MINISTRY OF HEALTHCARE OF REPUBLIC OF BELARUS EDUCATIONAL INSTITUTION «GOMEL STATE MEDICAL UNIVERSITY» Department of general and clinical pharmacology Head of the department: Teacher: TRAINING CASE HISTORY IN CLINICAL PHARMACOLOGY Ofa patient Metpywenxo W.B ae Fal name ae Being treated in the_TOKE department of ___ Grastroenterotog hospital Diagnosis: KF4.6 Doey2ot u HedmoyHenHbiu Lyuppoz Neuen tyuppoz_ nevertu Heutounennou Smucnoruu _¢ ys®pennod 6] xumuyeckou__axTusHocmu. ‘child pugh class © seventy Portal hyperiension decompensated Pronounced ascites of Grade Wt! Mancose expansion of /3 lower esophaqus Hepatomegaly with symptoms of hypersplemism, Thrombocytopenia: Bilateral_hydeothorax Hepahc encephalopathy Stage ! Anentia of chrome diseases of mud degree, Hypocibumimes Curator, zi Student of 6 course of _duc faculty of.603a group _Bugreankysap Dugeg Fullname Gomel, 201 year Scanned with CamScanner1. PASSPORT DATA: Fullname Tletpywenxo WUpuna Bacussesta , 2c Date of birth 1434 (4 years: Address PechySauxa Genapycb, TOMERCKAa OBAACTS, F Mognpe | FLake 4 Place of work, position held__QA0* Pemcneugtpct” , Nog coSrretts 6-p tonoeru Date of admission to the hospital 13.09.2031 Diagnosis on admission to the hospital KIA6 -Dpyroti_u weyrountenHeti Gyuppos MeveHu Uysppos Mevenu HeyTounerHod atuoxoruu < yiepennou EJ xanuiecco axTusroctero Child Pugh class 3 seventy; Poat hypertension decompensated 5 | Prnounced acces of Qrade Wi Vancose expansion of ewer Va Hepatomegaty with symptoms of hyperspleosm , thombecylopenia 3 Bilaterat hydesmneraxj Meperhe encephalopathy stage | Rnernia of enone disease of mild ceventy | Hypoaibuminemie I. CHIEF COMPLAINTS OF THE PATIENT (List patient’s complaints on the moment of curation arranging them in order of importance) Nelioaness of skin Vettouing of sclera Eniarged abdomen diffieutty sn breathing, General wearness . Sleep dsturbancer IILHISTORY OF THE PRESENT ILNESS (Describe in detail the disease from the mo- ‘ment of its first manifestation till the first day of curation with the obligatory indication of previous treatment and its effectiveness) Considers himself ul since 2018, when evrrhosis ofthe lwerwos first exposed. SHe took fablels *Urcedeorychohie acid” 250mg i capsules, Atimes o day Jn apni 2031, grade 3 Esophageal Tnfenor varicose vein was detected by FOS as a resutt of bleeding On _OF-07-2031, che emered the “Deparment of Resussifakon and Iotenswe care”, From there che eft and got stahonary Weaiment in the M4 YB CQ Mognpecaa ropogcxos SoasnutyaSy” S5e For further treatment she wos sent to this hospital TOKE, she aid not get Scanned with CamScannerher diagnosis so was admitted tothe gastroenterology department on F7.09.2021 . (FoKE) IV.DRUG ANAMNESIS (Clarify the previous methods of pharmacotherapy and indicate the most effective drugs) “She has Taxen the dug Usedeaqchoe aad 250mg , a capute ahmes aday “for_lwer earthess ap (fer Amonths penal) and Hs ineffecwe, Scanned with CamScannerV. PAST MEDICAL HISTORY (Give information on the heredity, allergies, past illnesses, hospitalizations, injuries, surgeries, substance abuse, obstetric/gynecologic history [if female], diet, sleep; pay special attention to predisposing factors for disease) Mempywenvo Vpuna Bacuvesa , Age= 4% gears, was bom 1 gomel Beas. She 1s venj actve and very goad in her physica\ actwity and Spats Sheqot mamed and having children, Thee 1 fe heredviany pathology Soodmens were goed. She had a complete education of seandany scheol Gunecctogical Wistoy = Requiar menswiations with noimal a preg full-tem pregnancy. Panent deste! have ang allerge ceactons K caviwomenial) food and dnages WE saniany conditions are _qood currently » she woking io the constuction . Spares. She used te take goed nuimbonal fed ke saup of vegetables, ~Seeles, some fatty produds, juice ere. Ste used te teks quater half of fequency and veguianiy of feed Antake § Nike 3 mes a day. Thee were no bad habits like «make of alcohol or smcking farm report of patent. The patient is taking curently medicine for Awer eimhesis uredecxyenotic eid 250mg - She hed wer disease in 2018 dcars-cnd wo hespniaiaed and vancose vein bleeding in em esophaqen aed admitted te emergency depaument- She us no} iefeaed wum anu Kind ¢f diseases We 18, Hivs Hepatts lor) Covid . Scanned with CamScannerVISTATE OF HEALTH AT THE MOMENT OF EXAMINING (Review of systems) GENERAL STATE__Sahsfactor, * Consciousness clear Actve pasion FACIAL EXPRESSION_Symmetcal, Yellow sctera BODY TYPE _Wermostenic GROWTH 130 sm. WEIGHT _33__ kg. SKIN AND MUCOUSES Pat yeitow, dey» hirger reduced. The mucosa of membmane ef eye 1s pink, webs » clean : Thele Ga sight Subecione of sclera, Body lemperaluie = 81-5'e. FINGERS AND NAILS _39y, Bnitic, clubbed nars, Nail Bed ‘Ss yellow SUBCUTANEOUS FAT The degree of development _s medeote We disibunen 1s even «pattem. The places of largest accumulation of fat 1 of abdomen, the thickness of skin feid- At the level f navel is 3-Sem. At the edges of rectus muscle of Atdomen 1s 2cm. Alscaputa is2em, Mi tnceps © Yacm PERIPHERAL LYMPH NODES Submanidubular = single, soft, elas, movatle y pamless paipatized Necks axillary, elbow and m fingers = Act paipable, MUSCLES _the muscte layer 1s well developed, muscle tne 6 Satisfied painless durng palpation Scanned with CamScannerBONES Posture cowect . Joiis of usual configuration. Symmetreal movement 19 them «9 fully panless. there are no congenital _atnormaty th JOINTS Normat_congqueation, the lempersiure of skin present in the joint is Normal » Extent ¢ passwe mevement are fies, Atsence of swelling 0 Sownts tne fendemess on paipanen 1S absent ond wndicahen of passive movements Hand wepection Poljarthnns, watch glasses and dug finger are not avauable RESPIRATORY SYSTEM Examination of respiratory system organs Breathing theug the nose, free, thyihme, Superficial Breothing Hype: chest Respratory fequency = 1 breaths/min Shape ofthe thorax caindncsls eaquiors Aewcneal Gigasi aogie = Saint ‘oth halves of chest The abdeminal_cucumference al tne level of umelicus increased Mouth The mucous membrane of mouh we signi \ctene nvoinng muceig Ane nght and left buccal mucosa. Dental canes was seen in relation te oxitiary left molars . Mandivular ght and lee molan , Scanned with CamScannerTongue “Tongue is syramemcal but having Wile bumps on the ips and sides of tongue. Teeth _Dentat_cane was Seen iN relahon to maxillany left molars, adye modular nan and left Throat _euoten threat 1s presentation Abdomen_Inaeased sve, pommapares in whe act of breathing he navel 1S pa_pushed ait. “There are Signs of dilation of vessels. Palpation_The stomach \s painful severe Soreness on th, tea, the presence of shempdie— free fiuid 10 abdomen . Deep: The stomach 1 painful ,smocths elashe, mobile. Sigmad intestine 6 palpated 0 the left ac aea in the foun of an elashe cywnder witha that surface Sem wide, movable, non-rumbiing, painless . Patpahon is difficult indeed cle toascdes right 1a spleen Tniestne : doesnet palpate due 1 soreness, Percussion, Low tympanc 15 determmed above the stomach ‘étomach boundan Percussion : upper = at ihe level on Aim edge along the mid clavaular line eft - along the antenor arm pit Wwe Rignt = left atong parasterfal line Bettom = Bem aveve the navel GENITOURINARY SYSTEM Examination_Uone 1s not _chstutbed~ No visitle changes Jower back area. und The vadney are not paipated. The Symptom of lumbe, Arnging +_segotwe «The bladder does not came out of the pubic bone an Scanned with CamScannerboth side Pasternacki's sign (costovertebral angle tenderness )_Negatwe Kidney palpation on the back, on the side, standing Kidneys are not paipable_on both sides Palpation of the bladder _Palpation and pereussion of bladder 1s act determined. Urination__Nocmat_fequenay of unne and pH NERVOUS SYSTEM, MENTAL STATUS Consciousness ‘5 clear, speech has not changed. Sensilwity «1s not impaired Phaynx, abdominal tendon — periosied! vefiexcs has been presened - “ine shell cymptems are negaive. The eyeball, condition of pupils and pupil reflexes are sormal- Vil. PLAN OF ADDITION INSTRUMENTAL AND LABORATORY EXAMINA- TIONS (Additional methods of examination allowing to obtain a more complete set of symptoms and syndromes peculiar to the supposed disease, as. well as detalization and Scanned with CamScanneris based on the need of each refinement of existing symptoms and syndromes. The plan is base' araclinical examination oe ehology) eed rere ont Le (if suspected aurommnut ad Serum ceruloplasme Cuith unclear eneiogy) Fema, tren fransfene saturatten (with unctear ehology) Examninahen by ophinalmacgst (search for Kaiser-ferseher n0as) Daily unnany capper excrenon (with unclear etiology, Yin ceratopiesen CT of 08 ( differential dagnosis with ler tumer) Brastography Laver blepsy, AFP ( ddferennal diagnosis for Wer tumour Dragnoshe paracentesis wrth analysis of ascthic fluid Ly Mandatory: No of cers 19 Ami & their differentiation » Album eatture Ly Addinonal = cytological examination, cates “glucese, amylase. 3) Can unclear efclogy) bactenotogical ef mycobactenum tuberculose, Blood elecholytes Nat and Kt unne Sodium von 1 day unne (with vefractony ascites, suspicion of non- comphance with the hyponamne diet VII. INSTRUMENTAL AND LABORATORY EXAMINATIONS DATA (Laboratory and instrumental examinations data and their clinical interpretation and reference values should be given) General blood analysis: Co3__ 3mm/4ac wae Bax IVE P Rec 2abxiob Conclusion Hop 3% g/e re +4 leukocytosis with Tin neutrophils: Het 30.57. Signs of Anema. Movs aaifl McH = 34.4 9g > Mente - 340 9/2 Per 129 x10 Row-sp 65.5 fl Row-Cv 14.4 7 mp Pow Heo gL Nev 4.46L peice aal Fe PCT ons Neubophl 60-47, Lymphayte 32-07 Mono 5.47- Eosino Baso 0.3 7- 2 Scanned with CamScannerOBuyWs Beso 4. Albumin 54.807 2. Alpha - 1 globulin 2.18 Conclusion! werease 18 gamma globulin . 3._Mpha-2-giobulin 6.10 4 A. Beta- giopulit to. s fi qaime gee ae ne KOATYsior PAMMA = 1 Achvated parhal Thrombin Time. AeTT su4 T 2. Prothrombin tre Index 0.42 VY Conclusion + ehronte hver disease 3. INR --fieaseg PE derurband® of blood factors afd AL Fibrinogen tas Y Vitamin K deficiency S__ Thrombin tne 19-4 Biochemical Analysis of blood Oduyuti SenoK 66-8 9/8 Mowesurta 3-6 menoi7e * Kpeatunur AS.0 mmole Movesas KucHOTa NT _gamol/e Xonectepuh oSuyud 3-3 mmol/L Jv Sluntonpoteuge Bttcocoul o.28 mmol/e Slunonpoteuget Huscod 164 mmoi/e Slunonpoteagt ouent HugHcd 0.38 mmel/® ; Tpurauujepugee 0.8.4 mmol). Kos@guwerit areporentiocty 3.2. Wepytonaayuun 24mg/e C-peactustinti Geaoe 16.8 mg/g at Buaupy&it oSuyuu Bia meome/2 AP Asiorunauurdotpantege pase 73 Eg/e 4t Rertiap tatamunOtparicgepaza 128 €q/e at UyenouHaa cpecqaraza 190 ego af Tausa rayrauurtparenentugaza Wo Eq/e AT Mg? 0.48 eamol/@ Giucesa HF mmol/e Aiburni 24 mmelfe Genclusion: Disturbance iq Liver function test - IX. RATIONALE FOR CLINICAL DIAGNOSIS (The patient's complaints, anamnesis vitae, anamnesis morbi, laboratory and instrumental examinations data should be taken into account) 13 Scanned with CamScannerK54.6_ DPyrod yw weyromenNai Guppog newenu Lyuppo3._ 4 ee HeyTounennod SYQomOTUG c yuepsentott Sfrautiqecko YeTuUGHocma ENieKpugh SEE C , decdmpensaied, acnve BEN Vancose Veins oNihe esophagus and Sagach 3.6.3 gcites Grade, 3 (efactory type). oval paren considenng panems complaints, she complains of yellouness ef skin and distension of abdomen , aise expenenced Yenlowing scera Pahenis has a hstor of wer disease, he aloo developed a complication of lower esophageal vanceal bleeding - Laboratory and insmmental agnosis: General blood analysis tevealed LeUcocyTosis with precommant neutrophils and SIGNS Of AGIMOCYNC ANEMIA. whechmenbe thc w likely duets chronis diseace Brochemical_bicod analyss feveated elevaied unc acid, chelesienn levels V7 elevated CRP, elevated bitiubin Elevated Lwer enzymes he, AST, ALT and _decreace in albumen showing imbalance or detencratien ‘of overat_ liver funcnonal test - Ceatulogram reveaied TAPTT, Prothrominindex¥y TINA, J Aibmnogen, Apeibrombin hme concluding signs of chronic lwer disease, coith disturbances of blood coaguiahon factors. Possible vitamin K deficiency - further classification of liver ainmhosis : Pathent developed comphcation. of portal hypertension, Lower vanceal esophageal bleeding of Grade 2 whrehwe (from anamnesis) Ascites of Grade 3 (iense ascites) making rdiffiautt for further lover Palpation and percussion (fem anamnesis) Refractory type , because not conwolled by Sodium restechon & maxmum use of Durencs .Cfrom anamnesis) Coid-pugh —cless-G- LRenve biochemical achwty, (aise somenmes repens are normal) Patent aiso hos restlessness, anxiety si ang distufbances i | Vaitennes span depite preserwed onentatton of hme and space colegonzing under stage |_hepanc encepnatopathy (from anamnests- Child pugh = Asatis 3 points i Encephalopathy 2 penta lp Total points = 1p Serum album 8 pains Giade [class = © Seram bilirubin 3 Ponts IN@ Bos | 4 Scanned with CamScanner