist (P) / amoxicillin due to the risk of bacterial endocarditis (P).

Under the condition of not proper choices time will be lost, bleeding may resume and the possibility of a detailed history collection will be lost in order to determine the probable causes of anemic syndrome. Later on the patient presents additional cause of anemia (except menorrhagia and vegetarianism), - severe gastrointestinal bleeding, which, in addition to the pre-existing severe anemic syndrome, determines the need to direct the patient to a hospital for immediate transfusion of packed RBC and further examination. Any delay is unacceptable.

Choice 2. Direct the patient to a hospital for immediate transfusion of packed RBC (E) / coagulogram, blood iron and consult a gynecologist to treat menorrhages (G) / ultrasound of the heart and psychiatrist’s consultation to exclude neurogenic anorexia or depression (P) / stop taking aspirin, iron replacement therapy and a blood test with reticulocytes in 10 days (P)

As the patient in the process of management presents her gastrointestinal bleeding which is likely to originate from the upper gastrointestinal tract, while directing the patient to the hospital for transfusion of packed RBC, and following the examination, it is worth to catheter the veins, provide oxygen therapy, bolus infusion of crystalloid fluids with strict monitoring, omeprazole 80 mg i/v bolus. Less valid options are (1), since neither vit. K1 (kanavit) nor the tranexam are not appropriate in these conditions. Hospitalization of the patient to a remote hospital is a fatal mistake, since relapse of bleeding is probable, the time is lost, and in the road it is impossible to ensure either the conduct of blood substitutes due to severe bleeding, or invasive methods of hemostasis of the ulcer bleeding, etc.

Choice 3. Catheter the veins, oxygen therapy, bolus infusion of crystalloid fluids with strict monitoring, omeprazole 80 mg i/v bolus (E) / catheterization of the peripheral vein, i/v epinephrine, infusion of crystalloid with dopamine, i/v omeprazole 80 mg and vit. K1 (kanavit) 10 mg (G) / catheterization of several peripheral veins, oxygen therapy, infusion of crystalloid bolus, tranexam 15 mg / kg once i/v slowly (1 ml / min), vit. K1 (kanavit) 10 mg i/v (G) / Hospitalization of the patient to a remote hospital (P).

Depending on the correctness of the selected preliminary steps, then manifestations of congestive heart failure or pulmonary edema of cardiogenic origin develop due to volume overload in the intensive care unit with the rapid introduction of crystalloids, and then packed RBC, in patients with pre-existing hypoxic cardiopathy on the background of severe iron deficiency anemia. In this regard, the correct tactic is to introduce oxygen therapy, lazix and depending on the effect – quick or slow prolonged infusion of packed RBC after a biological compatibility testing. The less true choice is to continue infusion of the second dose of packed RBC after a biological compatibility testing on the background of oxygenation through the mask and i/v bolus introduction of lazix without concomitant diuretic therapy. Wrong steps are will increase cardiac decompensation.

Choice 4. Oxygen therapy, lazix and depending on the effect – quick or slow prolonged infusion of packed RBC (E) / to continue infusion of the second dose of packed RBC after a biological compatibility testing on the background of oxygenation through the mask and i/v bolus introduction of lazix without concomitant diuretic therapy (G) / the continuation of packed RBC infusion without diuretics (P) / dexamethasone i/v, ultrasound of the heart, a cardiologist's consultation for the choice of further tactics or urgent esophagogastroduodenophybroscopy (P)

In the future, taking into account the history (menorrhagia) and gastrointestinal bleeding caused by taking nonsteroidal anti-inflammatory drugs (aspirin), it is advisable for the patient to be consulted by a gynecologist, to take oral ferrotherapy at a dose of 100-200 mg of elemental iron per day in 2-3 doses with control of CBC in 1 month, omeprazole 20 mg orally once daily for 6 weeks. Parenteral administration of iron drugs is not feasible and may be accompanied by additional risks of side effects.

Choice 5. Consultation of a gynecologist, oral ferrotherapy at a dose of 100-200 mg of elemental iron per day in 2-3 doses with control of CBC in 1 month, omeprazole 20 mg orally once daily for 6 weeks (E) /  consultation of the gastroenterologist for the exclusion of celiac disease, i/v ferrotherapy with the transition to oral iron sulfate administration, refusal to use non-steroidal anti-inflammatory drugs (G) / consultation of a psychiatrist and a nutritionist, omeprazole 20 mg orally 1 time per day for 4 weeks, parenteral - iron drugs (P).

In addition to the aforementioned mistakes, students may be guilty of mistakes due to a lack of knowledge and skills in identifying certain diseases (severe anemia) and complications (cardiogenic pulmonary edema), possible neglect and fixation, giving preference to a more likely condition – playing odds (after transfusion of packed RBC such more probable complication as transfusion reaction may be suspected, and the lung edema may be missed).

In the future, an intrauterine hormone system "Mirena" was assigned for the treatment of menorrhagia in premenopausal Olena Hayduk. The patient will have to take oral iron drugs for about 3 months in a prophylactic dose after hemoglobin normalization; omeprazole should be taken 20 mg orally once a day for 6 weeks for the healing of gastrointestinal erosions after the use of aspirin.

Learning Objectives

• Epidemiology, causes, clinical picture, laboratory diagnosis and management of iron deficiency anemia in the gender and age aspects
• Therapy of iron deficiency anemia with oral and parenteral administration of iron preparations. Indications, contraindications, dosage, complications.
• General principles of transfusion therapy. Indications for transfusion of red blood cells in iron deficiency anemia. Complications. Compatibility tests.
• Gastrointestinal bleeding. Causes, manifestations, diagnostics, differential diagnostics, tactics for urgent help.
• Menorrhagia. Algodysmenorrhea. Survey, diagnostics, tactics of conduct.
• Congestive heart failure with intact contractility of the heart. Volume overload. Diagnostics, tactics of management, emergency care.

Errors covered:

• System error
• Fixation
• Playing the odds

Author: Galyna Bilyk

Case outline

You are a young family doctor in polyclinic. Patient Maria Kosovan, 35 years old, looks a little tired, lofty. Mary complains of general weakness, rapid fatigability, periodic fever (37.0-37.2 C), anxiety, palpitations, periodic pain in small joints of the hands, swelling, frequent irritation. These symptoms began to notice about 3 months ago. Transmitted diseases - frequent catarrhal diseases, chronic noncalculous cholecystitis, menstruation from 13 years, sexual life from 20 years. No allergies were observed. Social history: married, working as a nurse for 12 years, no harmful habits, currently 6 months breastfeeding baby. Life history: 3 pregnancies, two of which ended in childbirth. First pregnancy without features, childbirth physiological, no complications, older daughter 5 years. 2nd pregnancy due to the developmental defects of the fetal egg ended up scratching for gestation for about 3-4 weeks 2 years ago. 3rd (delivery 6 months ago) complicated by the threat of interruption. The child was born in the gestation period of 39 weeks by means of a caesarean section. Written home on the 5th day after childbirth. Review: Temperature - 36.9 C, heart rate - 79 beats / min, BH - 20 / min, AP - 130/80.

Choices are denoted Excellent (E) / Good (G) / Poor (P)

Choice 1. To send for inspection and treatment in a hospital (G). Continue the examination and examination of the patient (E). Send home with a request to apply for examination in case of deterioration (P). Refer to the neurologist for review (G).

At the doctor after 4 months. After your last meeting, she started taking nimesil (1 sachet 2 times a day) and her condition improved;joint pain decreased, she was easier to do her homework. However, gradually the previous complaints returned and even intensified. There are volatile, unstable and short-term pains in the joints of the hands and feet, increased mucosal weakness, occasional uncomplicated pain in the upper abdomen is observed. A month ago Maria independently turned to the gastroenterologist who examined her, conducted an ultrasound examination and explained that the cause of periodic pain is more likely to be dyskinesia of the biliary tract. She was prescribed a low-fat diet and recommended a healthy lifestyle, including an increase in physical activity. She also notes that this winter began to feel low temperature intolerance, although she never loved cold weather, but suddenly she had a problem when her arms and legs became painful and there was a pallor of the skin of these areas. in the cold.

Choice 2. Biochemical blood test, rheumatologic tests, consultation of infectionist (E) Biochemical blood test, x-ray bristles, orthopedic consultation (G) Biochemical blood test, ultrasound examination, surgeon consultation (P).

In the hospital. You are a doctor of the pulmonary department. Objectively: the temperature is 38.2С, the breathing is 26-28 / min, the heart rate is 90-92 / min. Skin and visible mucous membranes are pale, dry, cheilitis on the lower lip. It was unheated, in the oral cavity in the cheek area, isolated minor small ulcers up to 3-4 mm. Neck and axillary lymph nodes are slightly enlarged, elastic, motile, moving, spherical, symmetrical, painless in palpation, small joints of the upper and lower extremities, slightly swollen, painful in palpation, mucosal tone and muscle strength are preserved, with palpation of mucous membranes there is an insignificant pain. On the upper and lower extremities there are redness areas with whitish-gray scales in the center, areas of scar atrophy, surrounded by a zone of hyperkeratosis and hyperemia along the rim, deformation of the nails.

Heart tones are rhythmic, weakening of the 1st and 2nd tones, systolic noise on the apex.

Choice 3. General blood test, general urinalysis, ECG (P), general blood test, chest x-ray, ECG (E), general blood test, EchoCG, ultrasound examination of pulmonary sinus (G)

Doctors suspected diagnosis of systemic lupus erythematosus

Learning outcome for VP case

• The syndrome of fever of unknown origin, infectious rash, clinical manifestations.
• Leading clinical symptoms and syndromes in systemic lupus erythematosus.
• Clinical course and complications variants.
• Laboratory and instrumental datas.
• Differential diagnosis of systemic connective tissue diseases.
• Treatment and clinical management of patients.
• Preventing complications.

Medical error

• insuffience skills;
• bravado;
• poor team working;
• playing the odds.

Author: Uliana Marusyk

Case outline

You are a resident doctor of the therapeutic department.

Your new patient is Maria, 35 years old.

She complained about repeated vomiting, suffering, severe headache, a feeling of compression and throbbing in the temples, tingling in the ears, laxity and weakness, partial urination.

According to anamnesis periodic headache of varying intensity disturbs about six months. With the words of the patient her mother is observed in a family doctor about hypertension.

Objectively: the skin is clean, slightly pale and dry to the touch. Turgor and tissue elasticity are moderately reduced. The tongue is covered with white layers. The percurious limits of the heart are not altered, auscultatively rhythmic tones, tachycardia is observed. The pulse on the radial artery is stable, with a high filling, 92 beats per minute. Respiratory rate 22 per minute. Percussion over the lungs, clear pulmonary sound, auscultative vezicular breathing is evenly performed on both sides, wheezing is absent. Abdomen is soft, nebolichny with palpation. AT 140/100 mm Hg. Axial body temperature 37.2˚С. The height of Mary is 172 cm, weight - 102 kg, BMI 39.8.

Choice 1. Hospitalize a patient in a therapeutic department / Give captopril and recommend contact wiyh family doctor / Urgent ECG

The patient is delivered to the therapeutic department, receiving furacemide at a dose of 40 mg once. The pulse on the radius artery is steady, with normal filling, 84 beats per minute. Respiratory rate 22 per minute. Abdomen is soft, nebolichny with palpation. AT 120/80 mm Hg., slight edema on the legs, specific odor of the mouth.

Choice 2. ECG, common blood test, urin alysis, ultrasound examination of the heart / ECG, common blood test, cardiologist’s consultation / ECG, common blood test, urine test, cardiologist consultation, ultrasound examination of the heart

Common blood test without pathological changes, in the urine analysis revealed acetone - +++, ultrasound of the heart - pathological changes weren’t detected.

Choice 3. Assign the patient to ceftriaxone in a dose of 1.0 g twice a day i/m / IT glucose-salt solution in a ratio of 2: 1 / biochemical blood test

The results of biochemical analysis of blood were obtained, hyperglycemia was detected.

Choice 4. Glucose-test / consultation of an endocrinologist / consultation of a nephrologist

Learning Objectives

• Differential diagnosis of the syndrome of hyperglycemia
• Leading clinical symptoms and syndromes in diabetes
• Differential diagnosis of acute and chronic complications of diabetes
• Leading clinical symptoms and syndromes in coma: ketoatsydotychna hyperglycemic, hypoglycemic
• Providing emergency assistance in a coma
• Diagnosis and tactics of patients with chronic complications of diabetes

Errors covered

• Sloth,
• Ignorance,
• Fixation