1

1. Patient М., female, 37 years, complains of delicacy, fast fatigability, giddiness,

bad appetite, labored swallowing of nutrition, the desire to eat chalk and plaster.
The patient is of a satisfactory nutrition. The skin and visible mucosa are pale.
Peripheral lymphatic nodes are not enlarged. There is vesicular respiration at
auscultation of lungs. Pulse is 96 per minute, rhythmical. Cardiac sounds are loud,
systolic murmur - above heart apex and pulmonary artery. BP is 110/70 mm Hg.
The tongue is of pale pink color, papillae are flattened. There is a tenderness of
abdominal wall in epigastric region at palpation.
Common blood analysis: erythrocytes – 2,8×1012/l, hemoglobin - 70 g/l, color
index - 0,7, reticulocytes - 2 %, leucocytes - 4,6×109/l, eosinophyls - 2 %, stab
neutrophiles - 3 %, segmentonuclear neutrophiles - 64 %, lymphocytes -
26 %, monocytes - 5 %, ESR - 17 mm/h. Serum iron - 3,3 mcmol/l, total iron-
binding ability of blood serum 140 mcmol/l (norm 50-84 mcmol/l).
What is your provisional diagnosis?
What qualitative changes of erythrocytes are characteristic for this disease?
 2
2. Patient В., male, 65 years, complains of general delicacy, bad appetite, difficulty
at a swallowing of food, dyspnea, edemas, unsteady gait, numbness of face and
inferior extremities. The patient thinks that he took ill about one half-year ago
when the above described complaints arose. Ten years ago he was operated on
tumor of stomach.
The state of the patient is serious. The skin and visible mucosa are pale with a
moderate icterus. Puffiness of face and edemas of inferior extremities are
expressed. Lymphatic nodes are not enlarged.
There is vesicular respiration at auscultation of lungs. Cardiac sounds are soft,
systolic murmur is above all points. Pulse is 108 per minute, rhythmical. BP is
90/60 mm Hg.
Tongue is bright red, sleek, with fractures. The liver is on 3-4 sm below the costal
arch, sensitive at palpation. The dimensions of liver according to Kurlov are 12-
10-8 sm. The inferior edge of lien is palpated.
Common blood analysis: erythrocytes - 1,1×1012/l, hemoglobin - 40 g/l, color
index - 1,3, reticulocytes - 0,1 %, thrombocytes - 160,0×109/l, leucocytes -
2,5×109/l, ESR - 42 mm/hour.
What is your provisional diagnosis? What are additional laboratory methods of
examination?
 3
3. Patient L., male, 42 years, complains of delicacy, sweating, rise in temperature.
Progressive deterioration of state has appeared within month, when pains of bones
and high body temperature have increased.
The state of patient is moderate. There are paleness and simple petechial
hemorrhages on the skin. Peripheral lymphatic nodes are not enlarged. Body
temperature is 37,2 ºС. Vesicular respiration is auscultated in lungs. Cardiac
sounds are clear. Pulse is 100 per minute. The liver and the lien are on 2 sm below
of costal arches, their edges are mild, and tender. The dimensions of the liver
according to Kurlov are 12-10-8 sm.
Common blood analysis: erythrocytes - 2,8×1012/l, hemoglobin - 95 g/l, color
index - 1,0, thrombocytes - 107×109/l, leucocytes – 29,0×109/l, myeloblasts - 43 %,
promyelocytes - 9 %, myelocytes - 10 %, eosinophils – 8%, basophils – 4%,
segmentonuclear neutrophiles - 24 %, lymphocytes - 2 %, ESR - 30 mm /
h.
What is your provisional diagnosis? What are additional laboratory methods of
examination?
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4. Patient L., female, 24 years, complains of delicacy, sweating, rise in

temperature, pain in mouth and throat, prolonged nasal and uterine bleeding.
Progressive deterioration of state has appeared within month, when pains of bones
and high body temperature have increased.
The state of patient is serious. There are paleness and multiple petechial
hemorrhages on the skin. Peripheral lymphatic nodes are not enlarged. There are
several ulcers at the mucous of oral cavity, gingival bleeding, bilateral purulo-
necrotic tonsillitis. Body temperature is 39,2 ºС. Vesicular harsh respiration and
dry rales are auscultated in lungs. Cardiac sounds are dull, accelerated. Pulse is 120
per minute. The liver are on 2 sm below of the costal arch, mild, and tender. The
dimensions of the liver according to Kurlov are 12-10-8 sm. The lien is palpated 8
sm below the left costal arch. The dimensions of the lien according to Kurlov are
17-12 sm.
Common blood analysis: erythrocytes - 2,0×1012/l, hemoglobin - 65 g/l, color
index - 0,9, thrombocytes - 57×109/l, leucocytes – 69,0×109/l, myeloblasts - 80%,
segmentonuclear neutrophiles - 15 %, lymphocytes - 4%, monocytes –
1%, ESR - 64 mm / h.
What is your provisional diagnosis? What is additional laboratory method of
examination?
 5

5. Patient К., female, 53 years, has arrived in clinic with complaints to delicacy,
sweating, from time to time a rise in temperature up to 37,2-37,5ºС, enlargement
of lymphatic nodes - cervical, axillary, inguinal.
Last 3 years frequently she was sick of acute respiratory diseases. One year ago
she has transferred the serious form of acute tonsillitis. Last 3-4 months it has
appeared increasing delicacy, loss of weight. For the first time she has found
small lymphatic nodes on the neck and in the axillary fossa. Last month a rise in
temperature up to 37,5ºС was observed, lymphatic nodes have apparently
increased.
The patient is of correct body build, subnuorished. The skin and visible mucosa are
pale with slight icterus. Lymphatic nodes enlarged up to chicken eggs are palpated:
cervical, inguinal, axillary. Lymphatic nodes are mild, not matted together, and
painless. There are weakened vesicular respiration, and diffuse dry rales at the both
lungs. Cardiac sounds are soft, rhythmical. Pulse is 92 per minute, rhythmical. BP
is 110/70 mm Hg.
Tongue is covered with white coatings, wet. The liver is on 1,5-2 sm below the
right costal arch, sensitive at a palpation. The lien is on 4-5 sm below the left costal
arch, painless at a palpation, dense.
Analysis of a blood: erythrocytes - 2,3×1012/l, hemoglobin - 74 g/l, reticulocytes
- 2 %, thrombocytes – 100,0×109/l, leucocytes 50,0×109/l, eosinophils - 1 %,
stab neutrophiles – 2%, segmentonuclear neutrophiles - 17 %,
lymphocytes - 79 %, monocytes -1 %, Botkin and Gumprecht cells 20 of 100
lymphocytes, ESR - 60 mm / h.
What is your provisional diagnosis? What is additional laboratory method of
examination?
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6. Patient H., male, 23 years, has arrived in clinic with complaints to delicacy,
sweating, from time to time a rise in temperature up to 39,5-40,0ºС, pain in mouth
and throat, prolonged nasal bleeding.
Disease began 3 weeks ago after a bathing in the river with a rise of body
temperature and pain in throat. Out-clinic treatment with antibiotics and aspirin
was ineffective.
The state of is serious. The skin and visible mucosa are pale with simple skin
hemorrhages. Lymphatic nodes enlarged up to chicken eggs are palpated: cervical,
inguinal, axillary. Lymphatic nodes are mild, not matted together, and painless.
There are several necrotic ulcers at the mucous of oral cavity, gingival bleeding,
bilateral purulo-necrotic tonsillitis. Body temperature is 39,0 ºС. There are
weakened vesicular respiration at the both lungs. Cardiac sounds are soft,
rhythmical. Pulse is 92 per minute, rhythmical. BP is 110/70 mm Hg.
Tongue is covered with brown coatings, dry. The liver is on 1,5-2 sm below the
right costal arch, sensitive at a palpation. The dimensions of the liver according to
Kurlov are 14-12-10 sm. The lien is on 4-5 sm from below the left costal arch,
painless at a palpation, dense. The dimensions of the lien according to Kurlov are
16-11 sm.
Analysis of a blood: erythrocytes - 2,0×1012/l, hemoglobin - 64 g/l,
thrombocytes – 41,0×109/l, leucocytes 98,0х109/l, stab neutrophiles - 1 %,
segmentonuclear neutrophiles – 5 %, lymphoblasts - 84%, lymphocytes -
9 %, monocytes -1 %, ESR - 68 mm / h.
What is your provisional diagnosis? What is additional laboratory method of
examination?
 7

7. Patient М., female, 35 years, is hospitalized in clinic because of the extremely

serious state. She complains of a strong extended pain over the whole abdomen.
Within several years there was repeatedly a punctulate hemorrhagic eruption on a
skin of hips and breeches. During the same time there was a moderate colicy pain
at the abdomen. Bloody stool was occasionally observed.
The state has worsened 3 days prior to hospitalization. Skin rash have appeared
again. Often calls to stool and bloody abjections instead of the formed feces were
during last 2 days.
The general state is serious. There are multiple spotted petechial skin rash at
extremities and breasts. Lymphatic nodes are not enlarged. Clear pulmonary sound
and vesicular respiration are revealed above both lungs. Respiration rate is 20 per
minute. Cardiac sounds are softened. Pulse rate is 120 per minute. BP is 90/70 mm
Hg. The abdomen is tensed and sharply painful in all departments at palpation.
Positive signs of the peritoneum irritation are revealed. Passage of gases is absent
Bloody abjections from the rectum are marked.
Common blood analysis: hemoglobin - 112 g/l, erythrocytes - 3,5×1012/l,
leucocytes 12,0×109/l, stab neutrophiles - 6 %, segmentonuclear
neutrophiles - 78 %, lymphocytes - 16 %, thrombocytes – 42,0×109/l, ESR -
36 mm / h.
What is your provisional diagnosis?
 8

8. Patient С., male, 63 years, complains of a sharp delicacy, giddiness,

discoloration of feces within 2 weeks (black stool).
He remembers that he was sick of influenza 3-4 weeks ago.
General state of the patient is serious. The skin and visible mucosa are pale. The
dotted hemorrhagic eruption is determined at the skin of face and extremities.
Peripheral lymphatic nodes are not enlarged.
Pulse is 110 per minute of satisfactory volume and strain, rhythmical. BP is 115/70
mm Hg. Cardiac sounds are softened, systolic murmur – above heart apex.
Respiration is vesicular at auscultation. Respiration rate is 20 per minute.
Abdomen is mild and painful at palpation in epigastrium. The dimensions of the
liver according to Kurlov are 9-8-7 sm. Pasternatsky's symptom is negative at
both sides. Stool is once a day, formed, of the black color.
Common blood analysis: erythrocytes - 1,2×1012/l, hemoglobin - 50 g/l, color
index - 0,7, thrombocytes – 200,0×109/l, leucocytes - 13, ×109/l, aniso
-poikilocytosis (++),ESR - 70 mm / h.
Analysis of urine is normal. Coagulation tests are without pathologic
changes.
What is your provisional diagnosis?
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9. Patient К., male, 50 years has arrived in clinic with complaints to the
general delicacy, giddiness, darkening in eyes, palpitation and abjection of mild
tarry feces during last day. He suffers a peptic ulcer of duodenum within 10 years.
General state is moderate. Consciousness state is sopor. Paleness of skin and
visible mucosa is present. Clear pulmonary sound and vesicular respiration are
revealed above both lungs. Respiration rate is 20 per minute. Cardiac sounds are
rhythmical, softened. Systolic systolic murmur is auscultated above the heart apex.
Arterial pressure is 85/50 mm Hg. Pulse is 96 per minute, rhythmical, of a
small filling and a strain. The tongue is wet, covered with white coatings. The
abdomen is mild and sensitive in at palpation in epigastrium. The liver and the lien
are not enlarged.
Common blood analysis: erythrocytes - 2,8×1012/l, hemoglobin - 76 g/l,
leucocytes - 5,3×109/l, eosinophiles - 2 %, stab neutrophiles - 2 %,
segmentonuclear neutrophiles - 60 %, lymphocytes - 30 %, monocytes - 6
%, ESR - 8 mm / hour, thrombocytes 180 ×109/l, reticulocytes - 12 %.
Analysis of urine - without pathology.
Analysis of feces - Gregersen test is sharply positive.
What is your provisional diagnosis?
 10

10. Patient М., female, 50 years, scientist, complains of the general delicacy,
sleepiness, collapse of work capacity, constipation.
This disease began gradually more than 5 years after surgical operation on the
occasion of goiter.
The face is round, yellowish-pale, amimic. The patient looks more senior than
the age. It is revealed the puffiness on dorsal surfaces of hands and foots; at
pressing a fossa is not formed. The skin is cool and dry at the touch. Nails are
fragile. The thyroid gland is not palpated. Body temperature is 35,8ºС.
Pulse is 56 per minute. Cardiac sounds are softened, rhythmical. BP is 100/80 mm
Hg. Pathologies from the side of systems of respiration and digestion are not
revealed.
ECG: Sinus bradycardia, small voltage of waves, elongation PQ up to 0,22
sec.
Radioisotope research: absorption of radioiodine - in 2 h of 2,6 %, in 4 h of 5,2 %,
in 24 h of 1,5 %.
What is your provisional diagnosis?
 11

11. The patient D., female, 27 years has arrived in clinic with complaints of
irritability, interrupted sleep, sweating, palpitation of heart at the rest, loss of
weight on 10 kg. Deterioration has been for last 3 months after acute respiratory
virus infection.
Body height is 175 sm, body weight is 42 kg, body temperature - 37,6ºС.
During the examination it is noticed a labile behavior of the patient, fast change of
mood, tearfulness, quick speech, exophthalmus, tremor of hands. Positive
signs of Grefe and Moebius are detected. The skin is mild and hot at the touch. At
swallowing the thyroid gland is visible. At palpation it is mild, painless. Peripheral
lymphatic nodes are not enlarged.
Clear pulmonary sound and vesicular respiration are revealed above both
lungs. Respiration rate is 18 per minute. Apex beat is at lin. medioclavicularis
sinistra, the area - of 3 sm, low, not resistant. The left border of the relative heart
dullness -is at lin. medioclavicularis sinistra. Pulse is 100 per minute, arrhythmic,
of irregular filling and strain. Arterial pressure is 150/60 mm Hg. Cardiac sounds
are accelerated, arrhythmic. Amplified I sound - at the heart apex, systolic murmur
- above heart apex and pulmonary artery. Abdomen is mild, painless. The height
of hepatic dullness is 11-10-9 sm. The edge of the liver is acute, mild, and
painless. The dimensions of the lien are 8-4 sm. Edemas are not present. Stool is
2-3 times a day, semi-liquid, brown, without pathological admixtures.
Common blood analysis: hemoglobin - 110 g/l, erythrocytes - 3,1×1012/l,
leucocytes - 8,2×109/l, ESR - 5 mm/hour, segmentonuclear
neutrophiles - 68 %, lymphocytes - 25 %, monocytes - 7 %.
ECG: atrial fibrillation 80-110 per minute, normal position of electrical axis
of the heart, smoothness of T-wave in V4-6 I, II, аVL.
What is your provisional diagnosis?
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12. Patient D., female, 28 years, is delivered in clinic in unconsciousness state. A

thirst, bad appetite, headache, delicacy have appeared during 2 weeks after
influenza. The day before there was abdominal pain, numerous vomiting (the
anamnesis is taken from words of the husband).
The general state is serious. The consciousness is absent, patient’s position is
passive. Respiration is deep and noisy (Kussmaul's respiration). Respiration rate is
32 per minute. The fruit odour from mouth is present. Skin is dry. Tongue is dry
and red. Pulse is 120 per minute, of the small filling and strain. BP is 95/60 mm
Hg. Abdomen is mild at palpation.
Common blood analysis: glucose - 45,4 mmol/l, creatinine - 0,12 mmol/l.
Analysis of urine: glucose - 16,2 mmol/l, protein - 0,9 g/l, specific gravity - 1030,
Lange's test (acetone) - positive.
What is your provisional diagnosis?
 13

13. Patient А., female, 43 years, has arrived in hospital department with complaints
of delicacy, sweating, numbness of lips and of tongue, sensation of general
trembling of the body, anxiety. Deterioration of the state has begun within day.
She suffers a diabetes mellitus during 1 year, accepts hypoglycemic tablets
Glurenorm. Within day she has eaten nothing (from words of the daughter).
The general state is serious. At the survey of patients convulsions have
developed, and then she has lost consciousness.
The skin is wet. Pupils are wide, pupillary reflex on light is absent. Respiration is
superficial, 20 per minute. Pulse is 84 per minute. BP is 120/60 mm Hg. From
the side of internal organs pathological changes are not revealed. Abdomen is mild,
painless. The liver according to Kurlov is 9-8-7 sm. Edemas are not present.
ECG: sinus rhythm of 80 per minute minute, RII> RI> RIII.
Common blood analysis: glucose - 1,4 mmol/l, creatinine - 0,009 mmol/l.
Analysis of urine: specific gravity - 1009, protein - absent, glucose - absent,
Lange's test (acetone) - negative.
What is your provisional diagnosis?
 14

14. Patient В., female, 27 years, complains of burning sensation, shortage of air,
shooting-pains at the left half chest, giddiness at the time of intramuscular
injection of Penicillinum. In 10 minutes she has lost consciousness.
The general state is serious. At the survey it is marked expiratory dyspnea, and
paleness of the skin. At examination of lungs it is revealed a clear pulmonary
sound, respiration with prolonged expiration, and whistling, diffuse rales.
Respiration rate is 28 per minute. Cardiac sounds are loud, arrhythmic. Pulse
is 112 per minute. BP is 60/40 mm Hg. Abdomen is mild, sensitive in epigastrium
at palpation. The liver according to Kurlov is 9-8-7 sm, the lien is not enlarged.
Edemas are not present.
What is your provisional diagnosis?
What is the urgent treatment?
 15

15. The patient S., male, 34 years, complains of dyspnea, sweating, delicacy, the

increased appetite, enlargement of volume of the abdomen, loss of work capacity.

At survey - body height - 178 sm, weight - 112 kg, body mass index – 35,3
kg/m2. The skin is light pink, wet. The subcutaneous fat is distributed uniformly.
The width of skin fold is 5 sm on anterior abdominal wall, 3 sm -in subscapular
region, 3 sm – at the back surface of the shoulder, 5 sm – at the top of the thigh.
Abdominal circumference is 146 sm, circumference of the hip - 68 sm.
Clear pulmonary sound and vesicular respiration are revealed above both
lungs. Respiration rate is 18 per minute. Borders of relative heart dullness: the left
- on 1 sm from lin. medioclavicularis sin., the right - on 1 sm to the right from the
edge of sternum. Cardiac sounds are softened, rhythmic. Pulse is 72 per minute,
BP - 150/90 mm Hg. The abdomen is protruding forward in vertical position of the
patient and uniformly flattened in horizontal position. At percussion the tympanic
sound is determined above whole abdomen in vertical, horizontal position and
lateral recumbent position of the patient. At palpation abdomen is mild, painless.
Liver inferior edge is palpated at the right midclavicular line 2 sm below costal
arch, rounded, painless, mild. The height of hepatic dullness is 14-12-11 sm.
Edemas are not revealed. The lien is not palpated.
Common blood analysis: hemoglobin - 130 g/l, erythrocytes - 4,2×1012/l,
leucocytes - 8,6×109/l, eosinophiles - 3 %, segmentonuclear neutrophiles
- 68 %, lymphocytes - 20 %, monocytes - 9 %, ESR - 11 mm/hour.
Biochemical blood analysis: glucose - 5,6 mmol/l, cholesterol - 7,8
mmol/l, bilirubin – 14,8 mcmol/l, АsАТ - 0,34 mmol/l, АlАТ - 0,68
mmol/l.
ESG: sinus rhythm - 88 per minute, left axis deviation, RV 5-6> RV4, STV 5-
6 below isoelectric line on 1 mm.
What is your provisional diagnosis?
 16

16. Patient G., female, 50 years, complains of thirst, dryness in the mouth,
frequent and abundant urination, itching of the skin in perineum. She has paid
attention to these signs about 2 months ago. About 3 years she suffers chronic
pancreatitis. Her mother suffered diabetes.
At survey: body height – 158 sm, body mass - 82 kg. The skin is dry, with
traces of scratchings, and redness of cheeks. Peripheral lymphatic nodes are not
palpated. The thyroid gland is not enlarged.
Clear pulmonary sound and vesicular respiration are revealed above both
lungs. Respiration rate is 18 per minute. Cardiac sounds are rhythmic, softened.
Pulse - 76 per minute, of the satisfactory filling and strain. Tongue is dry, covered
with a white raid. At palpation abdomen is mild, painless. The dimensions of
height of hepatic dullness are 10-9-8 sm. The edge of the liver is pointed, mild,
and painless. Pasternatsky's symptom is negative at the both sides of lumbar
region. Daily diuresis is 2,5 l a day.
Common blood analysis: hemoglobin - 110 g/l, erythrocytes - 3, 2×1012/l,
leucocytes - 6,6×109/l, ESR - 2 mm / hour.
Biochemical blood analysis: glucose - 11,6 mmol/l, total protein - 72 g/l,
cholesterol - mmol/l.
Analysis of urine: specific gravity - 1030, glucose - 2,0 mmol/l, acetone (+),
flat epithelium - 2-3, leucocytes - 3-4.
What is your provisional diagnosis?
 17

Situational problems of blood and endocrine diseases

1. Iron-deficiency anemia
Anisocytosis with microcytosis, poikilocytosis, and hypochromia of
erythrocytes
2. В12-deficiency anemia.
Bone marrow biopsy. Serum vitamin В12.
3. Chronic myeloid leucosis.
Bone marrow biopsy. Ph chromosome.

4. Acute myeloblastic leucosis. Bone marrow biopsy.

5. Chronic lymphoid leucosis. Bone marrow biopsy.
6. Acute lymphoblastic leucosis. Bone marrow biopsy.
7. Hemorrhagic diathesis, thrombocytopenic purpura (Werlhof's disease)
8. Hemorrhagic diathesis, hemorrhagic vasculitis.
9. Posthemorrhagic anemia
10. Hypothyroidism.
11. Hyperthyroidism
12. Diabetes mellitus, hyperglycemic coma.
13. Diabetes mellitus, hypoglycemic coma.
14. Acute anaphylaxis. Epinephrine, Dopaminum, glucocorticoids, Euphyllinum.
15. Alimentary obesity
16. Diabetes mellitus.