surgery

Source:  surgery    Tag:  bk virus hemorrhagic cystitis

EMERGENCY MEDICAL AID TASK No.1

Suddenly at meals a 10- year-old child had attack of suffocating (uncontrollable) cough. A child held his neck with his hands. An increasing acrocyanosis and cramping breathing was revealed. On examination, pulse was 132 beat/min, BP- 130/80 mm/Hg, RR- 28 breaths/min with the extra muscles involved in respiration. On auscultation, bronchial respiration with wheezes was heard over the lungs. What is the likely condition of the child?

1. What emergency medical treatment should be done firstly?

Answer: A patient has developed asphyxia due to the aspiration of foreign body. Emergency help must be given within few minutes otherwise it will lead to responsive(reflex) heart arrest. In this case it’s necessary to do Heimlich maneuver: Stand behind the patient. He/she may either be sitting or standing. The rescuer makes a fist with one hand, and places it, thumb toward the patient, below the rib cage and above the waist. The rescuer encircles the victim's waist, placing his other hand on top of the fist. In a series of 6-10 sharp and distinct thrusts upward and inward, the rescuer attempts to develop enough pressure to force the foreign object back up the trachea.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.1

Training a 13- year- old teenager got trauma. He complains of pain in the left supraclavicular region. There is limited function of the left upper extremity. In the region of left clavicle there is hematoma without deformation of skin, swelling and pain on palpation. X-ray of the left clavicle is done in the direct projection.

TASK:

1. Analyze the x-ray.

2. Make your diagnosis.

ANSWER:

On x-ray: transverse fracture of clavicle with the shifting in length and width.

DIAGNOSIS: Closed transverse fraction of left clavicle with the shift in length and width.

SITUATIONAL TASK № 1

A 38- year-old patient A. complains of paroxysmal pains in the right iliac and lumbar regions, which have already been for 3 hours. He had nausea with one-time vomiting. On physical exam, temperature is 37 C. The patient has dry tongue, slightly white coated; pulse - 98bt/min, rhythmic. He has soft abdomen, on deep palpation pain in the right iliac area is felt. In this region Blumberg sign is doubtful. On palpation of the right kidney region a moderate pain is felt. Pasternatsky’s symptom is positive in the right side. Blood analysis shows: Hb-123 g/l, L-10,5x10 9/l, ESR-15mm/hr. Urine analysis shows: Sp. density-1015, protein-0,033 g/l, L-5-6v.f.,Er.-8-10 v.f. On given data can’t differentiate between right sided colic pain of kidney and acute appendicitis.

1. What additional investigation is likely to be done?

2. What is your appropriate course of treatment?

Situational (task) problem no.1

Answers: US, absorbed and excretory urography, radio active renography, chromocystoscopy.

TYPICAL TASKS 1

A 65- year-old patient with diabetes mellitus, type II of moderate severity had

a phlegmon developed on the thigh which was surgically excised. Nevertheless the patient’s condition did not improve. She has hectic temperature, asthenia, dyspnea and persistent intoxication . General blood analysis reveals anemia, Hb-78g/l, leucocytosis-18 X 109/l, erythrocyte sedimentation rate (ESR) -45 mm/h. What complication of phlegmon is likely to happen? 2. What is the likely additional examination and treatment for this patient?

Task No1

Sepsis. Investigation: General blood analysis, general analysis of urine, glycemic profile, glycosuric profil, immunogram, blood culture sterility, culture from purulent part of wound for bacteriological investigation and its sensitivity to antibiotics. Treatment: antibacterial therapy, antiimflammatory drugs, correction of glucose in blood, revision of postoperated wound, HBO therapy.

EMERGENCY MEDICAL AID TASK No.2

Suddenly at meals a visitor of canteen had attack of cough. He held his neck with his hands. An increasing acrocyanosis and cramping breathing was revealed. On examination, pulse was 132 beat/min, BP- 170/100 mm/Hg. RR was 28 beat/min with chest muscles involved in respiration. On auscultation, bronchial respiration with wheezes was heard over the lungs.

1. What is the likely condition?

2. What emergency medical treatment should be done firstly?

Answer: A patient has developed asphyxia due to the aspiration of foreign body. Emergency help must be given within few minutes otherwise it will lead to responsive heart arrest. In this case it’s necessary to do Heimlich maneuver: Stand behind the patient. He/she may either be sitting or standing. The rescuer makes a fist with one hand, and places it, thumb toward the patient, below the rib cage and above the waist. The rescuer encircles the victim's waist, placing his other hand on top of the fist. In a series of 6-10 sharp and distinct thrusts upward and inward, the rescuer attempts to develop enough pressure to force the foreign object back up the trachea.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.2

A 13 year old child got a trauma during recess time. He complains of pain in the left shoulder girdle. Objectively: severe disturbed function of left upper extremity,a wound with length of up to 2 cm and till subcutaneous tissues, swelling of upper third of shoulder, painful and pathological movements. Blood supply and innervation of left arm is intact. X-ray of left shoulder bones was made in 2 projections.

TASK:

Analyze the x-ray, make your conclusion and put the diagnosis.

ANSWER:

1)Oblique fracture of surgical neck of left shoulder, with shift in length and sub-angle. 2)Opened oblique fracture of surgical neck of left shoulder with shift in length and sub-angle.

SITUATIONAL TASK № 2

Patient 43years old complains pain on left lumbal region, which is sometime, intensifies. During last 5 years small stones of yellow –brown color passes with urine. In US: enlargement of calyx-pelvic system of left kidney echo positive formation up to 20 mm with acoustic shadow. In absorb urogramm concrement shadow is not defined. In excretory urogramm-filling defect on right calyx part 22x18mm. In analysis of urine- protein-0,066g/l, L-10-15 in v.f.,Er.-10-12 in v.f., crystal of uric acid of moderate quantity.

What is your diagnosis?

Situational problem no.2

Urate nephrolithiasis,stone of left kidney,chr.pyelonephritis.

TYPICAL TASKS 2

A 68-year-old patient presents with ischemic heart disease and hypertonic disease, stage II. The patient complains of periodic pain in abdomen, decrease of appetite and body weight. On physical examination, BPis160/90 mm Hg, pulse-88 beats/min, rhythmic. An oval elastic pulsating lump is revealed in the left mesogastric region .It has a size of 10x8 cm ,moderately painful when palpated. Systolic murmur can be heard over the same area. Other symptoms of the abdominal organs are not revealed.

1. What is the most likely disease ?

2. What is the plan of investigation and treatment?

Task No2

Aneurysm of abdominal aorta. Investigation: General blood analysis, general analysis of urine, blood glucose level, coagulogram, biochemail analysis of blood, lipidogram, ECG, ultrasound of aorta, aortograhy. Operative treatment: aneurysmectomy with aorta-femoral bifurcation shunting followed by administration of drugs that improve blood circulation and antiatherosclerotic therapy.

EMERGENCY MEDICAL AID TASK No.3

A factory worker had an incised wound in the internal surface of lower third of the right shoulder. On physical examination, BP - 80/40 mm /Hg, HR - 120 per min, low pulse, and clouding of consciousness. Pulsatory bleeding from the wound on the shoulder is revealed. 1. What is the likely pathological condition?

2. What is the best treatment course?

Answer: A patient has external arterial bleeding from the wound of the lower third of the right shoulder. You should immediately press manually the bleeding vessel of the wound. Apply tourniquet on the upper third of the right shoulder. Then you should provide venous access, beginning with crystalloids (blood substitute infusion) therapy. Call for ambulance to transport the patient to the surgery department.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.3

A 3 year old kid got a trauma while playing in kinder garden. He complains about pain in the left lower extremity. Skin is intact. There is severe swelling in middle third of thigh, deformation, pathological movement, painful palpation, positive symptom ‘sticking heel’ .Vessel pulsation, movement and sensitivity of foot is intact. X-ray of left thigh was done.

TASK:

Analyze the x-ray, make your conclusion and put the diagnosis.

ANSWER: 1)Oblique fracture of middle third of left thigh bone with shift in length and width. 2)Closed Oblique fracture of middle third of left thigh bone with shift in length and width

SITUATIONAL TASK № 3

A patient 48 yrs. old was admitted with complains of pain on right lumber region having attaching character. On examination of urine-microhematuria, protienuria. Patient with right body posture. Palpation- pain on right region of kidney. Pasternatsky symptom is sharp positive on right side. In U.s. pyeloric part of right kidney and initia part of ureter is enlarged. Concrement of kidney and upper third of ureter is not defined.

What additional method is indicated for final diagnosis ?

Situational problem.no.3 Absorb and excretory urography after 10 and 20 minutes. If necessary – retrograde uteropyelograph.

TYPICAL TASK No.3

A 32-year-old patient after delivery presents with the dilatation of varicose vein of the right lower extremity .The varicose nodes are located in the leg and in the lower 1/3 of thigh. Later pain and edema in the area of the leg appeared.Induration and hyperpigmentation of skin could be seen in its lower 1/3 of internal surface.

1. What investigation should be done to solve the problem of deep vein and perforated vein of extremity? What is the most appropriate method of operative treatment?

Task No3

Ultrasound of veins in the right lower extremity. Surgical treatment, operation by Troyanova- trendelengburg-Bebkokk-Narata-kokett followed by prolonged compression therapy and administration of phlebotropic drugs for a period not less than 2 months.

EMERGENCY MEDICAL AID TASK No.4

A factory worker had an incised wound in the internal surface of lower third of the right thigh. On physical examination, BP - 90/50 mm/ Hg, HR - 110 per min, low pulse, and clouding of consciousness. Pulsatory red blood flow from the wound on the thigh is revealed.

1. What is the likely pathological condition?

2. What is the best treatment course?

Answer: A patient has external arterial bleeding from the wound of the lower third of the right thigh. You should immediately press manually the bleeding vessel of the wound. Apply tourniquet on the upper third of the right thigh. Then you should provide venous access, beginning with crystalloids (blood substitute infusion) therapy. Call for ambulance to transport the patient to the surgery department.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.4

A 14 –year-old child, while falling down, got a trauma of the right upper extremity. He complains about pain in the right forearm. Skin in the region of right forearm is intact. There is a mild deformation, limited function, swelling and painful palpation in the middle third of right forearm. X-ray of the right forearm was done in 2 projections.

TASK: Analyze the x-ray, make your conclusion and put the diagnosis.

ANSWER: 1)Transverse fracture of right radial bone with shift in width. Oblique fracture of ulnar bone with shift in length and sub-angle.

2)Closed trauma of both bones of middle third of right forearm with shift in length and sub-angle.

SITUATIONAL TASK № 4

Parents of 3 yrs. old doughter complains that not show normal urination and frequently walk with wet inner cloths. It was present from the moment of her birth. Analysis of blood and urine: without any pathological change.

What developmental anomaly have to think at first?

Situational problem no. 4 Ectopic anomaly of ureter

TYPICAL TASK No.4

A 42-year-old patient presents with rheumatic mitral heart disease resulted in constant form of ciliary tachyarrhythmia. Suddenly, acute ischemia of right lower extremity developed with pain, paleness of skin on the foot, limited movement of ankle-joint, as well as absence of arterial pulse of popliteal artery and foot artery.

1.What complication occurred in this patient?

2.What appropriate investigation must be done for the final diagnosis?

3.How would you treat this patient?

4.What kind of surgical treatment would you suggest?

Task No4 Acute emboli of popliteal artery. Additional investigation- ultrasound or angiography. Urgent embolectomy followed by heparin therapy and antiaggregant therapy

EMERGENCY MEDICAL AID TASK No.5

A 60- year- old patient presents to the family doctor with complaints on bad pulsatile headache in occipital area, noise in the ears, one-time vomiting, ? weakness. The patient has a 10 year history of hypertension. On physical examination, consciousness is moderately stuporous (RR-13).The patient has hyperemic face, symptoms of meningitis are absent. AP is 220/110 mm/Hg, pulse is tense, and its rate is 90 beat\min.

1. What is the likely pathological condition?

2. What is the best emergency management course?

Answer: The patient has a hypertensive crisis. Antihypertensive drugs of calcium antagonist group of dihydropyrimidine row or beta- blockers should be administered; sedatives and diuretics use is reasonable. The aim of therapeutic measures is to decrease AP to not more than 25% of initial one.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.5

5)A new-born, born with asphyxia and body mass of 1900 g , on the 8th day was noticed severe and sudden worsening of his condition.On inspection there is a protruding belly and light edema in lower part of anterior abdominal wall.Palpation is painful and child is agitated.Intestinal peristalsis is not heard.During intubation of stomach, got around 30 ml of intestinal contents.Stool was greenish with mucous.General blood analysis:leucocytes 12x10*9/l , juvenile 4%, stabbed 12%, segmented 61%, lymphocytes 12%, monocytes 11%.

X-ray was done in the vertical position.

TASK:

Analyze the x-ray and laboratory data and put a diagnosis.

ANSWER:

On x-ray,there is free air in the sub-angle of diaphragm.In blood analysis, there is leucocytosis and sharp left shift of formula till juvenile cells.The kid has perforative peritonitis.

SITUATIONAL TASK № 5

Patient 28yrs. old complains general weakness, dry mouth, periodic nasal bleeding, dull pain on lumbel region. On palpation of kidney-both sided gowing rugh, painless formation. In US - enlargement of both kidney, contains many exogenous form of size from 15 to 30mm. In analysis of blood: HB-102G/L, Er.-3,05x1012 /l, urea-19,6mm/l, L-8,6x109, creatinin-3,6mm/l.

Analysis of urine:sp. density-1004,protein-0,066g/l, L-16-18 in v.f.,Er.-8-10 in v.f.

Situational problem no.5

Polycystosis of kidney, chr. Pyelonephritis, chg. Renal insufficiency.

TYPICAL TASK No.5

A 53- year-old patient was admitted to the hospital with complaints on swelling pain in the right leg; edema of foot and leg, body temperature up to 38 C. On physical examination, Homans sign is positive. Arterial pulsation is normal.

1.What is the most likely disease?

2.What additional method of investigation should be done?

Task No5Acute thrombophlebitis of deep veins of right side lower extremity. Phlebograhy. Investigation- ultrasound of deep veins of the lower extremity. Conservative antiagggregants therapy, heparin therapy, fix temporary cava-filtre

EMERGENCY MEDICAL AID TASK No. 6

A 67- year- old woman presents to the emergency medical doctors with complaints on severe pulsatile headache in occipital area, noise in the ears, one-time vomiting, ? ,and weakness. The patient has a 14 year history of hypertension. On physical examination, consciousness is moderately stuporous (?-13 points).The patient has hyperemic face, symptoms of meningitis are absent. AP is 210/120 mm/Hg, pulse is tense, and its rate is 96 beat\min.

1. What is the likely pathological condition?

2. What is the best emergency management course?

Answer: The patient has a hypertensive crisis without complication. Antihypertensive drugs of calcium antagonist group of dihydropyrimidine row or beta- blockers should be administered; sedatives and diuretics use is reasonable. The aim of therapeutic measures is to decrease AP to not more than 25% of initial one.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.6

A newborn, on 2nd day of life, was noticed foamy discharge from the mouth, which after swallowing quickly accumulated.Intubation of stomach cannot be done.Oesography was done with 0.5 ml iodolipol.

TASK:

Analyze the x-ray and put the diagnosis.

ANSWER:

The kid has atresia of oesophagus with oesophago-tracheal fistula.

SITUATIONAL TASK № 6

A boy since last 6 month during urination feel himself uncomfortable, cry and stop urination. Disorder of urination till that was absent. Body temperature normal, kidney is not palpable, postarnadsky symptom is negative. No physical change of urine is visible. Examination of penis- preputium hyperemic, edematous. On removing of preputium small area of glans penis apex exposes.

What is your diagnosis ?

Situational problem no. 6

Phimosis, balanoprotitis.

TYPICAL TASK No.6

A 55-year-old patient has been suffering from intermittent claudication of the lower right extremity for the last 6 months. Distance of painless walking has been restricted up to 100 meters for the past few days. On exam, absence of the right popliteal arterial pulsation in the right lower extremity, positive ischemic symptoms are revealed.

1.What is the likely disease?

2.What extra method of investigation should be done?

Task No6

Obliterated atherosclerosis of vessels in the lower extremities, occlusion of femoral-popliteal segment in the right lower extremity. Investigation- ultrasound and angiography of artery in the lower right extremity. General blood analysis, general analysis of urine, blood glucose level, lipidogram, coagulogram, ECG. Fluography of lungs, RW. Treatment surgical-operation of femoral-popliteal allo-shunting followed by antiaggregant therapy.

EMERGENCY MEDICAL AID TASK No.7

A 38-year- old woman is admitted to the regional hospital in an unconscious state. On exam, the patient demonstrates coma (Glasgow coma scale -8). Lack of purposeful movements on painful irritation is revealed. Corneal and knee reflexes are depressed. On exam, skin and visible mucous membranes are dry. Physical examination shows noisy frequent respiration, RR -28 breathes/min, low rhythmic pulse, PR – 126 bpm, BP-100/60 mm/Hg, "fruity" odor from the mouth. Lab testing demonstrates hematocrit (PCV) - 0.53, blood glucose - 28.5 mmol/l, acute positive ketone bodies in urine, plasma potassium - 2.65 mmol /l.

1. What is the likely condition?

2. What is the most appropriate course of management?

Answer: The patient developed coma after ketoacidosis, a complication of diabetes mellitus. Parenteral insulin therapy under control of glycemia, rehydration therapy, and correction of electrolytes level and acid base condition of plasma should be administered.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.7

A newborn,on 5th day of life got increased respiratory and cardiac insufficiency.Skin is pale and there is severe cyanosis of nasolabial triangle.Cardiac borders are shifted to the right.Abdomen is not protruded, distented.X-ray of thoracic and abdominal organ was done.

TASK:

Analyze the x-ray and put a diagnosis.

ANSWER:The kid has left diaphragmatic hernia

No.7

Situational problem no. 7

Patient 65 yrs. old, mokes 45yrs.Since last month he suffers from dyspnoa, mainly after physical exortion, constant dry cough, one time appear cough with bleeding also. Objective: body temperature 37,20C, peripheral lymphatic notes are not palpable. On auscultation of lung: vesicular increase bronchial respiration over upper lobe of right lung. On x-ray examination : decrease pneumatization of upper lobe of right lung with mixed centre and widen pulmonary tree of right lung.

Give probable diagnosis of desease and plan of investigation.

Diagnosis:- central cancer of right lung

Plans of investigation:- GBA. GUA, blood sugar, Coagulogramm, ECG, sphirography, X-ray examination of lung ( roentgenography, roentgenoscopy, mammography), fibrobronchoscopy with biopsy and cytological examination.

TYPICAL TASK No.7

A 30- year-old patient D. developed intermittent claudication 3 months ago after overcooling of lower extremities.The patient feels pain in the right foot; has trophic ulcer of distal phalangeal bone of the1st toe . On exam, feet and lower 3rd of legs are marble in color. Distal parts of feet are of bluish-crimson color. Nails are dry and brittle. Arterial pulsation of feet is absent, but present on popliteal arteries .

1.What is the likely disease?

2.What extra method of investigation should be done?

Task No7Obliterative endoarteritis vessels of lower extremities. Investigations- ultrasound of artery or angiography, general blood analysis, general analysis of urine, blood glucose level, coagulogram, ECG. Lumbal sympatectomy, followed by antiaggregants therapy, antiinflammatory drugs and physiotherapy.

EMERGENCY MEDICAL AID TASK No.8

A 57-year-old woman is admitted to the hospital in an unconscious state. On exam, the patient demonstrates a state of unconsciousness (Glasgow coma scale -7). Lack of purposeful movements on painful irritation is revealed. Corneal and knee reflexes are depressed. On exam, skin and visible mucous membranes are dry. Examination shows noisy frequent respiration, RR -28 breathes/min, low rhythmic pulse, PR – 126 bpm, BP-110/60 mm/Hg, acetone odor from the mouth. Lab testing demonstrates hematocrit (PCV) - 0.54, blood glucose - 31.5 mmol/l, acute positive ketone bodies in urine, plasma potassium - 2.6 mmol /l.

1. What is the likely condition?

2. What is the most appropriate course of management?

Answer: The patient developed coma after ketoacidosis, a complication of diabetes mellitus. Parenteral insulin therapy under control of glycemia, rehydration therapy, and correction of electrolytes level and acid base condition of plasma should be administered.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.8

8)A one month old baby had fontain-like vomiting of curd milk 1.5 weeks ago, after which he started losing weight. On inspection there is hypotrophy with exichosis, decreased tissue turgor.X-ray of abdominal organ was done in the surgical department 12 hours after oral intake of 5% barium in breast milk. General blood analysis: ery 5.2x10*12/l, Hb 151g/l, leu 9.0x10*9/l.Electrolytes in blood serum: potassium 3.2 mmol/l, sodium 149mmol/l, chlorides 99mmol/l.

TASK:

Analyze the datas and put a diagnosis

ANSWER:

1)There is congestion of contrast in stomach till 12 hours, decreased pyloric canal and segmentary peristalsis of stomach.hypokaliemia and hyponatriemia in blood.

Situational Task No.8

In patient C, 52 years old , during self-investigation found dense formation of 2.5 cm diameter in right mammary gland, positive symptom of platform, secretion from nipple absent. Axillary lymph nodes are unpalpable. Tell preliminary diagnosis and initiate investigation.

Answer: Cancer of mammary gland. Investigation: Mammography, RW, General blood and urine analysis, biochemical blood analysis, X-ray of lung, coagulogram, ECG, consult with gynaecologist.

TYPICAL TASK No.8

Twelve days ago a 26-year-old patient P. had got knife injury in the lower 3rd of the right thigh. On exam, pulsating tumor, hematoma in the upper 3rd of the thigh is revealed. Auscultation of these zones gives systolic murmur. Pulsation of femoral and popliteal artery is present.

1.What is the likely diagnosis ?

2.How would you treat this patient?

Task No8

Wound, caused by knife, in the upper third of right thigh-damage of the edge of femoral artery and development of pulsating hematoma, formation of false aneurysm. Investigation; RW, general blood analysis, general analysis of urine, blood glucose level, biochemical investigations of blood, fluography of lungs, coagulogram, ECG, angiography, ultrasound of the artery. Treatment: operation- aneurysmectomy, vascular suture or plastic artery.

EMERGENCY MEDICAL AID TASK No.9

At examination a student felt weakness, giddiness, and lost consciousness, falling on the floor. Examination showed pale skin, dilation of pupils, frequent and superficial respiration, and presence of carotid artery pulsation.

1. What is the pathological condition?

2. What is the most appropriate course of management?

Answer: In this patient loss of consciousness developed as a result of disturbance of regulation of large vessels of CNS. It was a result of psycho-emotional stress because of examination. In this condition it is necessary to place the patient horizontally with elevated legs. Bring cotton moistened with liquid ammonia to the nose, or even inject caffeine or cordiamin (nikethamide) intravenously.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.9

9)A newborn, on 2nd day of life,has vomiting with bile content, distended abdomen, soft and painless on palpation. On the end of the first, meconium came out in small amount. X-ray of abdominal organs was made in 2 projection after introduction of 10ml iodlipol through gastric tube in the stomach.

TASK:

Analyze the x-ray and put the diagnosis.

ANSWER:

1) On the x-ray can be seen two levels of liquid with 2 depots of contrast, concording to stomach and duodenum, which are distended. Intestinal pnematisation is absent. X-ray was done in vertical position of the trunk.

2) Congenital high intestinal obstruction

In a Situational Task No.9

Woman, 42 years old, in duration of last 2 months appeared wet on the right nipple. Treatment with antiseptic bandage ineffective. On inspection, nipple and part of areola hyperemic. Dense formation in mammary gland absent, lymph nodes not enlarged. Put preliminary diagnosis. Formulate plans of investigation.

Answer: Cancer of right mammary gland. Investigation: Mammography, RW, General blood and urine analysis, biochemical blood analysis, X-ray of lung, coagulogram, ECG, consult with gynaecologist.

TYPICAL TASK No.9

Acute phlebothrombosis of varicose veins of the left lower extremity developed in a patient. A floating thromb in the orifice of large subcutaneous vein was revealed by ultra sound. The patient did not ask for any medical help at that time, as a result the condition of patient became worse suddenly. Arterial blood pressure lowered to 80/40 mm HG.Tachycardia developed, pulse rate became 120 beats /min. The patient became excited. The face, neck and upper half of the chest became cyanotic.

1.What complication developed in the patient?

2.How would you treat this patient?

Task No9

Thromboemboli of pulmonary artery branch. Urgent operation: venectomy by Troyanov-trenbelenburg with thrombectomy from subcutaneal big vein. Aftre patient recovers from shock ,installation of cava filter. Then give antiaggregant therapy, heparin therapy, antiinflamatory therapy, vasopressors in the reanimation pepartment. Investigations: general blood analysis, general analysis of urine,RW, blood glucose level, biochemical analysis of blood, fluography of lungs, coagulogram, ECG.

EMERGENCY MEDICAL AID TASK No.10

At operation procedure a medical student felt weakness, giddiness, and lost consciousness falling on the floor. Examination showed pale skin, dilation of pupils, frequent and superficial respiration, and presence of carotid artery pulsation.

1. What is the pathological condition?

2. What is the most appropriate course of management?

Answer: In this patient loss of consciousness developed as a result of disturbance of regulation of large vessels of CNS. It was a result of psycho-emotional stress because of presence at surgical intervention. In this condition it is necessary to place the patient horizontally with elevated legs. Bring cotton moistened with liquid ammonia to the nose, or even inject caffeine or cordiamin (nikethamide) intravenously.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.10

10) A one month old child had vomiting with bile content 9 hours ago. On inspection, in the surgical department, the child was agitated. Abdomen is protruding and asymmetric. On digital rectal examination, a small amount of yellow stool with blood. On x-ray of abdominal organs: pneumatisation of intestine is preserved but shifted on right side of abdomen. On irrigography, caecum is located high in infrahepatic region.

TASK:

Put the diagnosis

ANSWER:

Taking into consideration the high location of caecum,we may think about the incomplete twisting (ІІ stage) of the intestine together with twisting of the small intestine(agitation and blood in stool) which is indication for urgent laparotomy (strangulative obstruction) after short time preoperative preparation.

Situational Task No.10

Patient, 62 years old, complain on pain in retrosternum, difficult swallowing of solid food, salivation, in 2 months lost 15 kg of weight. Appetite is conserved. Objectively: sharp facial features, pale skin, decreased turgor, liver not enlarged. Tumor in abdominal region not palpated. Hemoglobin-86g/l,positive Gregerson reaction. In X-ray of esophagus found narrowing in lower and middle third, filling defect. About which diagnosis must be thought. Formulate plan of investigation.

Answer: Cancer of esophagus. Investigation:RW,general blood and urine analysis, biochemical blood analysis, X-ray of lung, coagulogram, ECG, fibroesophagoscopy with biopsy, X-ray of esophagus with barium contrast.

TYPICAL TASK No.10

A 53-year-old patient was admitted to the hospital with complaints on severe pain in the left shin;swelling pain in the left thigh, edema of foot, shin and thigh, spasmodic convulsions of gastrocnemius muscles, temperature up to 38,50C. She’s been ill for 3 days. Firstly, spasmodic convulsions of gastrocnemius muscles , followed by pain on the second day, and the day after edema developed. On exam, skin of left foot and shin was of bluish in color, tense and glossy (shiny).Сircumference of left shin and left thigh is 5 cm more if compared to the right ones. Movement is possible but extremely painful. At palpation of extremity pain is present along the vascular bundle, especially in popliteal fossa. Pressing of gastrocnemius muscles gives sudden pain. Arterial pulsation on popliteal artery and on foot artery was not determined due to edema.

1.What is the most likely diagnosis for this patient?

2.How would you treat this patient?

Task No10

Acute thrombophlebitis of deep veins in right knee. Investigations: general blood analysis, general analysis of urine, RW, blood glucose level, biochemical analysis of blood, lung fluography, coagulogram, ECG, consultation by gynaecologist, ultrasound of veins-pelvic and lower extremities.

Conservative antiagggregant therapy, anti inflammatory therapy, heparin therapy, apply elastic bandage on the lower extremities, in case of threatened thromboemboli of pulmonary artery- install cava filter.

EMERGENCY MEDICAL AID TASK No.11

On a trolley-bus stop a 58-year-old male suddenly lost consciousness. Examination showed absence of spontaneous breathing, acute paleness of skin, dilation of pupils, and absence of carotid artery pulsation.

1. What pathological state is the patient in at this time?
2. What is the most appropriate course of management?


Answer: Circulatory and respiratory arrest is probably caused by acute disturbance of coronary blood circulation. You should immediately start artificial ventilation of lungs and indirect heart massage. Call ambulance and transport the patient to the inpatient department.
SITUATIONAL TASK ON PEDIATRIC SURGERY No. 11
A new born,9th day of life,3 days ago started suffering from regurgitation, and then vomiting with bile and verdure, protusion of the abdomen, liquid faeces with mucous and blood. During the last 3 hours, the condition worsened acutely. There was acute protruding of the abdomen and palpation revealed contraction of abdominal muscles and pain all around the abdomen.Anterior abdominal wall is edematous, and edema of the scrotum was also noted.An X-ray of the abdominal cavity in vertical position was performed. Blood analysis: leucocytes-180.10*9/l , immature cells-3%, stabbed neutrophils-21%, segmented neutrophils-58%, lymphocytes-15%, monocytes-3%.
TASK:
1. What is your chief diagnostic consideration of X-ray investigation?
2. What is the initial diagnosis?
Give a conclusion about the X-ray investigation and put an initial diagnosis.
ANSWER:
1) On the X-ray survey of organs of the abdominal cavity, level of free gas was found under the diaphragm and there were shadowing in the lower part of the abdomen due to exudate. In the blood analysis, there was leukocytosis with left shift of the formula till immature cells.
2) Necrotic enterocolitis of the newborn.Perforation of the intestines.Perforative peritonitis.
SITUATIONAL TASK № 11

Patient, 66 years old, complains on dull pain in right hypochondrium, lost 12 kg weight in last 6 months, constipation ,bad appetite. Objectively: pale skin, decreased turgor. In right iliac region palpated infiltrate of 6X8 cm size, less movable. Hemoglobin-80g/l. Positive Gregerson reaction.
What is the most possible diagnosis? Initiate necessary investigation.
Answer: Cancer of caecum.Investigation:RW,X-ray of lung,general blood and urine analysis,biochemical blood analysis,irrigoscopy,colonoscopy with biopsy,coagulogram,ECG,consult with gynaecologist.

TYPICAL TASK No.11
After overcooling a 45-year-old patient had got pain in the right half of the chest, which was increasing at breathing. General weakness, chill, sweating, dry cough with temperature running up to 38-390C was observed. Even after antibacterial therapy for 8 days there was no improvement. Big amounts of purulent sputum with bad smell and blood streaks appeared suddenly at expectoration during cough. By the next day a condition of patient became considerably better, temperature decreased up to subfebrile, appetite grew, chill stopped. During cough at expectoration purulent sputum was up to 100-150 ml, quantity of which was increasing in the left lying position.

1.What is the most likely diagnosis for this patient?
2.What is the most likely plan of examination (investigation) and treatment?
Task No11
Open abcess of lung, right side. Investigation: RW, fluography and xray of lungs, general blood analysis, general analysis of urine, blood glucose level, biochemical analysis of blood, coagulogram, ECG, culture of sputum-bacteriological investigation and sensitivity to antibiotics an d BK. Puntutre of abcess and its sanation associated with antibacterial therapy or lower segment lobectomy with antibacterial therapy, drainage of abcess cavity by Monaldi.

EMERGENCY MEDICAL AID TASK No.12

A 47-year-old woman suddenly lost consciousness. On physical exam, there is absence of spontaneous breathing and carotid artery pulsation, acute paleness of skin, dilation of pupils.
1. What pathological state is the patient in?
2. What is the most appropriate course of management?

Answer: Circulatory and respiratory arrest is probably caused by acute disturbance of coronary blood circulation. You should immediately start artificial ventilation of lungs and indirect heart massage. Call ambulance and transport the patient to the inpatient department.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.12
In a newborn at the end of the 2nd day of life, there was appearance of protusion of the abdomen, vomiting with bile and then verdure.The infant is restless, skin is marble-like with a greyish color.A contrast X-ray of the organs of abdominal cavity was performed in the direct projection and vertically.
TASK: Analyze the X-ray film and put an initial diagnosis.
ANSWER:
On the X-ray survey, many asymmetrically located levels of liquid were visible.In the lower parts of the abdominal cavity, pneumatisation of the intestine was absent.According to the clinics and X-ray investigation, the initial diagnosis can be congenital inferior intestinal obstruction.
SITUATIONAL TASK № 12

Patient, 62 years old, smoker with frequently falls sick with pneumonia, during X-ray of the lung was found round form shadowing without clear border on the right lung lower lobe and increase root lung pattern.
Tell preliminary diagnosis. Iniatiate plan of investigation.

Answer: Peripheral cancer of right lung.Investigation:RW,fluography,X-ray of the lung,general blood and urine analysis,biochemical blood analysis,sugar in blood,coagulogram,ECG,sputum for bacteriological and sensitivity to antibiotics

TYPICAL TASK No.12

Two months ago a 36- year-old patient M. had a chemical burn (vinegar essence intake) of esophagus with formation of esophageal stricture and had medical bouginage. Manipulations were done under narcosis. It should be mentioned that two procedures were done without complications. At the third procedure in the evening a condition of the patient became worse. After the narcotic effect the patient suffered from intensive pain in the chest and interscapular region, odynophagia, palpitation and body temperature up to 380C with chills.
1.What is your likely diagnosis?
2.What is the most likely plan of examination (investigation) and treatment?

Task No12
Perforation of eosophagus, mediastinitis. Investigation: x-ray of esophagus using water soluble contrast substance. Drainage of pleural cavity, active aspiration, avoid meal through the mouth, perform gastrostomy. Investigations: RW, Fluography and xray of lungs, general blood analysis, general analysis of urine, blood glucose level, biochemical analysis of blood, coagulogram, ECG, culture from wound-bacteriological investigation and its sensitivity to antibiotics.

EMERGENCY MEDICAL AID TASK No.13

A general condition of in-patient with a lingering pulmonary tuberculosis history suddenly worsened. Examination revealed a state of anxiety, complaints on shortage of air breathing, dizziness, and increasing cyanosis. Skin was wet, body temperature - 38°C. RR was 46 breaths/min.Neck and upper part of shoulder muscles are involved in respiration. AP was 165/100, pulse - 140 beat/min.
1. What complication of tuberculosis is this patient suffering?
2. What is the most appropriate course of management?

Answer: Acute breath insufficiency, stage II developed in this patient. It’s necessary to start moistened oxygen inhalation, using nasal oxygen catheter or oxygen mask, Call for anesthesiologist to get a consultation as the above symptoms are an indication for hospitalization to the intensive care department and artificial lungs ventilation.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.13
In a 1.5 months old boy, 2 weeks ago regurgitation appeared, which quickly turned to fountain type vomiting of ‘curd’ milk. The amount of the vomiting mass is more than the amount of the previous milk intake. Treatment with spasmolytics by the pediatrician was without results. After admission in the pediatric surgical department, it was observed that the abdomen was lagged down, after feeding visible peristalsis in the form of ‘sand-clock’ in the epigastric region was found. Body weight at admission was 3000g ( when born – 3100g) During fibroesophagogastroscopy , pyloric lumen, upon intoduction of air opens up to the bulbar part. An X-ray of the organs of abdominal cavity was done 12 hours after intake of 5% Barium in milk.
TASK: Give an interpretation of the x-ray investigation and make a conclusion.
ANSWER:
On the x-ray film of the organs of the abdominal cavity, 12 hours after intake of contrast substance, most of it was located in the pyloric part of the stomach. Stomach is enlarged , its lower boundary is located on the level of iliac wings. According to clinics, endoscopy and X-ray investigation, the conclusion can be Congenital Pylorostenosis.
SITUATIONAL TASK № 13

A 59 years patient was sent to the surgical hospital from doctors of polyclinic for the examination of tumor of ascending colon. On examination in the right hypochondrium region thick infiltration is palpable, moderately painful. Symptoms of abdominal cavity irritation absent. From the anamnesis it was found that the patient condition became worse about 2 months ago, with diarrhea with intervals of constipation. General blood analysis: Hb 90 gm/l,E.S.R. 35MM/hr,
Leucocytes 8,8.
What method of investigation will be helpful to put correct diagnosis?
13.Contrst X-ray investigation of large intestine-Irrigoscopy.Colonoscopy,GAB,GAU,Coagulogram,consultation of gynaecologist,pleurography of the chest.

TYPICAL TASK No.13
A 42- year- old patient C., (Crimean Tatar) came from Uzbekistan 16 years ago. At fluorography in both lungs lower lobes rounded homogeneous shadows with exact borders were found. A patient had no complaints. While staying in middle Asia she’s been working in village locality and had sheep and dogs.
1.What is the most likely diagnosis?
2.What is the most likely plan of examination (investigation) and treatment?
Task13
Echinococus of both lungs, 1cm. Absorvative rengenography of chest in two projections, ultrasound of abdominal organs and retroperitoneal spaces, reaction lamex-precipitation. Operation- echinococ ectomy. Prophylactic investigation of family.

EMERGENCY MEDICAL AID TASK No.14
A general condition of in-patient with an acute lobar pneumonia history suddenly worsened. Examination revealed a state of anxiety, complaints on shortage of air breathing, dizziness, and increasing cyanosis. Skin was wet, body temperature - 39°C. RR was 47 breaths/min. Extra muscles were involved in respiration. On auscultation, a weak polymorphous crepitating breathing in the apex of the right lung was revealed. AP was 175/110, heart rate - 120 beat/min.

1. What complication of pneumonia course is revealed in this patient?
2. What is the most appropriate course of management?

Answer: Acute breath insufficiency, stage III was the complication of pneumonia course in this patient. It’s necessary to start moistened oxygen inhalation, using nasal oxygen catheter or oxygen mask. Call for anesthesiologist to get a consultation as the above symptoms are an indication for hospitalization to the intensive care department and artificial lungs ventilation.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.14
A 7 years old girl , for the last 2 years often suffered from cold and was treated by the pediatrician who put the diagnosis as recidivous bronchitis. For the last two months she had wet cough, more in the morning, with discharge of mucopurulent sputum, subfebrile temperature. She was hospitalized in the pediatric surgical department. Bronchosonation was done and catarrhal-purulent endobronchitis was found. After 4 bronchosonations, a bronchography was performed.
TASK: Analyze the bronchograph and put an initial diagnosis
ANSWER:
1)In the lower lobes of both lungs, cavities in the form of cysts and filled by contrast substance are seen.
2) Bronchoectatic disease. Double-sided cystic bronchoectasis of the lower lobe of both lungs
SITUATIONAL TASK № 14

Patient, 71 years old, was suffering with constipation from many years.3 days back after taking laxatives started increasing pain in stomach, nausea, stool was absent. On examination skin is pale ,grey, pulse 104 beats/min, arythmia, B.P 90/60 mm of hg, dry tongue. Abdomen is distended, tensed, painful on palpation in all parts. Peristalsis of intestine cannot heard. In the left hypochondrium region, Non movable tumorous infiltrate was palpable. Ampule of the rectum is empty, atony of anal sphincter. On X-ray of abdominal organs-multiple levels of small and large intestine.
What is the most probable diagnose? Give the plan of investigation?
Tumor of sigmoid colon.Acute obturative obstruction of large intestine.Irrigoscopy,colonoscopy,GAB,GAU,Coagulogram,electrolytes of blood,blood proteins,pleurography of the chest.


TYPICAL TASK No.14
A 48 year- old patient C., a tractor driver and in the past being a miner (28 years of service as a coal face-worker in the mine) because of pneumoconiosis left mining and came to Crimea. At the physical exercise stress had intense pain in the left half of chest, feeling of suffocation, dizziness, and compressive pains in the heart. A patient was admitted to the reception department of regional hospital in the extremely severe condition: acrocyanosis, swollen face, neck veins are stagnant (pronounced), the right half of the chest does not participate in respiration, intercostal spaces are dilated. On percussion to the right it is a high tympanic sound, to right- lung sound. Apical heart beat is displaced to the anterior axilliary line to the right; breathing on left side is not heard and is weak in the right side. Pulse is 120 beats per minute. PR is 36 per minute, Arterial pressure is 90/50.

1.What is your likely diagnosis?
2.What is your likely plan of examination and treatment?
Task14
Chronic non-specific pneumonia, bullous lungs, spontaneous pneumothorax, acute cardiac-pulmonary insufficiency. X ray of chest, pleural puncture. Decompression pleural puncture(drainage of pleural cavity) followed by constant active aspiration, situational medicamentous therapy.


EMERGENCY MEDICAL AID TASK No.15

At the polyclinic a 68 –year-old man presents with complaints on the absence of urine for the last 24 hours. He suffers from adenoma of prostate gland.
Examination shows wet, pale pink skin and body temperature -38 C. Bronchial breathing can be normally heard. Respiration rate is 24, AP- 165/100,
heart rate- 100. On palpation of abdomen a painful fusiform mass (18x9 cm)
is elicited.
1. What is the likely cause of anuria ?
2. What is the most appropriate course of management?
Answer: the patient has an acute urinary retention due to the increase in size of prostate gland which compresses the urine pathway. To provide free passage of urine, catheterization of urinary bladder is compulsory and if it does not help, then epicystostomy is necessary.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.15
A 2.5 year old girl 3 days ago started suffering from increase of body temperature up to febrility, dry cough and pain in the right side of the chest.An X-ray of the chest was done in the pediatric hospital
TASK: Analyze the X-ray and put the diagnosis.
ANSWER:
On the X-ray survey of organs of the chest, there was homogenous shadowing in the projection of the upper lobes of the right lung with clear lower boundaries.
Diagnosis: Acute destructive pneumonia, pulmonary form, right upper lobitis.
SITUATIONAL TASK № 15
A patient of 28 years came to the therapist with the complains, feeling of eyes tired, headache, especially at the time of reading. He is working in constructive bureau. 3 years back ophthalmologist prescribed glasses to the patient, but he didn’t use them. At the time of investigation: eyelids hyperemic, slightly edematous and thick. Along the edge of the eyelids are scaly.
Put the diagnosis?
15.Blefaritis.
TYPICAL TASK No. 15
A 42- year-old patient К. has consulted a surgeon concerning itch and burning in the area of the second finger of the left hand. A burning pain of pulsatory character has appeared. In the morning it began itching. A patient asked to help. At examination ungual phalanx of the second finger of the left hand is thickened
and has cyanotic and purple colour. At palpation a patient experiences a sharp pain. Active movements of a finger are limited because of pain. The temperature is 37,8С.
1.What is your likely diagnosis?
2.What is the most appropriate course of managament?

Task 15
Erysipeloid. Antiseptic bandage,dimexide. UFO 2nd finger, left kucmu. Antibiotics therapy


EMERGENCY MEDICAL AID TASK No.16

A 70-year- old woman presents to the paramedics with complaints
on the absence of urine for the last 24 hours. She suffers from urolithiasis. Examination shows wet, pale pink skin and body temperature -38 C. Bronchial breathing is weak in the inferolateral divisions with rales. Respiration rate is 24, AP- 165/100, heart rate- 120. On palpation of abdomen a painful fusiform mass (20x11 cm) is elicited.
1. What is the likely cause of anuria?
2. What is the most appropriate course of management?

Answer: the patient has an acute anuria due to urethral obturation. To provide free passage of urine, catheterization of urinary bladder, prescription of spasmolytics and analgetics, and urgent hospitalization to the urologic department is compulsory.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.16
16) In a 3 year old boy, hospitalized in the pediatric surgical department due to pulmonary form of destructive pneumonia of the right lung, there was sudden worsening of the condition appearing as pain in the right half of the chest, increasing dyspnea, restlessness , cyanosis of the nose and lips.An X-ray of the chest was urgently done.
TASK: Analyze the X-ray film an put a diagnosis.
ANSWER:
On theX-ray survey of the organs of the chest, the right lung is collapsed.
Diagnosis: Acute destructive pneumonia, pulmonary-pleural form, right-sided pyopneumothorax.

SITUATIONAL TASK № 16
A patient of 20 years complaining of secretion and reddening of the eyes, feeling of foreign particle. On examination: hyperemia and edema of mucous layer of eyes, tears from the eyes, blefarospasm, purulent secretion from conjunctiva sac.
What is the pathology, what is the reason of such symptoms?
16.Acute bacterial conjunctivitis.
TYPICAL TASK No.16
A 35-year-old patient N. was admitted to the reception department 30 minutes after a road accident. In the course of accident the patient had got injury on the sternum by the steering wheel. At the time of admission a patient’s condition was moderately severe, he suffered and complained of pain in the injured region which was increasing at movement and respiration. Skin was pale with acrocyanosis. Pulse was 96/min, rhythmic, A.P-100/60. Respiration was equally weakend on both sides. R.R. was 22/min. Borders of heart dullness were not expanded, heart sounds were dimmed. At palpation of presternum and mesosternum region symptomatic extended pain is manifested and swelling with deformation of sternum in a step-like form and pathological movement occurred.

1.What is your likely diagnosis?
2.What is your likely (examination) investigation in this situation?


Task No16
Horizontal fracture of chest, bruises of heart. X-ray of chest in two projections. Electrocardiogram. Hospitalisation, analgetics, blockade at site of fracture, indications of reparation of fractures in chest

EMERGENCY MEDICAL AID TASK No.17
At hospital reception a 40-year-old man complains of acute viral respiratory infection .He has a history of Addison’s disease for a long time. Physical examination shows frequent superficial breathing, unclear consciousness
(Glasgow coma scale -12). Respiratory rate is 28, BP- 60 /30, heart rate- 136, decreased diuresis. Laboratory testing shows sodium level of plasma-
128 mmol /l, osmolarity -267 mmol /l.

1. What is the likely cause of hypotension, hyponatremia and oliguria?
2. What is the most appropriate emergency medical aid?

Answer: It’s a typical picture of acute adrenal gland insufficiency developed as a result of Addison’s disease and acute viral respiratory infection. Glucocorticoid and mineralcorticoid deficiency appeared to be a cause of hypotension, hyponatremia and oliguria. Application of intravenous injections of glucocorticoids, antibacterial drugs and intensive infusion therapy of sodium liquids should be included into the complex therapy.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.17
17)A 4 years old boy was admitted in the surgical pediatric department with the complaints of dyspnea, increased body temperature ( 38.2 ), dry cough.An x-ray survey of organs of the chest revealed intensive shadowing with clear lower boundaries in the upper parts of the right hemithorax. Blood analysis: leucocytes 180.10*9/l , stabbed neutrophils 15%, segmented neutrophils 65% , lymphocytes 15%, monocytes 5%, ESR 30 mm/hr.
TASK: Put an X-ray diagnosis
ANSWER:
Acute destructive pneumonia, pulmonary form, right upper lobitis.

SITUATIONAL TASK № 17

Patient 72 years old is in urology department taking the treatment regarding kidney stones. After the injection of atropine started severe pain in the left eye, suddenly the site become worse. Objectively: Visual acuity for left eye – 0,01,eye is thick, but painless during palpation, congestive visible of eyaballvessels.
Your diagnosis?
Acute attack of primary glaucoma of left eye.
TYPICAL TASK No.17
A 46- year-old patient O. came to the reception department of the republican hospital himself twenty 20 minutes after chest trauma (wounding), which was caused by barbecue skewer in intrascapular space by one of drinking companions. The distance between bar and hospital was 500 m. After admission a patient was in a satisfactory condition, lightly drunk, he had complaints on the mild pain in the wound region, an unpleasant feeling of heart palpitating, dizziness. A bleeding from the wound stopped independently, a wound was 6x3 mm filled with blood clots. A shirt was blooded in the place of wound. Neck veins were stagnant. Borders of cardiac dullness were slightly enlarged.
Apex beat was not found, heart tones weakened, A.P-80/60, pulse 104beats/min, rhythmic and soft.
1.What is your likely diagnosis?
2.What is your likely plan of investigation and treatment?
17.Проникающее «точечное» ранение груди? Рентген грудной клетки в 2-х проекциях, ЭКГ. Допущены ошибки - не смотря на типичную клиническую картину проникающего ранения грудной клетки с ранением сердца и тампонадой сердца, больной не был взят экстренно в операционную для выполнения левосторонней торакотомии, а проведено рентгенобследование грудной клетки, в результате которого потеряно значительное количество времени, что привело к летальному исходу

EMERGENCY MEDICAL AID TASK No.18
A victim was taken out unconscious from the pool. Examination showed mydriatic pupils, pale skin, acrocyanosis. Isolated spasmodic breaths were revealed. Froth and water were discharging from the mouth.
1. What is the likely condition?
2. What is the most appropriate course of management?

Answer:
Fatal drowning took place taking into account froth and water discharge from the mouth. It is necessary to remove water from the lungs. For this procedure a rescuer
should put quickly a victim on the thigh of the rescuer’s leg and compress sharply back sides of the chest for 10-15 minutes and after that put a victim on the back again. At signs of clinical death it’s necessary to start cardiopulmonary resuscitation and do everything possible to transport a victim to the nearest hospital.


SITUATIONAL TASK ON PEDIATRIC SURGERY No.18

18) A nine year old boy was operated 12 days ago due to acute gangrenous perforative appendicitis, diffused purulent peritonitis. 3 hours ago , he started having sharp spastic pain in the abdomen, vomiting with bile , absence of gas release and faeces., auscultatively increased and uneven intestinal peristalsis with metallic sound, positive Abyxovskoi Bolnitsi symptom. An x-ray survey of the organs of the abdominal cavity was done.
TASK: Give an interpretation of the x-ray film and put a diagnosis.
ANSWER:The x-ray survey of the organs of the abdominal cavity in the direct projection and vertical position shows many asymmetrically located levels of liquid with ‘Kloiber’s cups’ above them.There are shadows in the lower parts of the abdomen and right mesogastrium.
Condition after laparotomy, appendectomy due to acute gangrenous perforative appendicitis, diffuse purulent peritonitis 12 days ago.Acute early inferior adhesive intestinal obstruction.
SITUATIONAL TASK № 18

A patient came to the therapist of the central republic hospital with complains on worsening of eyesight of right eye. From the anamnesis: the patient working as master, at the time of work a piece of metal entered in his eye. Objectively: tears from the eye, photophobia, blefarospasm, in the cornea can see perforated wound, anterior chamber is small, giffema, appearance of hypotonia during the palpation of eye.
Your diagnosis?
Ans; Perforative corneal wound of right eye,


TYPICAL TASK No.18
A 46- year-old patient O. came to the reception department of the republican hospital himself twenty 20 minutes after chest trauma (wounding), which was caused by barbecue skewer in intrascapular space by one of drinking companions. The distance between bar and hospital was 500 m. After admission a patient was in a satisfactory condition, lightly drunk, he had complaints on the mild pain in the wound region, an unpleasant feeling of heart palpitating, dizziness. The bleeding stopped as the wound was 6 * 3 mm filled with blood clots, the shirt was covered with blood in the place of wound, neck veins were stagnant, borders of cardiac dullness were enlarged slightly, apex beat was not found, heart sounds, BP was 80/60 mm/Hg. Pulse -104 beats per minute, rhythmic and soft. To confirm the diagnosis an x-ray of chest in two projections was performed and the patient had to stay with laboratory assistant in the x-ray lab. When the laboratory assistant returned with the x-ray results, the patient was found dead.
1. What diagnostic and medical mistakes were done by the doctor on duty?
2. What symptoms have already indicated on the trauma of heart (Beck triad),
3. What should the doctor on duty immediately have done?
18.Проникающее «точечное» ранение груди?
Рентген грудной клетки в 2-х проекциях, ЭКГ. Допущены ошибки - не смотря на типичную клиническую картину проникающего ранения грудной клетки с ранением сердца и тампонадой сердца, больной не был взят экстренно в операционную для выполнения левосторонней торакотомии, а проведено рентгенобследование грудной клетки, в результате которого потеряно значительное количество времени, что привело к летальному исходу


EMERGENCY MEDICAL AID TASK No.19
A 38- year- old patient had operative surgery of severe gastrointestinal bleeding. Total volume of blood loss was 2 liters. He had intraoperative hypotension (up to 50/20 mm for 30 min). For the first 24 hours after operation 100ml of urine has been excreted. Diuresis stimulation with the help of diuretics didn’t give any effect. Laboratory testing showed blood urea- 10mmol/l, creatinine - 150mmol/l, potassium level - 6,0mmol/l.

1. What is the likely condition?
2. What is the most appropriate emergency management?

Answer: As a result of prolonged disturbance of glomerular blood flow due to severe blood loss and hypotension, the patient developed acute renal insufficiency.
And it became a cause of diuresis, hyperazotemia, and hypercalemia lowering.
It’s necessary to reduce the amount of fluid infusion. To reduce the level of potassium you should administer glucose and insulin mixture. To improve glomerula blood flow it’s necessary to use dopamine in the dose of 1-3 mg/kg/min.
It’s necessary to administer laxative to excrete nitride products through the gastrointestinal tract. In case of inefficiency of the above mentioned measures,
start doing hemodialysis.


SITUATIONAL TASK ON PEDIATRIC SURGERY No.19

19) A 4.5 year old boy is being treated in the regional hospital for 2 weeks due to purulent inflammation of the right hip joint .( a puncture was done and pus was obtained).
Antibiotics were introduced in the affected joint.The general condition was not worsened and he was transferred to the surgical pediatric department where an x-ray of both femoral bones and hip joints was done.The right femur in the upper and middle third was edematous, palpation and passive movements of the right hip joint gave sharp pain.He also had subfebrile body temperature. Blood analysis: erythrocytes 2,7 . 10*12/l, Hb 84g/l, leucocytes 15,5 . 10*9/l, immature cells 1%, stabbed 18%, segmented 56%, lyphocytes 22%, monocytes 3% . There is expressed anisocytosis, ESR 32mm/hr.
TASK: Analyze the X-ray film, laboratory results and put the correct diagnosis.
ANSWER:
In the upper and middle third of the right femur , there is periostal reaction. In the region of the neck and head of the right femur, rough destructive changes, lysis of the bone with risk of pathological fracture in the neck region of the right femur are seen.Blood analysis reveals anemia, leucocytosis with left shift of the formula till juvenile cells, increased ESR.
Acute hematogenous osteomyelitis of the right femur, local form, right sided purulent coccyxitis.

SITUATIONAL TASK № 19

A patient of 40 years visited ophthalmologist with complains of decreased eyesight of right eye. From the anamnesis it is known that around 1,5 years back at the time of work on lathe with iron materials. At the time of work a piece of metal wounded his right eye. Vision was not disturbed, painless. Patient did not consult with the doctor.
Objectively: VOD (visual optical dextra) = 0.4.on endothelium of retina revealed pigmentation of brown color. On iris and anterior capsule of lens revealed granules of yellowish brown pigments. On fundus of eye reveal degenerative focus in form of hard granules like bone. On X-ray of orbit reveal intraocular foreign body of metallic consistency.
Put the diagnosis.
Ans:foreign body of right eye.
TYPICAL TASK No.19

A 46-year-old patient E. was staying in the pulmonology department having lower lobar pneumonia complicated with abscess of medium severe clinical course. All of a sudden the condition became worse. At the time of paroxysmal cough an acute pain in the left half of the chest, a feeling of apnea, dyspnea and palpitation occurred. On examination acrocyanosis, pupils dilation, perspiration, dyspnea participation of neck and upper part of shoulder muscles in respiration was revealed, patient felt himself better in the induced semi sitting position, pulse was 120 per min, satisfactory, BP- 110/60 mm/Hg , respiratory rate -28-30 /min. On chest percussion there is dullness of the left lower angle of scapula, absence of respiratory sounds and painful palpation of intercostal space.
1: What is a sudden worsening of patient’s condition connected with?
2: What methods of investigation should be urgently done?
19.Прорыв субплеврального гнойника в плевральную полость с формированием острого пиопневмоторакса.
Рентген грудной клетки в двух проекциях, плевральная пункция. Дренирование и санирование плевральной полости с активной последующей постоянной аспирацией его содержимого в сочетании с комплексной антибактериальной терапией.

EMERGENCY MEDICAL AID TASK No.20

A 40-year- old woman was operated for the right-side hydronephrosis. For the first 24 hours after operation 110ml of urine has been discharged. Stimulation of diuresis with diuretics appeared to be noneffective. Examination showed AP - 190/120, PR – 96.Laboratory testing showed blood urea 14 mmol/l, creatinin – 157 mmol/l, potassium level – 7,0 mmol/l.

1. What is the likely condition?
2. What is the most appropriate emergency management?

Answer: As a result of prolonged disturbance of glomerular blood flow due to severe blood loss and hypotension, the patient developed acute renal insufficiency.
And it became a cause of diuresis, hyperazotemia, and hypercalemia lowering.
It’s necessary to reduce the amount of fluid infusion. To reduce the level of potassium you should administer glucose and insulin mixture. To improve glomerula blood flow it’s necessary to use dopamine in the dose of 1-3 mg/kg/min.
It’s necessary to administer laxative to excrete nitride products through the gastrointestinal tract. In case of inefficiency of the above mentioned measures,
start doing hemodialysis.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.20

20) Analyze the given x-ray film of the bones in double projections and answer the following questions:
1.The x-ray of which bone is it?
2. What changes are seen in the bone?
3. X-ray diagnosis?
ANSWERS
1. X-ray of the femoral bone
2. Expressed total periostal reaction with destructive changes in both metaphysic.
3. Acute hematogenous osteomyelitis of the femoral bone.

SITUATIONAL TASK № 20

A 16-year teenager is suffering from lateral deviation of spinal chord. In X-ray investigation: “S” shaped deviation to lateral side at 35 degrees was found, torsion and presence of compensatory arch. Clinically can see muscular spindle and small rib hump, presence of torsion of spine.
Put diagnosis, with confirmation of stage of the process.
Ans: Scoliosis 3 stage.

TYPICAL TASK No.20
A 68-year-old patient was treated in the proctology department. At the time of defecation a painful bulging of mucous membrane from anal orifice was observed, while in horizontal position it disappeared. A patient didn’t have any painful feeling. Sometimes gas incontinence was observed.

1.What is your likely diagnosis?
2.What is your likely plan of treatment?
20.Выпадение прямой кишки 1 ст.. ОАК, ОАМ, ректальное исследование прямой кишки, ректороманоскопия, аноскопия Консервативное лечение.


EMERGENCY MEDICAL AID TASK No.21

A 52- year-old woman was brought to the reception department by the ambulance. She ate unknown mushrooms 5 days ago. A day before the patient had heavy nasal bleeding.
Physical examination showed deep unconsciousness (GCS -12). Skin was icteric and turgor - decreased. BP was 90/60, HR - 58. Liver border along the mid-clavicular line was 4cm below rib arch. Laboratory testing showed hemoglobin - 95g/l, blood sugar - 3mmol/l, general protein - 45g/l, general bilirubin - 180mcmol/l, direct bilirubin - 60mcmol/l, ALT - 4.5mmol/l, AST - 7mmol/l, prothrombin index - 45%.
1. What is the likely condition?
2. What is the most appropriate emergency treatment?
Answer: Acute hepatic insufficiency because of poisonous mushrooms (probably toadstool) developed in the patient. Laboratory testing showed hyperbilirubinemia,
hypoproteinemia, decrease of prothrombin index. This testing proved hepatic decompensation. Transaminase level increase pointed to the cytolysis development. Clinical manifestation of hepatic insufficiency produced consciousness disorder and hemorrhagic syndrome.
A complex emergency treatment includes amino acids and albumin to eliminate hypovolemia and hypoproteinemia, intravenous infusion of glucose solution for blood sugar level correction, FFP administration to normalize hemostasis indexes.
For detoxication dieresis and enterosorbtion are indicated.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.21
In newborn from polyhydroamnios primigravida, with body weight 3100 g, appeared foamy discharge from mouth and nose, 5 hours after birth. During sounding of eosophagus, the probe cannot go further after 7-8 cm from gums. Elephant’s test positive. During eosophagography, it was found a blind sac-like formation with contrast on level of 2-3 thoracic vertebrae ( see X-ray).
Put initial diagnosis.
Answer: congenital atresia oesophagus.
SITUATIONAL TASK № 21

A patient H, 62 years was a miner, went to traumatologist in polyclinic with complaints on piercing pain in the region of knee joint, which is periodically increasing and accompanied with occurrence of liquid in joints limited movements and crepitation. Pain is increased after rest, when patient starts to walk and in morning.
X-RAY investigations of both knee joints in standard projection were finding: narrowing of joint space 2-3 times when compared to norm. Endings of the bone grow deformed at the edge of cavity. Joint surface is deformed, with expressed displastic changes-damage of typical forms, proportion of condyles of femoral bones, with a zone of subchondrial sclerosis and oval space-dystrophic cavity. Put diagnosis, along with the stage of process. What is the etiology of the disease?
Ans: displastic deformative arthrosis of both knee joints 2 stage. The disease is connected with disturbance of growth in joint surface in the process of formation and further growth. Progression of the disease is connected with severe physical exsersion, which connected with his profession.


TYPICAL TASK No.21
A 32-year-old patient after stress has got disphagy, a problem in swallowing of solid foods. The patient didn’t get medical help in proper time. In the course of time the above stated symptoms were progressing. On the contrast x-ray of esophagus it was observed a constriction of lower one- third of esophagus in the form of a “mouse tail”, dilatation of esophagus above constriction up to 3-4 cm.
1. What is the likely diagnosis?
2. What is the likely surgical treatment?
21.Кардиоспазм 2-3 стадии. Пневмокардиодилятация либо бужирование
пищевода. При отсутствии эффекта оперативное лечение, направленное навосстановление пищеводно-желудочного пассажа (операции Геллера, Петровского Б.В., Захарова Е.И., Волобуева Н.Н. и др).

EMERGENCY MEDICAL AID TASK No.22
A 57-year-old patient was brought to the reception department by the ambulance. She ate unknown mushrooms 5 days ago. A day before the patient had nasal bleeding, nausea, repeated vomiting with gastric juice, after that “coffee grounds” like, colicky abdominal pains, diarrhea.
Physical examination showed deep unconsciousness (GCS -12). Skin was icteric and turgor decreased. BP was 90/60, HR – 58, RR-14. Liver border along the mid-clavicular line was 4cm below rib arch. Laboratory testing showed hemoglobin - 75g/l, blood sugar - 3mmol/l, general protein - 45g/l, general bilirubin - 180mcmol/l, direct bilirubin - 60mcmol/l, ALT - 4.5mmol/l, AST - 7mmol/l, prothrombin index - 45%.
1. What is the likely condition?
2. What is the most appropriate emergency treatment?
Answer: Acute hepatic insufficiency because of poisonous mushrooms (probably toadstool) developed in the patient. Laboratory testing showed hyperbilirubinemia,
hypoproteinemia, decrease of prothrombin index. This testing proved hepatic decompensation. Transaminase level increase pointed to the cytolysis development. Clinical manifestation of hepatic insufficiency produced consciousness disorder and hemorrhagic syndrome.
A complex emergency treatment includes amino acids and albumin to eliminate hypovolemia and hypoproteinemia, intravenous infusion of glucose solution for blood sugar level correction, FFP administration to normalize hemostasis indexes.
For detoxication dieresis and enterosorbtion are indicated.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.22
In newborn, is suspected atresia oesophagus. An esophagogram was done.
What can show this esophagogram and and put preliminary diagnosis.
Answer:
1. On esophagogram in anteroposterior view, can be seen blind sac-like formation with contrast on level of 2-3 thiracic vertebrae. The contrast didn’t go to the stomach. Darkening of right hemithorax due to aspiration pneumonia and significant amount of of gas in stomach and intestines.
2. Congenital atresia of esophagus, wide trache-oesophagal fistula with distal segment of oesophagus. Right side aspiration pneumonia.

SITUATIONAL TASK № 22
A patient 24 years, was admitted in traumatologic clinic with complains on acute pain in right lower extremity, which increases in the process of walking. He considers himself as a patient from 8 years; he cannot find the reason for the disease. Objective findings: Infiltration of soft tissue C/3 of the leg. On the effected extremity moment of leg is limited. On X-ray finding of right leg is found: In diaphysis of tibial bone thickening due to assimilation of many-layered periostitis. On anterior internal edge of the tibial bone was found destructive cortical layer with tendency of break through. In bone found separated cavities, which connect between themselves with damage integrity of endosteum 0n 6 cm. Give the data which is characterized for the above pathological process and tactics of treatment?
Гематогенный остеомиелит правой голени. Тактика лечения оперативная -некрсеквестрэктомия, с последующей лечебной иммобилизацией и массивной антибактериальной терапией
TYPICAL TASK No.22
A young patient having an ulcer anamnesis for a long time had got melena for several times a day, decrease of arterial pressure 100/60 mm/Hg, pulse -110 beats per minute, general weakness, dizziness.
1. How would you confirm the complication of peptic ulcer in the patient?
2. What is the likely plan of investigation and method of surgical treatment?
22.Язвенная болезнь, осложненная желудочно-кишечным кровотечением . Обследование: ОАК, ОАМ, коагулограмма, биохимические исследования крови, фиброгастроскопия. Оперативное лечение органосохраняющая операция на желудк е- селективная проксимальная ваготомия с прошиванием кровоточащего сосуда в язве и пилоро(дуодено)пластикой.


EMERGENCY MEDICAL AID TASK No.23
A worker of construction gang after working hard felt himself breathless and had severe constricting sternal pains. Paramedics performed an ECG exam and revealed signs of acute myocardial infarction. Physical examination showed loud breathing, crackles heard in the distance, He was coughing out pinkish froth. AP was 85/50, heart rate -128, RR -28 .
1. What is the likely condition?
2. What is the most appropriate emergency management?

Answer: The patient has myocardial infarction with complications of acute left ventricle insufficiency which brought to the development of cardiogenic pulmonary edema. It’s necessary to include oxygenotherapy, anesthesia, medications to reduce pinkish froth, dobutamine, for example, to improve the contractility of the myocardium, all these being a complex emergency management.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.23

In newborn ,at end of first day after birth, was found cyanosis nasolabial triangle, increase of breath at a rate of 80/min. Organs of mediastinum an apex tone of heart shift to right. In stomach ,through probe, was given 10,0 ml 5% barium solution in mother’s milk and after 2 hours, was done X-ray of organs of thoracic cage and abdomen.
Give an interpretation of X-ray film and put preliminary diagnosis.
Answer:
1. on X-ray film of thorax and abdomen in anteroposterior view, was determined significant deposit of contrast in stomach and multiple deposits of contrast in projection of left hemithorax. The contrast could flow there only by intestinal way.
2. congenital left-sided diaphragmal hernia.

SITUATIONAL TASK № 23
A patient 70 years complains on purulent fistula in middle one third of left femur. When fistula is closed after 7- 10 days there is swelling, hyperemia, increase of temperature till 39 C. Disease connected with trauma in 1944. In X-ray of left femur two projections found: In diaphysis thickened due to assimilation of many layer periostitis. In anterior exterior edge can be seen destructive cortical layer. In bone found separated cavities, which connect between themselves with damage integrity of endosteum on 6 cm.
Give the data which is characterized for the above pathological process and tactic of treatment?
Ans: Chronic posttraumatic osteomyelitis of left femur, fistular form.

TYPICAL TASK No.23
A day before a young woman all of a sudden had got a severe pain in the right iliac region. The patient’s general condition was satisfactory, temperature- 37.80C, pulse 100 beat / min, a wet tongue; abdomen was not swollen, participated in respiration, in the right iliac region overstrained, severely painful with positive symptom of rebound tenderness in the lower half of the abdomen. A Rowsing, Sitkovsky signs were positive, leukocytosis in blood 12. 3 x109 l.
1. What is the likely diagnosis?
2. What is the likely surgical treatment?

23.Острый деструктивный аппендицит. Экстренная операция аппендэктомия, санация правой подвздошной области, дренирование брюшной полости одним дренажом правой подвздошной области.


EMERGENCY MEDICAL AID TASK No.24
A 57-year- old male, who lives in a village, after working hard in the garden felt himself breathless and had severe constricting sternal pains. Paramedics performed an ECG exam and revealed signs of acute myocardial infarction. Physical examination showed loud breathing, crackles heard in the distance. He was coughing out pinkish froth. AP was 80/40, heart rate -130, RR -28.
1. What is the likely condition?
2. What is the most appropriate emergency treatment?

Answer: The patient has myocardial infarction with complications of acute left ventricle insufficiency which brought to the development of cardiogenic pulmonary edema. A complex emergency therapy includes oxygenotherapy, anesthesia, medications to reduce pinkish froth, dobutamine, for example, to improve the contractility of the myocardium.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.24
In newborn with body weight 2100g, on 2nd day of life develop respiratory and cardiovascular insufficiency; cyanosis, acrocyanosis, on left lung cannot be heard breathing, abdomen is sunk down. In stomach, through probe is given 10,0 ml 5% solution barium. After 12 hours, was made X-ray of organs of thorax and abdomen.
Give interpretation of X-ray and put diagnosis.
Answer:
1.on X-ray film of organ of thorax and abdomen in anteroposterior view, almost all contrast substance define in left hemithorax and small amount of it exit to rectum. Pneumatization of intestine in abdomen absent.
2.Congenital left-sided diaphragmal hernia ( maybe false) with significant defect in left dome of diaphragm, as if whole intestine has moved to pleural cavity.
SITUATIONAL TASK № 24
A patient was admitted to the hospital after the road accident. On inspection of patient: on percussion of right lung up to 7th intercostals space-tympanic sound. Inferiorly it is dullness of percussion sound. In auscultation, breathing of right lung cannot be heard. On palpation breathing can be felt. Reveal crepitation in bone. On inspection of right femur and shoulder: in middle third diaphysis there is deformation, shortening of length of segment. On differentiating with contra lateral side-pathological mobility. On x-ray of chest, diagram of right lung cannot be reveal. Can be seen pressed lung, level of fluid goes up to 7th rib to the right. Fractures of VII-VIII-IX-X ribs to the right are on axillary’s line. On x-ray of right hip and right shoulder in two projections reveal transverse fracture in middle 1/3 of diaphragm with deviation of fracture on length and its width.
Formulate the diagnosis of this patient.


Answer: Severe multiple trauma. Complicated fracture of VII-VIII-IX-X ribs to right on the anterior axillary’s line with damage of right lung. Right sided hemo-pneumothorax. It’s closed fracture of right thigh in middle 1/3 with deviation of fracture by length, width and under angle. It’s closed fracture of right shoulder with middle third with deviation of fracture on length, width and under angle. It’s traumatic shock-III degree.

TYPICAL TASK No.24
A 34-year-old patient T. was admitted to the hospital with peptic ulcer complicated by perforation. Severe pain in epigastrium region developed 2 hours ago. At the time of operation a perforated ulcer with diameter of 0.3 cm at the anterior wall of the duodenum was found out. Signs of peritonitis were absent.

1. What complication occurred as a result of perforated ulcer of duodenum?
2. What operation is necessary to perform in this patient?
ulcerative disease of duodenum, complicated by perforation. Organ restoring operation, selective proximal vagotomy, suturing the perforation orifice, duodenoplastic.

EMERGENCY MEDICAL AID TASK No.25
A 52- year- old male with acute alcoholic intoxication was brought to the reception department. Physical examination revealed deep unconsciousness (GCS -12).His reactions were not adequate. Psychomotor excitation and absence of verbal contact were revealed. Skin was icteric and turgor decreased. BP was 155/90, HR – 108, RR-14. Liver border was not palpable.
1. What is the likely condition?
2. What is the most appropriate emergency treatment?

Answer : The patient has an acute psychosis due to alcohol intoxication. Rapid relief of acute psychosis will be a success in case of intravenous injections of benzodiazepines as well as detoxication therapy (gastric lavage, enterosorbtion,
artificial dieresis).
SITUATIONAL TASK ON PEDIATRIC SURGERY No.25
In newborn, 5th day of life, which has been transferred from maternity home to children surgical department, and in which, after X-ray of organs of thorax and abdomen, has suspected left-sided diaphragmal hernia, was made irrigoscopy and –graphy.
Estimate results and purpose of this X-ray investigation.
Answer:
1. during irrigoscopy and –graphy, contrast substance has filled the loops of large intestines, which most of its parts located in left pleural cavity.
2. diagnosis congenital left-sided diaphragmal hernia confirmed.
3. the purpose of irrigoscopy and –graphy, is to determine possibility pathology of large intestine and determination of which part of intestine has moved to pleural cavity.
SITUATIONAL TASK № 25
Patient, 33 years old, had a trauma on the right leg after road accident. On investigation reveal a wound on the anterior-interior surface on the middle third of leg, size 10X3 cm. Pathological mobility and crepitation is relatively are located at the wound. On X-ray–fragmental fracture of both bone of both legs and middle 1/3 with deviation of fracture on length, width and under angle.
Your preliminary diagnosis. Show what measures should be taken and its results, which are necessary for doctor of ambulance at the place of the accident to the patient.
Answer; Severe trauma. Dull trauma of abdomen with rupture of spleen. Compression fracture of -II degree. Compression shock-III degree.

TYPICAL TASK No.25
A 38-year-old patient K. with cholecystopancreatitis was treated at the therapy department. Again a pain in epigastrium region, right hypochondrium appeared. This condition worsened a day ago. Pain increased in the right hypochondrium, a feeling of thirst and dryness in the mouth appeared. On palpation a positive symptom of Orthner, Mussie, “Blumberg sign” in the right hypochondrium developed. Body temperature was 38 C. Blood analysis revealed leukocytes of
12 x 109/l, ESR 25 mm/hr, urine analysis was without pathology, aspartate aminotransferase- 0.9 mmol/l, alanine melanotransferase- 0.5 mmol/l, general bilirubin -25 mmol/l. On ultrasonography (see ultrasound report).

1. What is the likely diagnosis?
2. What is the likely surgical treatment?


Task 25
Diagnosis acute destructive cholecysitis, ultrasound,general blood analysis, general urine analysis, transaminase in blood. Billirubin level in blood, protein in blood, coagulogram, electrolytes in blood. Tactics of treatment-urgent operation, cholecystecomy, revision of choleda.

EMERGENCY MEDICAL AID TASK No.26

A 45- year-old habitual drunkard after 5 days of alcoholic intoxication was brought to the reception department. Physical examination revealed deep unconsciousness (GCS -12).His reactions were not adequate. Psychomotor excitation and absence of verbal contact were revealed. Skin was icteric and turgor decreased. BP was 155/90, HR – 108, RR-14. Liver border was not palpable.

1. What is the likely condition?

2. What is the most appropriate emergency treatment?

Answer : The patient has an acute psychosis due to alcohol intoxication. Rapid relief of acute psychosis will be a success in case of intravenous injections of benzodiazepines as well as detoxication therapy (gastric lavage, enterosorbtion,

artificial dieresis).

SITUATIONAL TASK ON PEDIATRIC SURGERY No.26

A girl of 5 y.o, during 1 year complains of pains in lower part of abdomen, increased body temperature, often painful urination . the baby was hospitalized in surgical department. In urine analyse: protein – 0,99g/l, microscopy deposit: leucocytes – 10-15 in f.o.v, some places accumulation of 30-40 in f.o.v; erythrocytes - 8-10 in f.o.v, fresh; cylinders – hyaline – 2-3 in f.o.v. In purpose for confirmation of diagnosis, was done miction cystography .

Check out all analysis of different method of investigation and put diagnosis.

Answer:

1. on miction cystography can be determined unclear borders of lateral wall of urinary bladder and exit of contrast substance in right ureter and from left in pelviocalices system. Presence of leucocyturia and erythrocyturia , speak about chronic inflammation urinary bladder.

2. Chronic cystitis. Active bilateral cysto-ureteral reflux. From right 1st stage, from left 2nd stage.

SITUATIONAL TASK № 26

Patient, 38 years old, complaints on increased pain in the right half of pharynx, pain in tightness and difficulty on swallowing. Can swallow only fluid. General weakness, high temperature of body, 4 days back after had catarrhal tonsillitis. Objectively: voice of nasal character, difficult to open the mouth. Bright hyperemia of mucous cavity of pharynx, infiltration of tissue in the right near to tonsillar area. Right tonsil is deviated to medial line. Tongue is edematous and deviated to left, dense, increased and painful of supraclavicular and right submandibular lymphatic nodes. Otoscopically and laryngoscope-no pathology is reveal. On general blood analysis;(Leu.-12 x 10/L,eosinophils-0%,basophils-1,stab-12%,segmented-60%,lymphocytes-24%,monocytes-3%).

Formulate the diagnosis.

Answer: Paratonsillar abcess.Excision of paratonsillar abcess.

TYPICAL TASK No.26

A 38-year-old patient D. has been receiving treatment for duodenal ulcer for a long time. During the last month symptoms of overfilling at epigastric region after taking meal, periodic vomiting with undigested food, decrease of weight for 9 kg for a month, periodic convulsions of muscles of extremities developed.

1. What is the likely diagnosis?

2. What is the surgical treatment in this case?

Task 26

Ulcerative stenosis of pylorus . Investigation by x ray of stomach using barium contrast, fibrogastroscopy, general blood analysis, general analysis of urine, blood electrolytes. Treatment- operative, organo-restoring operation, vagotomy, pyloroplastic.

EMERGENCY MEDICAL AID TASK No.27

Ambulance brought a 35- year- old lady to the reception department with complaints on severe pain in the oral cavity and esophagus. It happened after consumption of a little quantity of unknown liquid with strong acidic taste. The

woman mistook it for the water. Examination revealed the state of excitement. The mucous membrane of oral cavity was hyperemic with patches of desquamation, edematous and bleeding. BP was 140/90, heart rate - 90.

1. What is the likely condition?

2. What is the most appropriate emergency treatment?

Answer: The patient experiences acute poisoning with corrosive substance, may be acid. A hospitalization to the surgical department is necessary. Complex treatment includes analgesics, washing of the oral cavity with weak alkaline solution. .

SITUATIONAL TASK ON PEDIATRIC SURGERY No.27

Boy 8 y.o, during last 2 years , periodically complains of dull pain in right half of abdomen, which sometimes accompanied by increase of body temperature till 38-39 deg. There was weakness and fatigue. The child began to lag in physical development. Blood analysis: leucocytes 10,8х109/л; stab neutophils 16%. Urine analysis: erythrocytes – fress 20-15 in f.o.v and single выщелоченные ; density – 1005; protein – 0,99 g/l, leucocytes – 10-20 in f.o.v. Urine analysis by Nechiporenko: leucocyturia – 8000; erythrocytes – 2000 in 1mkl. Was done retrograde pyelography.

Estimate X-ray pictures and the laboratory investigation method, put diagnosis.

Answer:

1. on retrograde pyelogramme, defined narrowing 1/3 right ureter with decrease peristalsis, and also dilation pelviocalices system. In blood analysis – leucocytosis and shift to left, in urine analysis – erythrocyturia, leucocyturia, isosthenouria.

2. hypoplasia in 1/3 right ureter, right-side hydronephrosis, chronic pyelonephritis in exacerbation phase.

SITUATIONAL TASK № 27

A worker, 20 years old, 6 days back contact with tonsillitis. 2 days back pain on swallowing increased and irradiates towards the ear. Appeared pulsating pain in the right half of neck. The patient is pale and feel irritated. Salivation from mouth. Speech is difficult, nasal voice. Opening of mouth is limited. Anterior palatine arch towards right is infiltrated, hyperemia. Uvula and soft palatine are also edematous. Tonsils are deviated towards medial line. On general blood analysis (Leu.12X10/L, eosinophils-0%, basophils-1%, stab-12%, segmented-60%, lymphocytes-24%, monocytes-3%, ESR-20mm/h).

Formulate the diagnosis.

Answer: Paratonsillar abcess .Excision of paratonsillar abcess.

TYPICAL TASK No.27

A patient was operated for strangulated inguinal hernia with necrosis of loop

of the small intestine and phlegmon of hernial sac. A laparotomy, resection of small intestine, sewing up of small intestine by anastomosis” side to side” was done. The wound was cleaned with antiseptic solution. Operation was finished with plastic surgery on the inguinal canal by one of the methods. Enteroparesis, symptoms of irritated peritoneum and clinical picture of peritonitis developed in the early post-operative period.

1. What complication is likely to occur in this case?

2. What surgical treatment is necessary in this case?

Task 27Loosening/opening of anastomose sutures peritonitis. Urgent repeated operation-relaparotomy resection of anastomosis, removal of ileostomes, sanation of abdominal cavity, peritoneal dialysis.

EMERGENCY MEDICAL AID TASK No.28

Ambulance brought a 27-year-old man to the reception department after vodka consumption. Examination showed sopor (GCS- 9), pale skin , acrocyanosis , injected sclera, od= os =5mm. BP was 140/90, heart rate -98,RR- 27.

On auscultation apical right lung breathing was weak. Bronchial breathing in the whole of the lungs with polymorphic rales was heard.

1. What is the likely diagnosis?

2. What is the likely emergency medical aid?

Answer: The patient has an acute poising by alcoholic surrogates. A complex treatment includes hospitalization, oral cavity washing out, stomach lavage, infusion therapy, antibiotic therapy to treat aspiration pneumonia.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.28

The child 12 years has addressed for medical help with the complaints on a pain in a stomach, which more often arise after physical loading. The pains carry changeable character and disappear independently. From words of the mother, the child during last 1,5 years is sick. Within one year at the child began to raise t0 of a body up to 37-380. Has decreased of appetite. The child began to lag behind in physical development.

The urine analysis: leucocytes - 10-15 in f.o.v; erythrocytes - single; cylinders – hyaline single; bacteria - have a lot ; protein - 0,33 g/l; creatinin - 0,7 mmol/l; sugar - 1 %. The analysis of urine by Zimnisky: density - 1007-1010, day time diuresis - 200 ml, night - 700 ml. Is executed excretory urography for 30 minutes.

The task:

Estimate X-ray picture, the data of laboratory methods of research and put the diagnosis.

The answer:

1. On excretory urogramm ,the expressed dilation of both ureters and pelviocalices system of both kidneys is marked. Outflow of urine from kidneys and urters is complicated. In urine analysis found leucocyturia, isosthenouria. Night diuresis exceeds day time one.

2. Bilaterial ureterohydronephrose

SITUATIONAL TASK № 28

Patient, 43 years old, often complain on tonsillitis accompany with high temperature. Pain in the chest region, joints and sub febrile temperature. The patient suffer from tonsillitis for the past 10 years. Three times the tonsillitis is complicated by paratonsillar abscess. On pharyngosopy: tonsils I-II degree of hypertrophy. Fragile and the lacuna is filled with pus. The tonsils are covered with the tissue. The anterior palate is stagnantly hyperaemia. Submandibular lymphatic nodes are painful. On palpation, the lymph nodes are increased in size. Other ENT organs are without any pathology changes.

Formulate the diagnosis.

Answer: Chronic decompensated tonsillitis. Tonsillectomy.

TYPICAL TASK No. 28

A 28 -year- old patient J. was admitted to the surgical department after

the road accident. On examination a skin paleness, pulse-110 beat/min,

BP-90/60 mm /Hg were revealed. Abdomen was overstrained and painful

in the left hypochondrium and in the meso- and epigastrium region; positive

“Blumberg sign”, dullness in the flat area of abdomen appeared.

1. What is the character of intra-abdominal damage?

2. What is the likely additional method of investigation?

3. What is the likely surgical treatment in this case?

Task 28

Diagnosis: closed trauma of abdomen, intraperitoneal hemorrhage. Investigation – laparocentesis with «шарящим катетром» or urgent laparoscopy, followed by laparotomy, revision of peritonel cavity stopping of bleeding(upon spleen rupture-splenectomy).

EMERGENCY MEDICAL AID TASK No.29

A 5- year- old child suffering from ARVI presents to the family doctor.

Suddenly at night the patient had inspiratory dyspnea with intercostal retraction and extra muscles help at breathing, wheeze, hoarse voice, barking cough. On examination, the child is excited and restless. The patient has temperature (38.5C), cyanosis of nasolabial triangle, pharynx mucosa is hyperemic, but without tongue deposits. The heart rate is 130, RR- 36.

1. What is the likely pathological condition?

2. What is the most appropriate course of management?

Answer: The patient has a subglottic edema with developing acute stenosing

laryngotracheitis. The clinical picture described corresponds to the laryngostenosis, type II. Treatment includes moderate sedatation, vapor inhalations of oxygen with sympathomimetics and glucocorticoids; intravenous injections of glucocorticoids, antihistamines; oral administration

of mucolytics; moderate dehydratation with diuretics.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.29

The girl, 10 years, during last 2 years complains of pain in the left half of abdomen. In the beginning pains carried character of unpleasant pressure in the abdomen without precise localization, quite often of alternating type. Last 6 months intensity of pain has decreased, but when she drinks liquid a lot, pain increases. Her parents also revealed, that after intake of big volume of liquid periodically,there is appearance of tumour-like formation in the left subcostal region . The above-stated complaints have served as an occasion for an urological investigation. It was performed an excretory urography due to a suspection of left-sided retropneumoperitoneuma. The analysis of blood: leucocytes - 9,6х109/L; stab neutrophils. - 11 %. The urine analysis: protein - 1,2 g/l; erythrocytes - 12-15 in in f.o.v; leucocytes - 10-8 in f.o.v; cylinders – hyaline casts 1-2 in f.o.v.

The task:

Estimate X-ray picture and these laboratory methods of research, put the diagnosis.

The answer:

1. On the excretory urography can be determined the dilation of the pelvicalices systems. In this case are extended large calyces because of intrarenal expansion of pelvis. Ureter is not contrasted. In the urine analysis, expressed proteinuria and moderate erythrocyt- and leucocyturia.

2. Obstruction of pelvio-ureteral segment at left side. Left-side hydronephrosis.

SITUATIONAL TASK № 29

Patient complaints on frequent tonsillitis, which he had been suffering since childhood. At the age of 24 years old, the tonsils is complicated by paratonsillar abscess, in duration of last year patient complaint pain in the heart region. Objectively: condition of patient is satisfactory. Pulse is rhythmic, 76 beat/min. In auscultation appears functional heart murmur. Other changes on the side of inner organ are not defined. On the palate reveal light hyperemia mucous membrane of anterior palatine arch. Tonsils are hard, scarring, attach to the arch of palatine. In lacunars of tonsil reveal pus. The lymphatic nodes of submandibular are dense, increase on palpation. Mucous membrane of posterior wall of throat is pink in color, with increase of single granuloma.

What is the diagnosis?

Answer: Chronic decompensated tonsillitis.Tonsilloectomy.

TYPICAL TASK No. 29

A 48-year- old patient C. suffered from acute destructive pancreatitis 6 months ago. She was again rehospitalized in the surgical department with the complaints of pain in the epigastric region. On examination elastic mass (8 x 6 cm) in the epigastric region is palpated. Symptom of abdominal irritation is absent. Symptoms of pancreatitis are hardly revealed.

1. What kind of pancreas pathology is revealed?

2. What plan of investigation and method of operation would you suggest?

Task 29

Pancreatic cyst., investigation ultrasound of peritoneal cavity, roengenography of peritoneal cavity and duodenum, general blood analysis and general urine analysis, biochemical analysis of blood. Treatment- surgical- cytojejuno anastomosis or cystogastro anastomosis

EMERGENCY MEDICAL AID TASK No.30

A 4.5- year- old child suffering from ARVI presents to the family doctor.

Suddenly at night the patient had inspiratory dyspnea with intercostal retraction and extra muscles help at breathing, wheeze, hoarse voice, barking cough. On examination, the child is excited and restless. The patient has temperature (38.5C), cyanosis of nasolabial triangle, pharynx mucosa is hyperemic, but without tongue deposits. The heart rate is 130, RR- 36.

1. What is the likely pathological condition?

2. What is the most appropriate course of management?

Answer: The patient has a subglottic edema with developing acute stenosing

laryngotracheitis. The clinical picture described corresponds to the laryngostenosis, type II. Treatment includes moderate sedatation, vapor inhalations of oxygen with sympathomimetics and glucocorticoids; intravenous injections of glucocorticoids, antihistamines; oral administration

of mucolytics; moderate dehydratation with diuretics.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.30

1.5 years ago, a 12 year old boy suffered from acute hematogenous osteomyelitis of the left б/берцовой bone.The diagnosis was put 7 days after the start of disease. At present, upon observation, there are 2 fistulas with purulent discharge on the lower third of anterior surface of knee. General blood analysis: leukocytes-22,0x109/l; stab – 19%. Urinalysis: density – 1018; protein – 0,33 g/l; erythrocytes – 5-7 in f.o.v.; leukocytes – 10-15 in f.o.v. bacterioscopy of pus from fistula gave gram(+) cocci and gram(-) rods.

Task:

Analyze x-ray and other extra methods of investigation, give clinical diagnosis.

Answer:

On x-ray the bones of left knee in 2 projections: many cavities with small sequestrae on lower third of left б/берцовой bone. Blood analysis – increased leukocytosis and stab shift. There are signs of kidney affection with purulent intoxication. Bacterioscopy gave mixed pathogenic flora. On the basis of the above named clinico-laboratory picture, we can puit the following diagnosis: chronic hematogenic osteomyelitis of left tibia, sequestrae-fistula form.

SITUATIONAL TASK № 30

Child, 5 years old, the parent’s complaint that he can’t sleep at night, noisy breathing, mouth always widely opens. Hoarse voice, swallowing of solid food with force, eats slowly. Objectively: abnormal taste, hard palate is high. Palatine tonsil is soft, big size, located in the midline. Arch of palatine is not changes, clear lacunaria, regional lymph nodes is not enlarged. In palpation investigated of the naso-pharynx reveal soft-elastic consistency formation, which cover the choanae.

What is the diagnosis?

Answer: Hypertrophy of palatine tonsil-III degree, Adenoid vegetative-III stage. Adenotomy, tonsillotomy

TYPICAL TASK No.30

A 22-year-old parturient woman B. a month after delivery has got pain in the right mammary gland with body temperature up to 380C. On examination of mammary gland infiltration in the upper external quadrant, hyperemia of mammary gland, severe pain and symptoms of fluctuation were observed.

1. What is the likely diagnosis?

2. What is the likely surgical treatment?

Acute purulent mastitis.Investigation:mammography,ultrasound of mammary gland,general blood and urine analysis.Urgent operation:opening and drainage of purulent cavity,antibacterial therapy,local dressing

EMERGENCY MEDICAL AID TASK No.31

To relieve teeth ache a young woman took 2 tablets of analgesic orally. After a while edema of face, eyelids and ears started developing, difficult noisy respiration and hoarse voice appeared.

1. What is the likely condition?

2. What is the most appropriate course of management?

Answer: The clinical picture, typical edema localization and its rapid progression state of Quincke’s edema development.To start emergency medical aid

it’s necessary to inject intravenously 05-07ml of 0.1 % adrenaline solution then continue its drop infusion. You should include to the treatment glucocorticoids and antihistamines, in case of respiratory insufficiency oxygen therapy is also of great importance.In case of inefficiency and respiratory insufficiency progression you should do trachea intubation and connect to artificial ventilation of lungs.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.31

A 12- years-old boy fell down on an outstretched left arm in the street. He complains of a pain in area of elbow joint and painful elbow motion. On physical examination, ecchymosis, swelling, and tenderness are in the left elbow area. Skin is undamaged. Deformity and limited elbow motion are marked. Anteroposterior and lateral x-rays of the left humerus with elbow joint is ordered.

Task:

1. Analyze of the presented x-rays, and perform a conclusion.

2. Make a clinical diagnosis.

Answer:

1. Supracondylar fracture of distal humerus with longitudinal displacement and angulation.

2. Closed supracondylar fracture of distal humerus with longitudinal displacement and angulation.

31. SITUATIONAL TASK

Patient , 38yrs old, complains on increased pain in the right half of pharynx, pain with tightness, difficulty on swallowing. Can swallow only fluid. General weakness, high body temperature, 4 days ago had catarrhal tonsillitis. Objectively:- voice of nasal character, difficult to open the mouth. Hyperemia of bright of mucous cavity of pharynx with infiltration of tissue in the near right tonisilar area. Right tonsil is deviated to medial line. Tongue is edematous and deviated to left, increased and painful supraclavicular and right submandibular lymphatic nodes. Otoscopically and laryngoscopicpy reveals no pathology. On general blodd analaysis( L. 12x10/l, Eos. 0%, Baso 1, Stab 12%, segmented 60%, lymp. 24%, mon. 3%)

Formulate the diagnosis.

Ans: Paratonsillar abcess. Excision of paratonsillar abcess.

TYPICAL TASK No.31

A14- year-old teenager has got asymmetry of thorax due to reduction of its left half, narrowing of intercostal intervals, weakening of breath, which was found out at physical examination. At medical examination it was established that the boy lags behind in physical development in comparison with the schoolchildren of his age and because of dyspnea he cannot do exercises properly at the lessons of physical culture.

1. What is the likely diagnosis?

2. What is the likely additional investigation to prove the diagnosis?

31. Hypoplasia of the left lung. Researches: X-ray of thorax, КТ of lungs, bronchography. Supervision at the lung specialist.

EMERGENCY MEDICAL AID TASK No.32

A young women was stung by a wasp. After a while edema of face, eyelids and ears started developing, difficult noisy respiration and hoarse voice appeared.

1. What is the likely condition?

2. What is the most appropriate course of management?

Answer: The clinical picture, typical edema localization and its rapid progression state of Quincke’s edema development.To start emergency medical aid

it’s necessary to inject intravenously 05-07ml of 0.1 % adrenaline solution then continue its drop infusion. You should include to the treatment glucocorticoids and antihistamines, in case of respiratory insufficiency oxygen therapy is also of great importance.In case of inefficiency and respiratory insufficiency progression you should do trachea intubation and connect to artificial ventilation of lungs.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.32

A7-years-old girl complains of recurrent pain in a right small back and sub febrile temperature during a month. Urinalysis shows 15 - 20 leucocytes. Voiding cystourethrogram is performed along with other imaging.

Task:

Put an initial diagnosis.

Answer:

Grade III active vesicoureteral reflux and ureteropelvic stenosis of the right kidney.

32. SITUATIONAL TASK

A worker, 20 yrs old, 6 days back contact with tonsillitis . 2days back pain on swallowing increased and irradiated towards the ear. In addition, appeared pulsating pain in the right half of neck. The patient is pale and feels irritated. Salivation is from mouth. Speech is difficult, nasal voice. Opening of mouth is limited. Anterior palatine arch towards right is infiltrated and hyperemic. Uvula and soft palatine are also edematous. Tonsils are deviated towards medial line. On general blood analysis ( L. 12, eos. 0%, bas. 1%, stab. 12%, segmented 60%, lymp. 24%, mono. 3%, ESR. 20mm/h).

Formulate the diagnosis.

Ans: Paratonsillar abcess. Excision of paratonsillar abcess.

TYPICAL TASK No.32

A 5- year-old patient K. is brought by his father to the reception department of the republican hospital informing that the boy playing on a floor in his cabinet suddenly has got paroxysm of stridulous cough with a picture of asthmatic fit. The child became restless, frightened, acrocyanosis appeared. Gradually his condition has improved, breath was normalized. At physical examination no pathology was revealed.

1. What is the likely explanation for this case?

2. What is the likely investigation to be done for this case?

32 Forein body of a bronchial tree. X-ray of lungs. Fibrobronchoscopy

EMERGENCY MEDICAL AID TASK No.33

A 24 year old male was brought by the ambulance to the reception department of district hospital. After traffic accident he got craniocerebral injury. At the moment of accident he had convulsions and was unconscious for 5 minutes.Examination showed consciousness onthe level of sopor (GCS- 9-10),OD=OS= 5 mm.

Moderate rigidity of occipital muscles, hyperreflexia, tendon reflex- D>S,AP 140/90, heart rate-48, RR- 27, superficial breathing is revealed. Examination of the eye fundus reveals stagnant discs of the optic nerves. Echoencephalography shows a lot of additional echo signals, with 2mm of midline structures displacement from the left to the right. On the X-ray of skull bones, bone deformation is not revealed. On CT scan , signs of intracranial hypertension was revealed.

1. What is the likely condition?

2. What’s the most appropriate course of management?

Answer: Neurological status, bradycardia with hypertension and tachypnoe, as well as additional methods of investigation evidence of posttraumatic brain edema of patient. Since the CT scan excluded focal brain damage with dislocation syndrome, the patient should be indicated conservative treatment for brain edema. Intensive conservative treatmentof brain edema includes adequate respiration management (artificial lung ventilation with moderate hyperventilation regime,if necessary), correction of hemodynamic indexes, formation of protective inhibition of the CNS with the use of barbiturates and sodium oxybutirates, elevate the head part of the bed to 30 degrees. Prophylaxis and immediate reduction of locomotor stimulation convulsions with the help of benzodiazepams or barbiturates, hyperglycemia with the use of dehydration therapy( osmotic diuretics and L- lysine escirnat.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.33

A male neonate was born in asphyxia due to an entanglement of umbilical cord. On the 2nd day of life the bilious vomiting is appeared. Meconium stool is passed. Epigastrium is distended. Gastric lavage was performed and about 40.0 ml of greenish content was aspirated. Plane abdominal radiograph was made.

Task:

1. Analyze of the presented x-ray, and perform a conclusion.

2. Make an initial diagnosis.

Answer:

1. The “double bubble” gas shadow above and the absence of gas in the distal bowel.

2. Congenital high intestinal obstruction.

33. SITUATIONAL TASK

Patient 43 yrs, old, often complains on tonsillitis accompany with high temperature. Pain in the chest region, joints and subferbrile temperature. The patient suffers from tonsillitis from the past 10yrs. Three times the tonsillitis is complicated by paratonsillar abcess. On pahrayngoscopy tonsils, I-II degree is hypertrophy. Fragile and lacuna is filling with pus. The tonsils are cover with tissue. The anterior palate is stagnantly hyperemic. Submandibular lymphatic nodes are painful. On palpation, the lymph nodes are increase in size. Other ENT organs are without any pathological changes.

Formulate the diagnosis.

Ans: Chronic decompensate tonsillitis. Tonsillectomy.

TYPICAL TASK No.33

A 42 –year-old patient complains of spasmodic pain in a stomach, nausea, vomiting, a delay of stool and gases. The patient had an operation on perforating stomach ulcer in the past. On physical examination, pulse is 94 beat/min, AP- 90/60, tongue is dry. The abdomen is moderately tympanitic and dissymmetric, splash is determined. Peristaltic noise is periodically inhanced. On survey X-ray

Kloyber cups of small intestine are revealed.

1. What is the likely diagnosis?

2. What is the most appropriate course of management?

33.Ileus (spikes). Conservative actions within several hours (cleaning, siphon clismes, paranephral novocain blockade), intravenous therapy, spasmolytics, at an inefficiency – operation: laparotomy, separation of spikes

EMERGENCY MEDICAL AID TASK No.34

A 28-year-old man, after he had fallen from the 3-d floor, was admitted to the reception department of the hospital with craniocerebral trauma. During the accident he had convulsions.

Examination showed coma (GCS- 6),OD=OS= 5 mm.S ymptomatic rigidity of occipital muscles, hyperreflexia, tendon reflexes- D>S,AP 150/100, heart rate-54, RR- 38, arrhysmic, superficial breathing is revealed. Examination of the eye fundus reveals stagnant discs of the optic nerves .Echoencephalography shows a lot of additional echo signals, with 2mm of midline structures displacement from the left to the right. On the X-ray of skull bones, bone deformation is not revealed. On CT scan , signs of intracranial hypertension was revealed.

1. What is the likely condition?

2. What’s the most appropriate course of management?

Answer: Neurological status, bradycardia with hypertension and tachypnoe, as well as additional methods of investigation evidence of posttraumatic brain edema of patient. Since the CT scan excluded focal brain damage with dislocation syndrome, the patient should be indicated conservative treatment for brain edema. Intensive conservative treatmentof brain edema includes adequate respiration management (artificial lung ventilation with moderate hyperventilation regime,if necessary), correction of hemodynamic indexes, formation of protective inhibition of the CNS with the use of barbiturates and sodium oxybutirates, elevate the head part of the bed to 30 degrees. Prophylaxis and immediate reduction of convulsions of locomotor stimulation with the help of benzodiazepams or barbiturates, hyperglycemia with the use of dehydration therapy( osmotic diuretics and L- lysine escinat).

SITUATIONAL TASK ON PEDIATRIC SURGERY No.34

A healthy neonate of the 1st day of life has had an abdominal distention in 18 hours after birth, followed by vomiting. Physical examination revealed hard palpable masses throughout the abdomen that are movable in any direction. Meconium is not passed. Plane abdominal radiograph shows multiple loops of dilated small bowel and coarse granular “soap – bubble” appearance. Gastrograffin enema was given.

Task:

1. Analyze of the presented x-ray.

2. Make an initial diagnosis.

Answer:

1. Unused small colon (microcolon) is on the film that is sign of simple meconium ileus.

2. Congenital low intestinal obstruction. Meconium ileus.

34.

Patient complains on frequent tonsillitis, which he had been suffering since childhood. At the age of 24 tonsils got complicate by paratonsilar abcess. In duration of last year patient complains pain in heart region. Objectively: condition of patient is satisfactory. Pulse is rhythmical with 76 beats / min. On auscultation appears functional heart murmur. Other change on the side of inner organ is not defined. On the palate reveal, light hyperemic of mucous membrane of anterior palatine arch. Tonsils are hard, scarring, attached to ach of palatine. In lacunars of tonsil reveals pus. The lymphatic node of submandibualr is dense, enlarged on palpation. Mucous membrane of posterior wall of throat is pink in color with increase of single granuloma.

What is the diagnosis?

Ans: Chronic tonsillitis. Tonsillectomy.

TYPICAL TASK No.34

The patient complains of pain in epigastrium and the right hypohondrium. He is sick within a week. At the beginning the pain was very sharp, then its intensity has decreased, and after that an icteric colouring of skin and sclera appeared. The stomach is strained and painful in the right hypohondrium. Orthner symptom is positive . At ultrasonic invastigation shows stones in a gallbladder, a wall of gallbladder is 0.7 cm, choledochal diameter – 1.5 cm, structure of pancreas is

nonuniform. Bilirubin - 86 ммоl/l, direct bilirubin – 42 ммоl/l .

1.What is the likely diagnosis?

2.What is the additional investigation in this case?

3. What is the most appropriate course of management?

34. Acute calculose cholecystitis, choledoholytiasis, mechanical jaundice. Retrograde holecystoholangiography, endoscopic papillotomy, КТ, research alkaline phosphotase of blood, АlТ, АsТ blood. The delayed operation holecystectomy, holedoholytotomy, holedohostomy

EMERGENCY MEDICAL AID TASK No.35

A victim was found in the street in an unconscious state and brought to the hospital.

On examination, state of deep unconsciousness(GCS-11), OD = OS = 5 мм., smell of alcohol was revealed. Skin was cyanotic and cold. Dense edema of face and of palms, general muscular rigidity,superficial respiration, RR -12, bradycardia(40 beats per min), BP - 100/40 mm Hg, rectal temperature 30°С was found out.

1. What is the likely condition?

2. What’s the most appropriate course of management?

Answer: The patient has general overcooling. It’s necessary to remove wet clothes and cover with woolen blankets. Then continue with intravenous infusion therapy

(salt solutions by heating them up to 37-38°C),insufflation of wetting oxygen,

purulent and septic complication prophylaxis,arrhysmia prophylaxis(lidokain,cordaron),permanet cardiomonitoring.

Important! In order to prevent burns, the temperature should not exceed skin temperature of patient more than 2°С. Stop active warming, when rectal temperature increases up to 35°С.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.35

Parents bring their 14-month-old boy to the emergency department with a 1-day history of “tumor” mass in the right half of abdomen. Mother discovered it fortuitously while bathing the child. Renal Ultrasonography and Excretory Urogram with retro-pneumoperitoneum were made.

Task:

1. Analyze of the presented x-ray, and perform a conclusion.

2. Make an initial diagnosis.

Answer:

1. Large tumor mass is in the projection of right kidney and its intrarenal origin is visible.

2. Wilms tumor (nephroblastoma) of the right kidney.

35. SITUATIONAL TASK

Child 5 yrs old, the parent’s complaints that he can’t sleep at night, noisy breathing, mouth always widely open. Hoarse voice, swallowing of sloid food with force, eats slowly. Objectively: abnormal taste, hard palate is high. Palatine tonsil is soft, big size, located in midline. Arch of palatine is not change, clear lacunar, regional lymph nodes is not enlarge. In palpation investigative of the naso-phayrnx reveal soft- elastic consistency formation which cover the choanace.

What is the diagnosis?

Ans: Hypertrophy of palatine tonsil III degree, adenoid vegetative III stage. Adenotomy,

tonsillectomy.

TYPICAL TASK No.35

All of a sudden a young woman has got strong pains in the right lower part of abdomen. Her general condition is satisfactory, temperature -37.8 C, pulse –100 beat/min. A tongue is wet. The abdomen is not swollen and is not participating in the act of breath, in the right iliac part of abdomen, the bottom departments and mesogastric areas it is strained with sharp pain. There is a positive Blumberg sign in the lower half of abdomen, right and left iliac areas, mesogastric area. Rovsing, Sitkovsky signs are positive. Leukocytosis is 12.3 х10 .9 in 1l.

1. What is the likely diagnosis?

2. What is the necessary additional investigation?

3. What is the most appropriate course of management?

35. Acute destructive appendicitis. Researches: GBA, GUA, consultation of the gynecologist. At doubt in the diagnosis – a laparoscopy. Emergency operation appendectomy with drainage of abdomen cavity

EMERGENCY MEDICAL AID TASK No.36

A 39- year- old drunk man was found asleep in the street. He was brought to the hospital by the ambulance.

On examination, state of coma (GCS-7), OD = OS = 5 мм., smell of alcohol was revealed. Skin was cyanotic and cold. Dense edema of face and of palms, general muscular rigidity,superficial arrhythmic respiration, RR -7, bradycardia(40 beats per min), BP - 70/40 mm Hg, rectal temperature 27°С was found out.

1. What is the likely condition?

2. What’s the most appropriate course of management?

Answer: The patient has general overcooling. It’s necessary to remove wet clothes and cover with woolen blankets, elevate the head part of the bed to 30 degrees. Then continue with prophylaxis and immediate reduction of convulsions of locomotor stimulation with the help of benzodiazepams or barbiturates; intravenous infusion therapy (salt solutions by heating them up to 37-38°C and blood substitutes)to correct hemodynamics indexes; for adequate breathing management trachea intubation with the following artificial lung ventilation is necessary; purulent and septic complication prophylaxis, arrhysmia prophylaxis(lidokain,cordaron),permanet cardiomonitoring, use of dehydration therapy( osmotic diuretics and L- lysine escinat).

Important! In order to prevent burns, the temperature should not exceed skin temperature of patient more than 2°С. Stop active warming, when rectal temperature increases up to 35°С.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.36

Mother brought her 5-month-old boy to the hospital with a 1-month history of dysphagia and vomiting of undigested food. Barium esophagogram demonstrates dilated esophagus and narrowing at the lower esophageal sphincter.

Task:

1. Make an initial diagnosis.

2. Name the additional diagnostic examinations.

Answer:

1. Achalasia of esophagus.

2. Esophageal manometry and endoscopy.

36. SITUATIONAL TASK

Patient A. 38 yrs complains attacking pain on right iliac and lumbar region during 3 hours. Nausea with vomiting. Temperature 37 C, dry tongue, white coated, pulse 98 /min, rhythmic, soft abdomen, on deep palpation pain on right iliac area. On this region, shotkin-blumberg symptom is doubtful. On palpation, the right region of kidney gives modersate pain. Pasternatsky symptom is positive on right side. Analysis of blood: Hb 123g/l, L – 5-6 .f.v., ESR 15 mm/hr. Analysis of Urine: Sp. Density – 1015, protein – 0,033g/l, L- 5-5 f.v. Er. 8-10 f.v. On given data can’t differentiate between right sided colic pain of kidney and acute appendicitis.

What additional investigation can help in such situation?

Ans: US, absorbed and excretory urography, radio active renography, chromocystoscopy.

TYPICAL TASK No.36

A 48-year-old patient C. has been ill on cholelithiasis for a long time. She refused a systemic surgical treatment; 5 days ago the condition worsened. Jaundice appeared after the pain syndrome in the right hypochondrium, last 2 days the hectic temperature is marked. On examination the abdomen is strained, painful in the right hypochondrium, positive Orthner’s syndrome is manifested. On ultrasound stones in gallbladder and in holedoch are revealed, holedoch is dilated about 15 mm.

1. Enumerate complications of cholelithiasis manifested in the patient?

2. What is the additional investigation?

3. Specify a character of surgery.

36. Acute calculose cholecystitis, choledoholytiasis, mechanical jaundice. Retrograde holecystoholangiography, endoscopic papillotomy, КТ, research alkaline phosphotase of blood, АlТ, АsТ blood. The delayed operation holecystectomy, holedoholytotomy, holedohostomy

EMERGENCY MEDICAL AID TASK No.37

A 7-year-old child has been suffering from acute tonsillitis for a week. All of a sudden the body temperature increased to 40,8`C. The patient had tonoclonic spasms.

1. What is the likely condition?

2. What is the most appropriate emergency medical aid?

Answer:The convulsion syndrome developed in the child due to the body temperature increase . At convulsion development it is necessary to fix the head and hold the tongue to prevent it from being bitten off. To stop the convulsion, it is necessary to introduce intravenous or intramuscular injections of benzadiazepams(sibazon) or barbiturates (thiopental sodium). Further therapy is indicated for prophylaxis and treatment of fever with the help of NSAID (treating main disease) - the acute tonsillitis.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.37

A 4-month-old boy was treated in intensive care unit for right lower lobe pneumonia during 9 days. In the evening the patient has become agitated with markedly increasing of breathlessness and tachycardia. The nurse ordered a plane chest radiograph.

Task:

1. Put an initial diagnosis.

2. What is the indicated management?

Answer:

1. Acute necrotizing pneumonia, right pyopneumothorax.

2. Thoracocentesis and drainage of right plural cavity.

37. SITUATIONAL TASK

Patient 43 yrs old, complains pain on lumbar region, which is sometime intensifies. During last 5 yrs small stones of yellow brown color passes with urine. In US: enlargement of calyx-pelvis system of left kidney echo positive formation up to 20 mm with acoustic shadow. In absorb urogramm concernment shadow is not defined. In excretory urogramm-filling defect on right calyx part 22x18mm. In analysis of urine-protien 0,066g/l, L- 10-15 in f.v, crystal of uric acid of moderate quality.

What is your diagnosis?

Ans: Urate nephrolithiasis , stone of left kidney , chr. Pyelonephritis.

TYPICAL TASK No.37

Yesterday at cooking a 30- year-old patient A. had got a vapor burn of the right hand. She treated herself with medications she had. Next morning a wide blister which was partially open was formed on the back of the right hand. Serous exudate was flowing from it. Morbidity and hyperemia were manifested.

1. What is the likely diagnosis?

2. What is the likely medical treatment?

37.Burn of the right hand of 2 degrees. GBA, GUA, crop of a burn separated from the area on a tank of research and sensitivity antibiotics. Local treatment of a burn, antibyoticotherapy.

EMERGENCY MEDICAL AID TASK No.38

A 5-year-old child has been suffering from acute lacunar tonsillitis for a week. All of a sudden the body temperature increased to 39,8`C. The patient had generelized tonoclonic spasms.

1. What is the likely condition?

2. What is the most appropriate emergency medical aidmanagement?

Answer:The convulsion syndrome developed in the child due to the body temperature increase . At convulsion development it is necessary to fix the head and hold the tongue to prevent it from being bitten off. To stop the convulsion, it is necessary to introduce intravenous or intramuscular injections of benzadiazepams(sibazon) or barbiturates (thiopental sodium). Further therapy is indicated for prophylaxis and treatment of fever with the help of NSAID (treating main disease) - the acute lacunar tonsillitis.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.38

A 5-years-old girl was treated at hospital for right upper lobe pneumonia during 7 days. Plane chest x-ray shows right upper lobe pneumonia and atelectasis.

Task:

Which procedure should be undertaken?

Answer:

Bronchoscopy.

38. SITUATIONAL TASK

A patient 48 yrs. Old was admitted with complains of pain on right lumbar region having attaching character. On examination of urine: microhematuria, protienturia. Patient with right body posture. Palpation- pain on right region of kidney. Pasternatsky symptoms is sharp positive on right side. In US, pyeloric part of kidney and initial part of ureter is enlarged. Concernment of kidney and upper of ureter is not defined.

What additional method is indicated for final diagnosis?

Ans: Absorb and excretory urography after 10 and 20 min. If necessary – retrograde uteropyelography.

TYPICAL TASK No.38

At sowing campaign a 41- year-old patient had got trauma of the right thigh. A ground got into the wound. In the field conditions the wound had been cleaned, aseptic bandage applied. At night the temperature rose up to 39 С, the thigh increased in size, the edema rose to inguinal area. Intoxication appeared.

1. What is the likely diagnosis?

2.What is the most appropriate course of management?

38. Acute anaerobic an infection of a thigh. Urgent research separated from a wound (bacterioscopy) crop from a wound on a tank research, sensitivity antibiotics, X-ray of soft tissues of a thigh, GBA, GUA, sugar of blood. Opening of soft fabrics and fascial spaces of a thigh, as cuts, antibiotics of a wide spectrum, oxigenation, local treatment of wounds.

EMERGENCY MEDICAL AID TASK No.39

In a hot weather a 60-year-old male was admitted to sanatorium medical center after a long stay on the beach. He became pale,felt himself bad, repeatedly vomited, was excited, then for short-term lost consciousness. Examination showed deep unconsciousness (GCS- 12), disorientation, uncoordinated movements, hyper reflexion, hot, wet, hyperemic skin,body temperature 40,2 C, absence of meningeal symptoms. AP- 85/30 mmHg, heart rate-115, thready, arrhythmic pulse, RR- 28. ECG revealed sinus arrhythmia and presence of sporadic atrial extrasystoles.

1. What is the likely condition?

2. What is the most appropriate emergency medical aidmanagement?

Answer:Anamnesis of pathological condition developed and clinical picture shows evidence of heat stroke. It is necessary to move the patient to a colder location, take off the clothes, and cover the skin in the region of large vessels with cold water or ice bags. Start inhalation of oxygen, intravenous injection of glucocorticoids, and start infusion therapy for rehydration.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.39

A 7-years-old boy was admitted to hospital with right pneumonia. Plane chest x-ray was made.

Task:

Analyze of the presented x-ray, and put an initial diagnosis.

Answer:

Right middle lobe pneumonia and atelectasis.

39.

Parents of 3yrs. Old daughter complains that she do not show normal urination and frequently walk with wet inner cloths. It was present from the moment of her birth. Analysis of blood and urine:- without any pathological changes.

What developmental anomaly has to think at first?

Ans: Ectopic anomaly of Ureter

TYPICAL TASK No.39

A 35-year-old patient presents to the proctologist with complaints on periodic prolapsed piles from anus at defecation which then are retracted. Earlier bleedings were not plentiful in the form of blood streaks from the rectum.

1. What is the most likely diagnosis?

2. Which is the most likely next step?

39Chronic hemorrhoids of 3 stage, operative treatment hemorrhoidectomy by Milligan-Morgan is recommended

EMERGENCY MEDICAL AID TASK No.40

In a hot weather a 63-year-old male was admitted to sanatorium medical center after a “sun bath” on the beach. He became pale,felt himself bad, repeatedly vomited, was excited, then for short-term lost consciousness. Examination showed deep unconsciousness (GCS- 12), disorientation, uncoordinated movements, hyper reflexion, hot, wet, hyperemic skin,body temperature 40,2 C, absence of meningeal symptoms. AP- 85/30 mmHg, heart rate-115, thready, arrhythmic pulse, RR- 28. ECG revealed sinus arrhythmia and presence of sporadic atrial extrasystoles.

1. What is the likely condition?

2. What is the most appropriate emergency medical aidmanagement?

Answer:Anamnesis of pathological condition developed and clinical picture shows evidence of heat stroke. It is necessary to move the patient to a colder location, take off the clothes, and cover the skin in the region of large vessels with cold water or ice bags. Start inhalation of oxygen, intravenous injection of glucocorticoids, and start infusion therapy for rehydration.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.40

A 8-years-old girl was admitted to hospital with acute paroxysmal abdominal pain, and vomiting twice. Duration of disease is 9 hours. One year ago the girl was operated for an acute gangrenous appendicitis. Retention of stool is during last 24 hours.

Plain radiographs demonstrate obstructive features (Kloiber’s cups), and contrast studies was started to define the cause of obstruction.

Patient was treated with nasogastric decompression, intravenous fluid resuscitation and stimulation of peristalsis, and enema. This intervention didn’t have any clear evidence of clinical improvement. Contrast study was made in 6 hours.

Task:

1. Analyze of the presented x-ray.

2. Put an initial diagnosis.

3. Which treatment is indicated?

Answer:

1. Kloiber’s cups and contrast medium accumulation are visible.

2. Acute adhesive obstruction.

3. Urgent surgery is indicated.

40. SITUATIONAL TASK

Patient 28yrs. Old complains general weakness , dry mouth, periodic nasal bleeding , dull pain on lumber region. On palpation of kidney both sided gowning rugs, painless formation. In US examination enlargement of both kidneys which contains many exogenous form of size from 15 to 30 mm. In analysis of blood: Hb. 102g/l, Er. 3,05x10^12/l, urea 19,6mm/l, L 8,6x10^9, creatinin 3,6mm/l. Analysis of urine: Sp. Density 1004 , protein 0,066g/l, L 16-18 f.v.. Er. 8-10 in f.v.

Give your diagnosis.

Ans: Polycystosis of kidney, chr. Pyeleonephritis , chg. Renal insufficiency.

TYPICAL TASK No.40

A 47- year-old patient presents to the surgeon with complaints of existing fistula with poor purulent contents in perianal area. Earlier an operation was done (dissection of acute anal abscess). Later in a month a fistula appeared next to the anal orifice which was periodically discharging puss in small amounts.

1. What is the most likely diagnosis?

2. What is the most appropriate course of management?

40.Chronic paraproctitis, additional methods of research – fistulography, manual research of a rectum, rectoromanoscopy, treatment operative, opening of a cavity of abscess with excisionof fistula.

EMERGENCY MEDICAL AID TASK No.41

A victim was taken out of pond being unconscious. On examination, mydriatic pupils, pale skin,acrocyanosis.sporadic arythmic breathing, absence of AP and pulsation of carotid arteries were revealed.Froth and water were discharged from the mouth.

1. What is the likely condition?

2. What is the most appropriate emergency medical aid management?

Answer: We can speak of drowning taking into account froth and water discharge

from the mouth. It is necessary to remove water from the lungs. For this procedure a rescuer should put quickly a victim on the thigh of the rescuer’s leg and compress sharply back sides of the chest for 10-15 minutes and after that put a victim on the back again. At signs of clinical death it’s necessary to start cardiopulmonary resuscitation and do everything possible to transport a victim to the nearest hospital.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.41

A 11-years-old boy was admitted to hospital with acute hematogenous osteomyelitis of the right tibia. Other purulent niduses are absent. Punctures, aspiration, and drainage of bones marrow were done.

Plain radiograph of the right tibia in lateral projection was made in 12 day from onset of disease.

Task:

1. Analyze of the presented x-ray.

2. Put a clinical diagnosis.

Answer:

1. Displacement of periosteum of the right tibia, lytic changes in area of distal metaphysis and diaphysis, traces of punctures and drainage of bones marrow, and needle in the distal metaphysis are visible.

2. Acute hematogenous osteomyelitis of the right tibia, local form.

Situational Task No. 41

A boy, 6 months of age during 24 hrs, was restless, crying and stopped urination. Before this, such disturbances of urination was absent. Temperature was normal, kidney is impalpable, negative Pasternatsky symptom. Absence of gross visual urine abnormalities. During penis inspection – muscular coat was revealed to be hyperemic and edematous. When the muscular coat was irritated, it exposes suddenly a small part of верхушки головки. What is your diagnosis?

Phimosis, Balanorchitis

TYPICAL TASK No.41

A 26-year-old patient is examined by proctologist. Fistula with serous and purulent

exudate on the clock mark “9 hour” in the perianal region is revealed. On intubation

fistula takes place medially from anus.

1.What is the likely diagnosis and additional methods of examination?

2.What is the most appropriate course of management?

41.Chronic paraproctitis, extrasphincteric fistula, additional methods of research – fistulography, manual research of a rectum, rectoromanoscopy, treatment operative, opening of a cavity of abscess with excisionof fistula.

EMERGENCY MEDICAL AID TASK No.42

A victim was taken out of pond. On examination, consciousness,breating and main arteries pulsation were absent. Mydriatic pupils didn’t react to the light.Froth and water were discharged from the mouth.

1. What is the likely condition?

2. What is the most appropriate emergency medical aid management?

Answer: We can speak of drowning(clinical death) taking into account froth and water discharge from the mouth. It is necessary to remove water from the lungs(in case it’s not a contraindication for cardiopulmonary resuscitation). For this procedure a rescuer should put quickly a victim on the thigh of the rescuer’s leg and compress sharply back sides of the chest for 10-15 minutes and after that put a victim on the back again. At signs of clinical death it’s necessary to start cardiopulmonary resuscitation and do everything possible to transport a victim to the nearest hospital.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.42

Task:

1. Analyze of the presented x-ray. Which of radiologic studies do you assess?

2. Put a radiologic diagnosis.

Answer:

1. Anteroposterior radiograph of the right hip shows contrast material in the adjacent soft tissues, in the subperiosteal area, and within the medullary cavity after pus had been aspirated. The contrast material demonstrates the extent of the abscess. An abscessogram.

2. Chronic osteomyelitis of the right hip.

Situational Task No. 42

A patient 20 y.o complained about « закисание» and reddening of eyes and he felt presence of foreign bodies. During investigation hyperemia and edema of mucous membrane, tearing, blepharospasm, purulent discharge from conjunctiva was revealed.

What type of pathological condition resembles such clinical picture?

Prescibe your treatment.

Acute Bacterial conjunctivitis

TYPICAL TASK No.42

A 42- year-old patient was admitted to the hospital for emergency treatment. Hematemesis has arisen suddenly. The patient indicates that it has already happened for the 3-d time for 2 years. In the history obtained Botkin's disease is revealed. On examination, clearly defined venous network on abdomen wall in the form of « caput medusae »is revealed. A big spleen, dense edge of liver at a costal arch is palpated.

1. What is the likely diagnosis?

2. What is your plan of investigation?

3. What is the most appropriate course of management?

42.The diagnosis – a bleeding from varicouse veins of a esophagus, a cirrhosis of a liver. Installation of Blackmore tube. Inspection – fibroesophagoscopy, ultrasonic of a liver, after a stop of a bleeding – splenoportography, a laparoscopy, research of blood on markers of a hepatites

EMERGENCY MEDICAL AID TASK No.43

The patient came to draw a tooth to the dentist. After injection of 0.5% Novocaine solution he felt acute weakness, dizziness. On examination,nettle rash on the skin of neck and chest,hypopnoe,RR-36,AP 60/20,heart rate-128 were revealed.

1. What is the likely condition?

2. What’s the most appropriate course of management?

3. What medication is necessary to administer?

Answer: The patient developed anaphylactic shock.You should start emergency medical aid with intravenous injection of 1 ml of 0.1% adrenalin solution with its following

intensive infusion. Glucorticoids and antihistamines treatment should be included into

the complex therapy.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.43

A 10-years-old boy was admitted to hospital with complaints about acute pain in the right shin, edema of the right ankle, inability of bear weight, fever and chills, general malaise. Onset was 2 days ago. The day before onset he played soccer and was struck by one of players. An acute hematogenous osteomyelitis of the distal right tibia was diagnosed. Surgery was performed. Anteroposterior and lateral radiographs of the tibia was made after surgery.

Task:

1. Name of the principles of surgical management of an acute hematogenous osteomyelitis for children of this age group.

2. Which of the radiologic imaging has to be added to complete the diagnosis?

3. Put a clinical diagnosis.

Answer:

1. Punctured aspiration, drainage of bones marrow, drainage of purulent cavities, and immobilization by splint.

2. Plane chest radiograph.

3. Acute hematogenous osteomyelitis of the distal right tibia, local form.

Situational Task No. 43

A patient 72 y.o was undergoing treatment in neurological department on basis of urolithiasis. After injection of atropine, patient complains of severe pain on the Left eye, sharp worsening of the vision. Objective investigation: Sharp vision of left eye - 0.01, eye is dense, absence of pain during palpation , presence of vascular injection upon the eye ball, cloudiness of the cornea. Estimate your diagnosis. Prescribe your treatment.

Acute primary attack of glaucoma of the left eye.

TYPICAL TASK No.43

The patient complains of sharp abnormality at the act of defecation, discharge of small amounts of blood with fecal masses, and also constipation because of morbidity of the defecation act. On digital investigation of anterior abdominal wall dilatation of sigmoid colon in a balloon-like form is revealed.

1. What is the likely diagnosis?

2. What are the additional methods of investigation?

3. What is the most appropriate course of management?

43.Dolihisigma, additional inspection: irrigoscopy, colonoscopy, treatment - operative: a resection of sigmoig after preliminary preoperative preparation

EMERGENCY MEDICAL AID TASK No.44

The patient came with fructure of forearm bones to the traumatologic center. After injection of 0.5% Novocaine solution for local anesthesia he felt acute weakness, dizziness. On examination, deep uncosciousness(GCS- 13),nettle rash on the skin of neck and chest,hypopnoe,RR-34,AP 40/00,heart rate-130 were revealed.

1. What is the likely condition?

2. What’s the most appropriate course of management?

3. What medication is necessary to administer?

Answer: The patient developed anaphylactic shock.You should start emergency medical aid with intravenous injection of 1 ml of 0.1% adrenalin solution with its following

intensive infusion. Glucorticoids and antihistamines treatment should be included into

the complex therapy.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.44

A 4-years-old toddler was admitted to hospital with complaints about pain in the left upper arm, edema of the left elbow, and absence of movements of the left arm, fever, and general malaise. Onset was 11 days ago. She was treated for an acute arthritis since 2nd day of disease. However the condition of patient deteriorates progressively and local inflammatory signs are manifesting. Anteroposterior radiograph of the left humerus was made.

Task:

1. Put a radiologic diagnosis.

2. Which of surgical treatment has to be applied for this patient?

Answer:

1. Acute hematogenous osteomyelitis of the left humerus, local form.

2. Punctured aspiration, drainage of bones marrow, drainage of purulent cavities, and immobilization by splint.

Situational Task No. 44

A patient complains about worsening of Right eye vision. According to his anamnesis, a metallic piece fell into his eye while working in industry. Objective investigation: presence of tearing, photophobia, blepharospasm, presence of gaping wound, on the cornea, soft anterior chamber, гифема, hypotonic eye during palpation.

Put your diagnosis. Prescribe your treatment.

Penetrating injury of cornea of the red eye

TYPICAL TASK No.44

The patient arrived at the hospital by ambulance with complaints on presence of very painful pineal mass in the region of anus, periodic discharges of scarlet blood with stool. On exam, painful at palpation lumps of cyanotic and blood red color at anal area on the clock mark “3, 7 and 11 hour” are revealed.

1. What is the likely diagnosis?

2. What is the most appropriate course of management?

44The diagnosis – a hemorrhoids, a thrombosis of hemorrhoidis units. Treatment conservative, with the subsequent operation hemorrhoidectomy by Milligan-Morgan

EMERGENCY MEDICAL AID TASK No.45

A victim was found by paramedics on the ground with an electric wire in the hands in the state of unconsciousness.

1. What is the likely condition?

2. What is the likely heart rate disorder?

3. What is the most appropriate course of management?

Answer: The patient developed ventricular fibrillation and stagnation of the circulation in the result of electrical injury. The primary action: should be termination of contact of the victim with the source of current( switch off the main switch, keep wire aside using a dry stick) to prevent electrical injury for paramedics by contacting with the body of the victim. Then carry out cardio-pulmonary resuscitation with the compulsory defibrillation.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.45

A 12-years-old boy was treated for acute hematogenous osteomyelitis of the right tibia 1 year ago.

Now the all signs of exacerbation of disease are manifesting. The patient was admitted to hospital. Anteroposterior and lateral radiographs of the right tibia was made.

Task:

1. Analyze of the presented x-ray.

2. Which of treatment has to be applied for this patient?

Answer:

1. Displacement of periosteum of the right tibia, lytic changes in area of distal metaphysis and diaphysis with sequester.

2. Conservative treatment and surgery - sequestrectomy in 3 months.

Situational Task No. 45

Patient 40 y.o came to the ophthalmologist with complains of decreased vision of the Right eye. According to his anamnesis, 1.5 years ago, when he was working with an iron machinery. His right eye was strucked by an iron splinter. On that moment, his vision was not decreased, eye was not painful and that’s why he didn’t seek any doctors help.

Objective investigation: V [OD]=0,4. On corneal endothelium, brown coloured dust deposit was revealed. On the iris and anterior capsule of lens, granulated yellow brown pigments were revealed. On the fundus of the eye, some degenerative focus in the form of “bone corpuscles” was revealed on X-ray examination of the orbit and it was determine that it was foreign intraocular body of metallic consistency.

Put your diagnosis. Prescribe your treatment.

Removing of foreign intraocular bodies.

TYPICAL TASK No.45

A patient, who had a resection of stomach on Billroth– II two years ago, complains of the general weakness, dizziness, nausea, salivary discharge. shiver in the body, palpitation, heart rate 100-110 b/min, feeling of obstruction in the heart area.

1. What is the likely diagnosis?

2. What is the surgical treatment?

45.The diagnosis – a dumping-syndrome, 2 st. Treatment conservative. At absence of effect repeated reconstructive operation on Zaharov-Genle. Methods of reseach: FGS, X-ray of stomach and an intestines with barium, glycemic structure.

EMERGENCY MEDICAL AID TASK No.46
A victim was found by paramedics on the ground with an electric wire in the hands in the state of unconsciousness.On examination,sporadic arythmic inspirations, both pupils’ mydriasis were revealed.Carotid arteries pulsation,AP were absent.
1. What is the likely condition?
2. What is the likely heart rate disorder?
3. What is the most appropriate course of management?
Answer: The patient developed ventricular fibrillation and stagnation of the circulation in the result of electrical injury. The primary action: should be termination of contact of the victim with the source of current( switch off the main switch, keep wire aside using a dry stick) to prevent electrical injury for paramedics by contacting with the body of the victim. Then carry out cardio-pulmonary resuscitation with the compulsory defibrillation.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.46
A 14-years-old boy was admitted to hospital with complaints about pain and edema in the distal third of right femur. Duration of complaints is about 5 months. Complaints were appeared after contusion of the right thigh. The patient has no history of fever. Anteroposterior radiograph of the right femur was made.
Task:
1. Put an initial diagnosis.
Answer:
1. Osteosarcoma of the right distal femoral metaphysis.
Situational Task No. 46

A patient 65 y.o smokes for almost 45 years . Since last month, he experiences dyspnea especially during physical exertion, constant dry cough, hemoptysis for once. Once inspection ; temp : 37.2 °C, peripheral lymph nodes was impalpable, during auscultation of lungs , increased bronchial breathing on the upper lobe of the right lung was revealed. During x-ray examination, decreased of ventilation of the upper lobe of the right lung with shifting of organs of mediastinal to the right side and dilation of root of the lungs was revealed.
Put your preliminary diagnosis for this disease and create a plan of investigations.

Central Lung cancer of the Right lung

Investigations:
General Blood analysis, General Urine analysis, Glucose level in blood, Coagulogram, ECG, Spirography, Roentgenological investigations of lungs ( roentgenography, roentgenoscopy,mammography), fibrobronchoscopy with biopsy and immunological investigation.

TYPICAL TASK No.46
The patient was operated for duodenal ulcer(Billroth-II type) 3 years ago. He complains ofswelling pains in the epigastric area, feeling of weight after meal. Pain intensity is growing and soon after that follows plentiful biliary vomiting,
sometimes with food staff. Localized pain in the galbladder and pancreas projection is revealed. A dense -elastic of longitudinal form, painful lump is
palpated in this place.

1. What is the likely diagnosis?
2. What is the most appropriate course of investigation and management?

46 DOS, a syndrome of afferent loop, a dumping-syndrome 2 items of weight. Treatment conservative. At absence of effect repeated reconstructive operation on Zaharov-Genle. Methods of reseach: FGS, X-ray of stomach and an intestines with barium, glycemic structure.


EMERGENCY MEDICAL AID TASK No.47

A 47-year-old man, suffering from epilepsy for a long time, is admitted to the reception department with the repeated generelised tonoclonic spasms. In the intervals between the spasms he is not recovering from the state of unconsciousness.Coma and acrocyanosis developed.His breathing is independent.RR is 32,AP-200/100,heart rate -112.
1. What is the likely condition?
2. What is the most appropriate course of management?
Answer: The patient has the epileptic seizure. Introduction of anticonvulsives
is inefficient. The only way to arrest convulsions is muscle relaxants injections
and artificial lung ventilation.Besides hypotensive and dehydratation therapies
are necessary in such a case.
TASK OF CHILD SURGERY № 47


A 6-years-old boy was admitted to hospital with complaints about vague left flank pain and sub febrile temperature during last 3 months. On physical exam a palpable abdominal mass was found in the left hypochondriac region. Urinalysis shows hematuria. Radiologic studies were ordered and angiography was made for accurate diagnosis

Task:
1. Put
an initial diagnosis.
На артериограмме в проекции нижнего полюса левой почки видно, что крупные артериальные сосуды сдвинуты и серповидно изогнуты. Наблюдается тень "отрыва" мелких артериальных стволов в проекции нижнего полюса. Киста нижнего полюса левой почки.

Situational Task No. 47

On a female patient 52 y.o, during investigation, revealed dense formation for about 2.5 cm in diameter on Right breast. Positive “square symptom”, absence of any nipple discharge, axillary lymph node was impalpable.
Put your preliminary diagnosis for this disease and prescribe your investigations.

Breast Cancer.

Investigations:
Mammography, RW, General Blood analysis, General Urine analysis, Glucose level in blood, Biochemical investigation of blood, fluorography of lungs, Coagulogram, ECG, Gynecological consultation.

TYPICAL TASK No.47

A 33- year-old patient was urgently operated for duodenal perforated ulcer. The excision of ulcer was done with pyloroplastics by Jadd + truncal (stem)vagotomy. Now he complains of dull pains, feeling of overfilling and swelling in epigastrium and the right hypohondrium after meal, biliary eructation, bitterness in the mouth, heartburns.

1. What is the likely diagnosis?
2. What is the most appropriate course of surgical treatment?
47The diagnosis – postvagotomyc syndrome (gastrostasis) treatment conservative, washing of a stomach, at an inefficiency repeated operative treatment pyloroplastic or gastroenteroanastomosis

EMERGENCY MEDICAL AID TASK No.48

A 54-year-old man, suffering from epilepsy for 26 years, is admitted to the reception department with the repeated generelised tonoclonic spasms. In the intervals between the spasms he is not recovering from the state of unconsciousness.Acrocyanosis developed.His breathing is independent.RR is 32,AP-200/100,heart rate -112.
1. What is the likely condition?
2. What is the most appropriate course of management?
Answer: The patient has the epileptic seizure. Introduction of anticonvulsives
is inefficient. The only way to arrest convulsions is muscle relaxants injections
and artificial lung ventilation.Besides hypotensive and dehydratation therapies
are necessary in such a case.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.48
A 6-years-old boy was operated 14 days ago for stenosis of the right uretero-pelvic junction. Pyeloplasty with pyelostomy were performed. Now an acute intensive right flank pain is appeared. Radiologic study was done.
Task:
1. Which of the radiologic imaging was done?
2. Put the radiologic diagnosis.
Answer:
1. Ante-grade pyelography.
2. Recurrence of stenosis of the right uretero-pelvic junction.
Situational Task No. 48

A female patient 42 y.o, complains of nipple retraction for past 2 months. Treatment by ointment bandage didn’t improve the condition. During inspection of nipples and areola, it was hyperemic, covered with crust with presence of superficial defect. Dense formation was absent in the breast. Lymph nodes not enlarged. Put your preliminary diagnosis. Create your plan of investigations.

Breast Cancer of the Right mammary gland.

Investigations:
Mammography, RW, General Blood analysis, General Urine analysis, Glucose level in blood, Biochemical investigation of blood, fluorography of lungs, Coagulogram, ECG, Gynecological consultation.
TYPICAL TASK No.48


The patient who has carried 2 years ago a resection 2\3 of a stomach on Hoffmeister-Finsterer in occasion of a stomach ulcer, has complaints to sharp weakness, attacks of palpitation, inflow of heat to the face and dizzinesses at the use of sweet and dairy food. Deficiency of weight of a body – 15 kg. On X-ray – losted part of stomach small sizes with continuous evacuation of barium in the expanded allocating loop, is available small reflux in resulting loop.
Specify the diagnosis, additional methods of inspection.
What operative intervention is necessary for the patient?


48.The diagnosis: DOS, a combination a dumping-syndrome and a syndrome of afferent loop. Treatment conservative. At absence of effect repeated reconstructive operation on Zaharov-Genle. Methods of reseach: FGS, X-ray of stomach and an intestines with barium, glycemic structure

EMERGENCY MEDICAL AID TASK No.49
A 32-year- old man,standing in a queue, suddenly lost consicuesness and fell down.Breathing is absent, acute paleness of skin is developing, pupils are mydriatic,pulsation of carotid arteries is absent.
1. What is the likely pathological condition?
2. What is the most appropriate emergency medical aid management?
Answer:The patient developed apnoe and circulatory arrest, may be in the result of acute coronary circulation insufficiency. Artificial ventilation of lungs and closed-chest heart massage should be done immediately and transportation to the hospital with the help of paramedics is of great importance.

SITUATIONAL TASK ON PEDIATRIC SURGERY No.49
A 9-years-old girl was admitted to hospital with complaints about the left flank pain, fever and chills, and general malaise. On physical examination a local tenderness in the left flank is present. Blood cells count and urinalysis show leukocytosis and pyuria. Excretory urogram was done after initial symptomatic therapy and improving of patient’s condition.
Task:
1. Put a clinical diagnosis.
2. Which of treatment has to be applied for this patient?
Answer:
1. Duplication of the left kidney.
2. Conservative treatment of the secondary pyelonephritis, observation.

Situational Task No. 49
A female patient 42 y.o, complains of nipple retraction for past 2 months. Treatment by ointment bandage didn’t improve the condition. During inspection of nipples and areola, it was hyperemic, covered with crust with presence of superficial defect. Dense formation was absent in the breast. Lymph nodes not enlarged. Put your preliminary diagnosis. Create your plan of investigations.

Breast Cancer of the Right mammary gland.

Investigations:
Mammography, RW, General Blood analysis, General Urine analysis, Glucose level in blood, Biochemical investigation of blood, fluorography of lungs, Coagulogram, ECG, Gynecological consultation.

TYPICAL TASK No.49
The patient of 46 years was admitted to surgical hospital with complaints to strong pains in the upper half of abdomen, squeezing character, vomiting. 5 years ago has carried resection of a stomach. Soon after operation the specified complaints, especially after reception fat and a spicy food began to appear. Recently these pains became more frequent. A abdomen soft, moderately painful in epigastric area. A positive symptom of Mayo-Robson.
It is possible to think of what disease?

49 DOS, chronic pancreatitis, treatment conservative, ac. inspection: ultrasonic of abdomen cavity, X-ray of stomach with barium, research of enzymes of a pancreas

EMERGENCY MEDICAL AID TASK No.50

A patient suffered from acute pneumonia complicated with the right sided purulent pleuritis and was on indoor treatment. Suddenly his condition became worse.
He was complaining of anxiety,shortage of air for breathing,dizziness.
Examination showed wet and cyanotic skin,temperature- 39C,breathing with the help of extra muscles, RR-46, AP-155/100, heart rate-130.
1. What is the likely complication?
2. What is the further most appropriate course of management?
Answer:The course of disease was complicated by the development of acute
respiratory failure of type 2.It’s necessary to start inhalation of wet oxygen
through nasal catheter or oxygen mask and consult anesthesiologist as the symptomatology indicates on artificial lung ventilation and hospitalisation to the
department of intensive care.
SITUATIONAL TASK ON PEDIATRIC SURGERY No.50
A 5-years-old girl was admitted to hospital with complaints about vague abdominal pain, loss of appetite and fatigability during last 6 months. Urinalysis shows pyuria. Radiologic study was done after initial therapy.
Task:
1. Which of the radiologic imaging was done?
2. Put a clinical diagnosis.
Answer:
1. Voiding cystourethrogram.
2. Vesicoureteral reflux, type V.
Situational Task No. 50

Patient 66 y.o complains of dull pain on Right iliac area, weight loss for about 12 kg during the past 6 months, constipation decreased appetite. Objective investigation: pallor skin, decreased turgor, on Right iliac area an infiltrate for about 6x8 cm was palpated and it was slightly mobile. Hb – 80 g/l. Positive Gregresan Test. What is the most probable diagnosis. Initiate the most probable investigation for this patient.

Sigmoid Colon Cancer
Investigations:
RW, fluorography of lungs, General Blood analysis, General Urine analysis, Glucose level in blood, Biochemical investigation of blood, irrigoscopy, colonoscopy with biopsy, Coagulogram, ECG, Gynecological consultation

TYPICAL TASK No. 50
The patient of 42 years was admitted to the hospital by emergency help. Bloody vomiting has arisen suddenly. The patient marks, that within 2 years such bleeding begins in 3-rd time. In the anamnesis Botkin's disease. At survey the expressed venous network on abdomen wall in the form of « caput medusae ». The big spleen, dense margo of a liver at a costal arch is palpated.
What the urgent help to the patient will consist?

50.The diagnosis – a bleeding from varicouse veins of a esophagus, a cirrhosis of a liver, the emergency help - installation of Blackmore tube, conservative therapy, inspection FEGS, splenoportography. Biochemical research of function of a liver. Treatment conservative, at an inefficiency – operation of type Tanner, splenorenal anastomosis.