1. A 65-year-old man complains of difficulty swallowing of solid food, weakness, weight loss.

Occasionally mentions a pain in the epigastrium with irradiation to the back. The first
manifestations of dysphagia appeared 4 months ago, after which it did not disappear and
gradually increased. The pain has been noticeable for the last two weeks. He has been smoking
for 40 years, about a pack of cigarettes daily. He drinks strong alcohol two or three times a week
and prefers spicy food. A pensioner, he worked as a worker at an asphalt plant.
Objective: appears exhausted. Skin and mucous membranes are normal. Body temperature:
36.8 ° C; RR: 16 / min; Pulse 72 beats / min, regular; BP 130/80 mm Hg. Auscultation of the
chest gives clear breath and cardiac sounds. Percussion of the chest is unremarkable. On
palpation, the abdomen is soft, with moderate tenderness in the epigastrium. Bowel sounds
are as usual.
Applications:
* Barium esophagram
* Laboratory tests results
Questions
1, Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3, Give an assessment of the laboratory parameters.
4, What additional diagnostics are required?
5. Suggest curative tactics.
Task 1
1Diagnosis: chronic surgical pathology of the alimentary canal, Esophageal cancer.

2Diagnostics: Barium swallow- severe stricture / stenosis that inhibits endoscopic evaluation.

3Findings : Asymmetrical and irregular borders of the esophagus .

4 Additional diagnostics: Esophagogastroduodenoscopy with biopsy, CT scan

5.Treatment: Neoadjuvant chemoradiation

Surgical resection (Esophagectomy)

Post operative antibiotics : Cefuroxime 1.5g

2. A 27-year-old woman complains of acute attack of severe pain in the right lumbar region,
frequent urination, nausea, periodic vomiting. The pain radiates to the right inguinal, labia
majora and right thigh, almost independent of changes in body position. The urge to urinate
repeats every 10-15 minutes. Urine is excreted in small portions. The above attacks recurred 2-3
times a year, but were less intense and short-lived.
Objective: the patient is restless, constantly changes a body position, and gets out of bed. Body
temperature: 36.8°C; RR: 20/min; Pulse 72 per min, regular; BP 130/80 mm Hg. Auscultation of
the chest shows clear breath and cardiac sounds. Palpation reveals a protective muscle tension in
the right lumbar region; the area of the right kidney is painful.
Applications:
* Abdominal CT scan

* Laboratory tests results.

Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the X-ray examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Prescribe medication

Task 2
1.Diagnosis : acute surgical pathology of the abdomen, acute urolithiasis

2.Diagnostics: x- ray evaluation – presence of stones and ureter dilatation

3.Lab test: Gross hematuria , leukocytosis

4.Treatment : hospitalize in surgical department

Uretero-renoscopy , a transurethral endoscopic procedure

Percutaneous nephrolithotomy

5. Post operative antibiotics : cefuroxime 1.5g

3. A 51-year-old man complains of pain in the left hypochondrium that radiates to the left arm
and neck when trying to lie down in his supine position, general weakness, and thirst. Three
hours ago, he was returning from a friend's birthday party and fell on the rails with his left side
while crossing the railway track.
On examination, patient is in serious condition. The skin and conjunctivae are pale. The smell of
alcohol from the mouth is detectable. The jugular veins are not dilate. A pulse is regular, of weak
filling, 108 beats / min. BP 105/75 mm Hg. Breath and cardiac sounds are clear to
auscultation.
There is a linear abrasion in the left costal arch area. The abdomen is moderately enlarged, its
respiratory movements are limited. Palpation reveals pain and slight muscle tension in the left
hypochondrium, pain in the left costal arch, a moderate rebound sign. Bowel sounds are
decreased.
Applications:
¢ Abdominal CT scan
* Laboratory tests results.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the X-ray examination.
3. Give an assessment of the laboratory parameters.
4, Suggest surgical tactics.
5. Prescribe medication

Task 3
1.Diagnosis : acute surgical pathology of the abdomen , blunt abdominal trauma ,complicated with splenic
rupture .

2.Diagnostics :abdominal CT scan -presence of hematoma

Kehr’s sign - referred pain in the left shoulder

4.Treatment : hospitalize in surgical dept.

Urgent laparotomy
 5.Post operative antibiotics

4, A 57-year-old woman complains of feeling of heaviness in her right side and intermittent pain
in the right hypochondrium, night fever up to 38.5°C with chills, weakness, loss of appetite. She
underwent a laparoscopic cholecystectomy due to prolonged severe attack of cholecystitis,
accompanied by fever, three weeks ago. Within the postoperative period, there are daily episodes
of fever.
Objectively: the patient looks exhausted. Her skin is dry, wrinkled; the skin fold straightens with
a delay. Body temperature 37.8°C. Pulse 92 beats/min; BP 138/80 mm Ig. Breath sounds are
moderately decreased in the chest right lower part. Heart sounds are clear. There are
postoperative scars on the places of laparoports on the abdominal wall. Palpation in the right
hypochondrium and tapping on the right costal arch course a pain. The lower edge of the liver is
3 cm below the edge of the costal arch. Bowel sounds are clear.
Applications:
¢ Abdominal Ultrasound
* Laboratory tests results.
Questions
1. Determine a clinical diagnosis.-Sepsis/ Abscess
2. Formulate the conclusion of the abdominal ultrasound.
3. Assess the laboratory parameters.
4. Suggest surgical tactics.
5. Prescribe medication

5. A 56-year-old woman complains of changes in the skin of her right breast. She says the skin
around her right nipple has become red and "crusty" over the past few months. The left nipple

and areola are normal. The patient have not visited a doctor for 4 years. Patient’s history includes
episodes of recurrent heartburn, about which she takes omeprazole irregularly. She has an adult
son; does not smoke, does not drink alcohol. She is in menopause since the beginning of this
year.
Objective examination. Body temperature: 36.8°C; DP: 156/90; RR: 14/min; Pulse: 72/min.
Breath and cardiac sounds are clear to auscultation. Palpation of the right breast reveals a solid 2-
centimeter lump in the upper, outer quadrant of the right breast that is not fixed to the chest wall.
The skin over the mass is poorly folded. The right nipple and the areola have an eczematoid,
scaly appearance. Examination of the left breast is unremarkable. Axillary lymph nodes are not
enlarged. Abdomen is unremarkable.
Applications:
° Mammogram
¢ Laboratory tests results
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. What additional diagnostics are required?
5. Suggest curative tactics.
Task 5
Diagnosis: chronic surgical pathology of the breast , breast cancer (early stage)

Diagnostics: CT scan of chest , excision biopsy of the lump

Treatment : mastectomy , chemotherapy and hormonal therapy

6. A 76-year-old woman developed and gradually increased a diffuse cramp-like abdominal pain,
nausea. She vomited several times without any relief, first with altered food and then with bile. A
bloating, flatulence presents. Patient fell ill the day before, in her opinion, after the birthday party
of the daughter-in-law. The last defecation occurred the day before yesterday. Patient underwent
an open operation due to destructive cholecystitis, local peritonitis. History includes
hypertension, she takes lisinopril, atorvastatin, clopidogrel as prescribed by her family doctor.
Objective examination: obese patient in a serious condition. Body temperature: 36.7°C; BP:
158/94 mm Hg; RR: 26/min. Pulse 108 beats/min, regular. The skin is dry and the conjunctiva
is pink. The tongue is dry, covered with a yellowish plaque. Breath sounds are clear to auscultation.
Heart sounds are clear with accent of the second tone on the aorta. The abdomen is enlarged.
Along the midline of abdominal wall, there is a deformed postoperative scar, in the middle part
of which an asymmetric protrusion of 15 x 12 cm presents. An attempt of a palpation the
protrusion is sharply painful, intense. Bowel sounds are uneven, with periodic amplification; the
noise of "splash" is defined. Abdominal percussion reveals high tympanic sound.
Applications:
* Abdominal Radiogram
* Laboratory tests results.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the abdominal radiogram.
3. Assess the laboratory parameters.
4. Suggest surgical tactics.
5. Prescribe medication

Task 6
Diagnosis : acute surgical pathology of the abdomen, post operative complication , intestinal obstruction
with adhesions

Diagnostics : x- ray -proximal bowel dilatation

Multiple air-fluid levels and stacked dilated loops of small bowel – kloibers cup

Lab tests : leukocytosis , hyponatremia , increased urea and creatinine .

Treatment : hospitalize at surgical dept.

Urgent surgical intervention ( laparotomy , elimination of intestinal obstruction.

I/V fluid 400ml NACL

Analgesic – ketorolac 3% 1ml 3t/d i/m

Spasmolytics
 Prophylaxis administration of antibiotics ( ceftriaxone 1g 2t/d in 200ml sol. I/V)

7. A 32-year-old woman complains of abdominal pain, fatigue, dizziness, frequent (up to 18

times a day) bowel movements with blood and mucus. low-grade fever, weight loss up to 20 kg
during the year. She works as an accountant; does not smoke; takes a dry wine occasionally. She
mentions episodes of joint pain.
The patient is exhausted and appears ill, has a pale skin and conjunctiva. Body temperature:
37.3°C. Blood pressure 106/60 mm Hg. Pulse 98 per 1 min. Breath and heart sounds are clear to
auscultation. The abdomen is symmetric, participates in respiratory movements. Palpation of the
abdominal wall reveals a pain in the projection of the colon, which presents as a spasmodic cord
in the right half. Bowel sounds are decreased.
Applications:
¢ Colonoscopy picture
* Laboratory tests results.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the Colonoscopy.
3. Assess the laboratory parameters.
4. Suggest surgical tactics.
5. Prescribe medication

Task 7

Diagnosis : chronic surgical pathology of the abdomen ,ulcerative colitis ,severe degree.

Diagnostics : colonoscopy – pseudo polyps, ulcers, erosions

Lab tests : ++ perinuclear ANCA, + ESR, ++ CRP , leukocytosis , anemia

Treatment : proctocolectomy with an ileal pouch -anal anastomosis

Medication : 5 -amino-salicylic acid derivatives – sulfasalazine 500mg/6h per os

Corticosteroids – prednisolone 40mg /day per os

Post operative antibiotics

8. A 62-year-old man complains of a cough with sputum, weakness, loss of appetite, weight loss,
and shortness of breath when walking up the stairs. The sputum is dominantly mucus-purulent,
sometimes contains a blood. Patient mentions episodes of joint pain as well. He has been
smoking for 44 years, about a pack of cigarettes a day, so he considers cough as a common. He
used to work as a mechanic and is now retired. He drinks strong alcohol two or three times a
week.
Objectively: asthenic man with normal skin and mucous membranes. Body temperature: 36.8°C:
RR: 22 / min; Pulse 78 beats/min; BP 138/82 mm Hg. The veins of the neck are not dilated.
Cervical and axillary lymph nodes are not enlarged. There is deformation of the end phalanges of
the fingers due to their thickening. A lung auscultation reveals decreased sounds in the lower left.
On percussion a dull sound presents above a place of respiratory weakening. Heart sounds are
clear. The anterior abdominal wall is soft and painless on palpation.
Applications:
° Chest CT scan
* Laboratory tests results
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. What additional diagnostics are required?
5. Suggest curative tactics.

Task 8

Diagnosis : chronic surgical pathology of the lung , cancer of the lung

Diagnostics : chest x ray – cavitation lesion

Irregular margins , large size

Bronchoscopy – tissue biopsy

Treatment : surgical resection of the left lung.

9. A 59-year-old man complains of abdominal pain, weakness, nausea, and fever. He has been
smoking for 42 years, about a pack of cigarettes a day. He works as a driver, prefers meaty, fatty
foods; consumes a dry wine occasionally. Patient notices similar, but much lighter episodes in
the past; the complaints disappeared usually in 1-2 days on their own.
The patient is of hypersthenic body type. Skin and mucous membranes are normal. Body
temperature: 38.1°C. Blood pressure 146/90 mm Hg. Pulse 104 per 1 min. Breath and heart
sounds are clear to auscultation. The abdomen is symmetric, participates in respiratory
movements. Palpation of the abdominal wall reveals tenderness and moderate defense in the left
lower quadrant. The rebound sign is negative. Bowel sounds are decreased. Rectal examination
does not find any abnormalities.
Applications:
* Irigogram
* Laboratory tests results
Questions
1. Determine a clinical diagnosis.-Crohns diseiase / colitis/ chronic pancreatitis/ chronic
cholecystitis
2. Formulate the conclusion of the radiological examination.
3. Assess the laboratory parameters.
4. Suggest surgical tactics.
5. Prescribe medication

10. A 62-year-old woman mentions an appearance and progression of weakness and weight loss
(approximately 8 kg within last 3 months). Upon detailed questioning, it was found that the
patient is prone to constipation, recently notices the appearance of black stools. She takes
nebivolol, aspirin, simvastatin as prescribed by her family doctor. She has never smoked and
does not drink alcohol. Her mother died at the age of 58 after surgery that was performed due to
intestinal obstruction.
On examination: the patient appears ill. The skin is dry and the conjunctiva is pale. Body
temperature: 36.8°C; RR: 16 / min; Pulse 62 beats/min. BP 142/80 mm Hg. Breath and heart
sounds are clear to auscultation. The abdomen is symmetric, participates in respiratory
movements. Palpation of the abdominal wall is painless, without defense. Bowel sounds are
detectable. Rectal examination does not find any abnormalities in rectal ampoule; there is a black
feces on a glove.
Applications:
* Irigogram
* Laboratory tests results
Questions
1 Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. What additional diagnostics are required?
5. Suggest curative tactics.
Task 10

Diagnosis : chronic surgical pathology of the abdomen, colon cancer.

Diagnostics : flexible sigmoidoscopy

Treatment : colectomy, left hemicolectomy , sigmoid colectomy .

11. A patient of 25 years complains of continuous pain in his right iliac region, the intensity of
which decreases in the position of lying on the right side with bent legs, dry mouth, general
weakness, fever up to 37.9°C, lack of appetite. The pain appeared in the epigastrium last evening.
Two hours later the nausea and single vomit occurred. Pain increased till morning and moved to
aright iliac area. The body temperature increased to 37.6°C, a pulse rate became 90 per min.
He has no significant past medical history and takes no medications. He smokes for about 4
years 7-8 cigarettes daily. Does not use strong alcohol, occasionally - beer and energy drinks.
T: 38.1°C; BP: 122/80 mm Hg; RR: 15/min.; P: 98/min, SpO2 98%.The patient is athletic
appearing. Auscultation of the chest gives clear breath and cardiac sounds. Percussion of the
chest is unremarkable. On palpation, the abdomen is markedly tender in the right lower region;
there is involuntary guarding with a fairly rigidity and rebound tenderness. The liver and
spleen are not palpable. Bowel sounds are slightly decreased.
Applications:
* Sonogram of the abdomen in the pain area
* Results of CBC.
Questions
1. Determine a clinical diagnosis.-
2. Formulate the conclusion of the ultrasound examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Acute Appendicitis
2. US: thickening of the appendix walls, increase echogenicity of the
surrounding fatty tissue.
3. Lab data: Neutrophil leukocytosis, shifting the formula to immature
forms(left)
4. Laparoscopic & laparotomy appendectomy (retrograde/antegrade)
5. Hospitalization to surgical department.
Urgent surgery(appendectomy), optimally-laparoscopic
Medication after surgery
IV fluid
Emperical antibiotics (cephalosporins e.g Ceftriaxone 1g 2t/d, imipenem,
fluorquinolone)
Anagelsics (promedol, ketorolac 3%-1ml 3t/d)
Spasmolytics (nospa, papaverine)?

12. A 56-year-old man presents to the emergency room with a 3-days history of bouts of
worsening abdominal pain, with nausea and vomiting. The pain is located mostly in right
hypochondriac; radiates through to the right shoulder, right side of patients back. The fever, dry
mouth, general weakness, lack of appetite, bloating are mentioned as well. The disease has
begun, it is believed, after using of fried meat. Patient took pancreatin, drotaverin, amoxicillin,
ibuprofen with a temporary effect. On further questioning, he admits to previous bouts of similar
abdominal pain over the past 6 months but never so intensive. The history is marked with
hypertension, which requires taking of perindopril/indapamide 1 tablet once a day. Patient works
as a private entrepreneur; he does not smoke; consumes alcohol episodically.
Objective examination reveals rather heavy condition. T: 38.6°C; BP: 152/94 mm Hg; RR:
25/min.; P: 112/min, SpO2 96%. The patient is fatty appearing. The body mass index is 30.85.
Scleras are subicteric. Auscultation of the chest gives clear breath and cardiac sounds. Percussion
of the chest is unremarkable. The tongue is covered with yellowish bloom. There is abdominal
tenderness in the right upper quadrant with guarding, especially during inspiration. Rebound sign
is positive here. Tapping on the right edge arc is sharply painful. Bowel sounds are slightly
decreased.
Applications:
* Sonogram of the abdomen in the pain area
* Results of blood tests.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the ultrasound examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)
Task 12
Diagnosis : chronic surgical pathology of the abdomen, chronic calculus cholecystitis, exacerbation stage
complicated with peritonitis .

Diagnostics : ultrasound – thickening of gallbladder , solid rounded formation in its lumen .

Positive murphy sign , presence of gallstones .

Lab tests : neutrophilic leukocytosis , ++ESR, ++ bilirubin( mechanical Jaundice ) , ++ CRP

Treatment : urgent hospitalization in surgical dept.

Laparotomy cholecystectomy

Tube drainage of abdominal cavity

Medication and diet changes : i/v fluid (normal saline 400ml 1t/d )

Antibiotics – ceftriaxone 2t/d i/v

Spasmolytics (no spa , papaverine )

Analgesics ( ketorolac 3% 1ml 3t/d i/m .

13. A 49-years-old fatty man presented with the attack of severe abdominal girdle pain that has
appeared after the enormous eating of meat and fat meal. The pain is located in epigastria and
left hypochondriac area, irradiates to the back. Severe nausea, multiple vomiting, which does not
bring facilitation, takes place. Patient notes difficulty of breathing, weakness, delay of intestinal
emptying. The condition is progressively worsened.
The patient is extremely heavy, the skin is pale, with cyanotic areas, and breathing is superficial.
PR is 128 per min.; BP is 90/50 Hg mm, RR 28 per min.; SpO2 92%. Breath and cardiac sounds
are rather clear. A tongue is dry, covered a white raid. An abdomen is moderately enlarged, with
gaseous distention, soft. Palpation reveals pain in epigastria and left hypochondric area. where
the infiltration is noted. Peritoneal signs are negative. The Meyo-Robson’s sign is positive.
Applications:
* Sonogram of the abdomen
* Results of blood and urine tests.
Questions
1, Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Acute pancreatitis with septic shock

2. X-ray: edema of the pancreas. Para pancreatic accumulation of fluid
3. Lab data: Neutrophilic leukocytosis. Hyponatremia, increase urea,
creatinine. Hyperbilirubinemia, increase amylase.
4. Hospitalization in the surgical department
No surgical treatment unless if stone is present, distal papilla endoscopy
(papilosphincnectomy)
5. Medication (hospitalization)
IV fluid (Normal saline 800ml)
Anagelsics (promedol, ketprolac 3%-1ml 3t/d IM)
Protease inhibitor (contrical, aminocaproic acid)50mg IV individually
Somatostatins (octreopide)

14. A 30-year-old man presents to the emergency department with sudden onset of severe
epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain
occurring nearly every day and relieved by antacids. He takes two packs of cigarettes and several
cups of coffee daily.
On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of
37.8°C, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 14/min. His lungs are
clear. The remainder of his examination reveals diminished bowel sounds and a markedly tender
and rigid abdomen. Percussion of abdomen gives box sound above right chondric arc. Fairly
rebound tenderness presents.
Applications:
* Radiogram of the abdomen
* Result of blood test.

Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Perforation of the digestive organ of the abdominal cavity(presumably,

perforation of duodenal ulcer)-peritonitis
2. X-ray: pneumoperitoneum(perforation of the digestive organ of the
abdominal cavity-air between the liver and right diaphragmatic Crura )
3. Lab. Data: Neutrophil leukocytosis, shift to the left.
4. Hospitalization to the surgical dept.
Urgent surgical intervention(first 1-2hrs of hospitalization)
Laparotomy, suture of the perforation, drainage of abdominal cavity
Truncal vagotomy, highly selective vagotomy, Bilrote 1&2 in gastric ulcer
5. Medication
Analgesic: ketorolac 3%-1ml 3t/d IM
Antibiotics therapy: 4th gen cephalosporins, cefepim 1g 2t/dIV in 200ml
physiological sol
 Infusion therapy(because patient can’t eat after surgery): NaCl 400ml IV
PPI: pantoprazole 0,04 2t/d IV in 100 ml of sol.

15. A 40-years-old thin man has been suffering from gastric ulcer for a long time. During last 2
days the pain became less intensive. At the same time, an increasing weakness, dizziness
appeared. This morning, rising from a bed, he lost conscious on a few seconds. Patient is smoker,
coffee drinker; avoids strong alcohol.
PR is 108 per min.; BP is 90/50 Hg mm, RR 26 per min.; SpO2 96%. The patient is moderately
heavy, with pale skin. Breath and cardiac sounds are rather clear. There is none intensive pain in
the epigastric area. Peritoneal symptoms are absent.
Rectal exam reveals black stool.
Gastro-duodenal endoscopy was performed, photo is added
Applications:
* Endophoto
* Results of blood test.
Questions
1. Determine a clinical diagnosis.
2. Describe the endoscopic picture.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Chronic gastric ulcer ; gastrointestinal bleeding of ulcerous genesis

2. Endoscopic picture: Bleeding in the lumen of the digestive tract
3. Lab. Data: Anemia of moderate degree(1 degree)
4. Hospitalization to a surgical department
Endoscopy hemostasis (Argon coagulation, pressed) ,medication
5. Medication
IV fluid 400ml
PPI: pantoprazole 0,04 2t/d IV
Inhibitors of Fibrinolytics: Tranexamic acid 0,5 IV 3t/d, Aminocapronic acid,
Etamcylate
FFP: single-group 200ml IV
Oxygen therapy
Additional info: other reasons of GI bleeding: Trauma due to burn of the
esophagus, stomach due to swallowing of corrosive subs.
Vein dilatation( Mallory Weiss syndrome)
Tumors and cancers
16. A 68-year-old man complains of ache in his right hypochondriac, which radiates through to
the right shoulder, right side of the back, lumbar area; nausea and vomiting with the bile; low
grade fever; dry mouth, general weakness, lack of appetite, bloating. The pale stool and dark
urine.are mentioned as well. The disease has begun, it is believed, after using of fried fatty meat
3 days ago. Patient took pancreatin, drotaverin, amoxicillin, ibuprofen with a temporary effect.
On further questioning, he admits to previous bouts of similar abdominal pain over the past 6
months but never so intensive and without any changes in the stool and urine. The history is
marked with hypertension, which requires taking of perindopril/indapamide | tablet once a day.
Patient is pensioner. He does not smoke; consumes alcohol episodically.
T: 37.6°C; BP: 144/90 mm Hg; RR: 21/min.; P: 112/min, SpO2 96%. The patient is fatty
appearing. The body mass index is 31.22. Skin and sclera are icteric. Auscultation of the chest
gives clear breath and cardiac sounds. Percussion of the chest is unremarkable. The tongue is
covered with yellowish bloom. The exanimation of abdomen reveals the tenderness and
moderate guarding in the right upper quadrant, especially during inspiration; with mild rebound
pain. Tapping on the right edge are is sharply painful. Bowel sounds are slightly decreased.
Endoscopic retrograde cholangiography was performed.
Applications:
* Result of endoscopic retrograde cholangiography
* Results of blood test.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Gallstone disease, chronic calculus cholecystitis. Cholecholithiasis.

Mechanical jaundice.
2. US: Enlargement of the common bile duct, defects in the filling of the
round form(concrements) in the lumen of the of the common bile duct, gall
bladder.
3. Lab data: Neutrophil leukocytosis, displacement of the formula to
immature forms(left), hyperbilirubinemia for direct bilirubin
4. Hospitalization in the surgical dept.

Operative intervention: papillosphincterotomy, drainage if the common bile

duct(under x-ray control), cholecystectomy (optimally endoscopic)
5. Medication
IV fluid, 400ml
Emperical antibiotics (4th gen. cephalosporins, imipenem, cefepim 1g 2t/d
IV, fluorquinolone)
Anagelsics (promedol, ketorolac 3%-1ml 3t/d IM
Spasmolytics (nospa, papaverine)?
Additional data: Oddi sphincter is cut to widen it, so as to remove stones
from the c.b.d and collect in it.
Task

17. A 45-year-old man presents to the emergency department in extremely poor condition. The
patient is somnolent, flabby, adynamic, and in marked distress. He can not tell about the onset of
the disease. According to the neighbor, who accompanies the patient, within 4 days did not leave
the house. He is alone; abuse of alcohol. Not employed.
Vital signs reveal a temperature of 39.3°C, BP of 78/46 mmHg, pulse rate of 132/min, and
respiratory rate of 32/min. Patient appears obviously exhausted. The skin is pale, the turgor is
lowered. His lungs are clear. The remainder of his examination reveals markedly tender and rigid
abdomen with absence of bowel sounds. Percussion of abdomen gives box sound with dullness
downward. Fairly rebound tenderness presents.
Applications:
* Radiogram of the abdomen
* Result of blood tests.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4, Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Acute diffuse peritonitis(presumably severe perforation origin)

2. X-ray: pneumoperitoneum( air in abdominal cavity)
3. Inflammatory process: Neutrophil leukocytosis , shift to the left,
hyponatremia, increased urea, creatinine.
4. Hospitalization to the surgical department
Urgent surgical intervention (laparotomy, restoration of the integrity of
the digestive tube and its decompression by one of the methods, sanation
and drainage of the abdominal cavity)
5. Medication
IV fluid 800ml normal saline
Anagelsics (promedol, ketorolac 3%-1ml 3t/d)
Antibiotics (cefotaxime,ceftriaxone 1 g 2t/d in 200ml sol. IV
Metronidazole 0,5 2-3t/d
Vasopresor (dopamine, epinephrine)?
Alimentation: Double Nasogastric tube( small into stomach for feeding,
larger in duodenum for gas evacuation)

18. A 45-years-old man complains of a diffuse increasing pain in abdomen, mostly in right-side
and in hypogastric area. The vomiting has occurred several times. The delay of gas and intestinal
content evacuation is noted. History is remarkable by the appendectomy which has been
performed several years ago. He is smoker; takes strong alcohol occasionally.
At the physical examination: the general condition is grave, body temperature is 37.6°C, pulse
rate is 100 per min, BP is 110/70 Hg mm. Patient appears pale, diaphoretic and dyspneic. Breath
and cardiac sounds are rather clear. Abdomen is asymmetric, with moderate pain at
palpation,intestinal sounds are weak, and the Hippocratic (succussion) sounds are defined.
Percussion gives box sound above abdomen.
Applications:
* Radiogram of the abdomen
* Result of blood test.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Acute intestinal obstruction

2. X-ray: Air-fluid levels in the bowel (Klojbers bowel/cup)
3. Neutrophils leukocytosis, hyponatremia, increased urea, creatinine
4. Hospitalization to a surgical department
Urgent surgical intervention (laparotomy, elimination of intestinal
obstruction, decompression of the digestive tube, at the critical ischemia of
the intestine-adequate resection)
5. Medication
IV fluid 400ml NaCl
Analgesic (ketorolac 3%-1ml 3t/d, IM)
Spasmolytics
Antibiotics (Ceftriaxone 1g 2t/d in 200ml sol IV)

19. A patient of 56 complains of the pain in muscles of the right thigh, foot and legs. which
occur when walking at a distance of about 150-200 m. He mentions deterioration at the damp
cold weather. Periodically, spastic abdominal pain is appearing after eating. Patient is a
bricklayer; smokes more than 40 years, about a packet of cigarette a day. Alcohol consumes 1-2
times a week.
The man is of asthenic body structure. The skin looks normal. Mucous are of pale pink. BP:
140/76 mm Hg. PR: 68 per 1 minute. RR: 18 per 1 minute, SpO2 98%. Auscultation finds
vesicular breath sounds. Cardiac sounds are rhythmic. clear. The abdominal wall is soft and
painless on palpation. Intestinal sounds are as usual. Skin of the lower extremities is pale and
dry; hyperkeratosis of nails, hypotrophy of muscles is present. Pulse on the arteries of the right
leg and foot, the popliteal artery is not determined. The patient has an angiogram (attached).
Applications:
° Angiogram
° Result of blood test.

Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4, Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Obliterating arterial atherosclerosis with occlusion of the femoral-popliteal

segment to the right. Chronic ischemia of the lower extremity of the 2B
degree.
2. Arteriography: The defect of filling in the arterial femoral and popliteal
segment to the right(manifestation of obliterative atherosclerosis).
3. Lab data: Hypercholesterosemia, dislipoproteinemia.
4. Hospitalization in the vascular surgery department
Surgical angioplasty( Endoartherectomy, shunt (bypass operation),
endocascular inflation (dilation & shunt)
5. Medication
In postoperative period: 
Analgesic: ketorolac 3%-1ml 3t/d IM
Anticoagulant: Enoxyparin 0,4ml SC 2t/d or Heparin
Additional data: Endarterectomy: Removing of the atherotic plague and
the infected intima of artery.

20. The patient is 56 years old, complains of swelling and pain in the left leg, which progress.
The disease began a day ago; symptoms arose in the evening after a long time sitting (the man is
a driver). The patient come to physician, was examined by a surgeon. the ultrasound of lower
extremities was performed. The man smokes about 40 years. History is marked with
appendectomy in adolescence, allergy to penicillin in the form of urticaria.
BP: 140/76 mm Hg. PR: 68 per | minute. RR: 18 per 1 minute, SpO2 98%. The skin looks
normal. Mucous are of pale pink. Auscultation finds vesicular breath sounds. Cardiac sounds are
rhythmic, clear. The abdominal wall is soft and painless on palpation. Intestinal sounds are as
usual. There is a left thigh swelling (an increase of 10 cm in comparison with the right one), a
shin (an increase of 10 cm in comparison with the right one). The signs of Moses and Homans
are positive
Applications:
* Sonogram
* Result of blood test.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of Sonography.
3. Give an assessment of the laboratory parameters.
4, Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments).

1. Acute Leo-femoral phlebothrombosis (Deep vein Thrombosis) of left lower

limb.
2. X-ray: Occlusion of the left iliac, femoral and popliteal veins.
3. Lab data: Neutrophil leukocytosis, hyperfibrinogenemia(N=2-4)
4. Hospitalization to the vascular surgery department
Regional thrombolysis with implantation of cava-filter, forgarty ballon
Catheter,
prophylaxis (inferior venue cava filter), compression stockings
5. Medication
Heparin 50000/ LMW heparin (enoxaparine 1mg/kg)
Change to warfarin with INR control
Thrombolytics therapy (tenectaplase, streptokinase)
Rivaroxaban 20mg/day
Phlebotonics (phlebodia, detratex)
Diclofenac sodium 2,5%-3ml IM

Additional data: Moses sign is making pressure on the ankle and the
patient is asked to flex his leg so as to put a pressure on the muscle. Presence
of pain is positive sign. 
Complications of phlebothrombosis: embolism, osteopenia, GI-bleeding,
pneumonia. 

21. The patient of 56 years old complains of a sharp pain in the left shin and foot, limiting of
movements in the joints of the lower extremity. The pain has appeared suddenly; the patient
immediately applied for help, was examined by a therapist. a surgeon, the ultrasound of the legs
was performed. Patient smokes over 40 years, about a pack of cigarettes a day. The history is
marked with myocardial infarction (4 years ago). Sometimes, the dyspnea on exertion comes. In
case of deterioration of well-being, he asks for a doctor, however, he refuses to take the medicine
regularly.
Patient appears moderately severe. BP: 118/76 mm Hg. PR: 118 per | minute. RR: 18 per |
minute, SpO2 98%. The skin looks normal. Mucous are of pale pink. Auscultation finds
vesicular breath sounds. Cardiac sounds are rhythmic, clear. The abdominal wall is soft and
painless on palpation. Intestinal sounds are as usual. His left foot and lower third of the tibia are
sharply painful and cold. The pulsation of the left femoral artery in inguinal area is clear, of other
arteries of the extremity is not determined.
Applications:
° Angiogram
° Result of blood test.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4, Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Thromboembolism of the femoral artery to the left

2. US: Blockage of the main bloodstream at the level of the femoral artery to
the left(manifestation of thromboembolism)
3. Lab. Data: Neutrophil leukocytosis, hyperfibrinogenemia ( N=2-4)
4. Hospitalization in the vascular surgery department
Emergency surgical intervention
thromboembolectomy by the use of fargaty catheter
5. Medication (hospitalization)
Analgesic (Ketorolac 3%-1ml 3t/d
Heparin 5000-10000iu, Enoxaparun 0,8ml SC 2t/d
Thrombolytics (streptokinase, tenectaplase,?
Antiaggregant (aspirin/clopidogrel)?
Prophylaxis of ulcers: PPI; pantoprazoke 0,04ml

22. A man of 27 complains of the pain in the right half of the chest (predominantly in the back,
periodically radiates to the shoulder), which increases when trying to breathe deeper, cough;
moderate dyspnea while walking. Back pain on the right appeared 2 days ago after the patient
fell down on the stairs. The next day patient came to a family doctor; after a physical
examination, a diagnosis was concluded: intercostal neuralgia; Ibuprofen was prescribed (200
mg daily). On the evening the dyspnea became worse, patient was admitted to emergency. Chest
X-ray in frontal view was performed (attached).
T: 36.8°C; BP: 138/84: RR: 29/min.; P: 88/min.; SpO2: 92%. The patient is in moderate
respiratory distress. His jugular veins are not dilated. Breath sounds are absent on the right and
normal on the left. The chest is hyperresonant to percussion on the right and resonant on the left.
Heart sounds are normal. The abdomen is unremarkable.
Applications:
¢ Chest X-radiogram
° Results of laboratory tests.
Questions
1. Formulate a clinical diagnosis.
2. Does the patient need any immediate aid?
3. Give the conclusion of the radiological examination.
4. Give an assessment of the laboratory parameters.
5. Suggest a surgical tactics.
6. Prescribe medications.

1. Right-sided spontaneous pneumothorax

2. Does not need an immediate hospitalization.( this pneumothorax us none-
tension. No manifestation of compression and displacement of the
mediastinum: No arterial hypotension, tachycardia, swelling of the neck
veins, no displacement of the heart)
3. X-ray : right-sided total pneumothorax
4. Neutrophil leukocytosis shift to the left
5. Hospitalization to the surgical department
Drainage of the pleural cavity in the 2nd intercostal midclavicular
SCT scan to identify causes if the pneumothorax and treatment in a
specialized thoracic dept if necessary ( video thoracoscopy or thoracotomy)
6. Medications
Analgedic: Ketorolac 3%-1ml 3t/d IM

Antibiotic prophylaxis: Ceftriaxone 1g 2t/d IM 

23. A 52-year-old man complains of fever up to 39°C, cough with purulent sputum with bad
smell, moderate dyspnea, weakness. He mentions episodic hemoptysis as well. Patient fell ill
three weeks ago after catching cold, did not come to the doctor. Patient has been smoking for 35
years, pack of cigarettes daily. He consumes alcohol 1-2 times a week; works as a welder.
T: 38.3°C; BP: 116/78 mm Hg: RR: 21/min.; P: 110/min.; SpO2: 94%. The body mass index is
20.62. The patient is diaphoretic, in moderate respiratory distress. The skin is pale. Breath
sounds are normal on the left; but are decreased, with crepitation in the mid dorsal area on the
right, The percussion of the chest reveals resonant sound with the area of dullness on the right.
Heart sounds are decreased. The abdomen is unremarkable.
Applications:
* Chest X-radiogram
° Results of laboratory tests.
Questions
1, Formulate a clinical diagnosis.
2. Give the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest a surgical tactics.
5. Prescribe medications

1. Acute abscess if the lower line of the right lung

2. X-ray: There’s round cavity with horizontal level of fluid( abscess of the
lower live of the right lung)
3. Lab data: Neutrophil leukocytosis with shift to the left, turbulent
sputum(with high level of leukocytes, bacterial necrotic masses)
4. Hospitalization to a surgical department
External drainage of the abscess, FBS
5. Medication
Oxygen therapy
IV fluid 
IV broad spectrum antibiotics:Meropenem 1g 3t/d IV
Diclofenac sodium 2,5% 3ml 1t/day IM
Metronidazole ( because of gram -&+ strep, clostridial anaerobes)

24, A 52-years-old man presents with the pain in the left half of the chest. fever up to 39°C, dry
cough, dyspnea, which decreases in the position on the left side, weakness. He fell ill three
weeks ago after catching cold, took paracetamol. Over time though, there was a decrease in the
intensity of pain; but the dyspnea has appeared and gradually become worse. Patient has been
smoking for 30 years, above pack of cigarettes a day.
T: 38.3°C; BP: 115/60 mm Hg; RR: 29/min.; P: 118/min.; SpO2: 90%. The patient is diaphoretic,
in moderate respiratory distress and appears pale. Breath sounds are absent on the left lower area
and normal on the right. The percussion of the chest reveals the dullness to the left downwards
and resonant sound to the right. Heart sounds are decreased. The abdomen is unremarkable.
Applications:
* Chest X-radiogram
* Results of laboratory tests.
Questions
1. Formulate a clinical diagnosis.
2. Give the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest a surgical tactics.
5. Prescribe medications.

1. Left sided pleural empyema

2. X-ray : presence of free fluid in the left pleural cavity
3. Lab data: Neutrophil leukocytosis with shift to the left
Purulent pleural fluid( with high protein content, leukocytes, bacteria,
necrotic masses)
4. Hospitalization in the surgical department
Drainage of the pleural cavity(6-7th intercostal space posterior auxiliary
line)bilou’s drainge 
5. Medication
IV fluid NaCl 400ml 
Analgesic: Diclofenac sodium 2,5%-3ml 1t/d IM 
Antibiotics broad spectrum: Meropenem 1g 3t/d IV(is a reserve group
during sepsis, so we will start with 
Cefepim 1g 2t/d IV, metronidazole 0,5 2t/d 
Additional info: in chronic emphysema we do decortication +pleurectomy 
In post-operative period we do sanitation 
25. A 62-years-old man complains of the pain in the left half of the chest, fever up to 39°C,
cough with expectorating a lot of grayish sputum with bad smell, severe dyspnea, which slightly
decreases in the position on the left side, weakness. He fell ill three weeks ago after catching
cold, did not come to the doctor. The dyspnea appeared suddenly last evening. Patient has been
smoking for 45 years, above pack of cigarettes a day. He is alone; abuse of alcohol.
T: 38.3°C; BP: 115/60 mm Hg; RR: 29/min.; P: 118/min.; SpO2: 90%. The body mass index is
17.62. The patient takes orthopneic position, is diaphoretic, in severe respiratory distress and
appears extremely poor. The skin is cyanotic, pale. Breath sounds are absent on the left and
normal on the right. The percussion of the chest reveals the box sound above the 3rd rib with
further dullness downwards on the left and resonant sound on the right. Heart sounds are
decreased. The abdomen is unremarkable.
Applications:
* Chest X-radiogram
* Results of laboratory tests.
Questions
1, Formulate a clinical diagnosis.
2. Give the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4, Suggest a surgical tactics.
5. Prescribe medications

1. Left-sided pyopneumothorax (Lung gangrene/abscess)

2. X-ray : presence of fluid and air in the left pleura cavity
3. Lab data: Neutrophil leukocytosis shift to the left

Purulent pleural fluid (with high protein content, leukocytes, bacteria,
necrotic masses) 
4. Hospitalization in thoracic surgical dept. 
Drainage of the pleural cavity( fluid/ pus use 6-7th intercostal space
posterior axillary line. For air- 2nd intercostal midclavicukar line) 
5. Medication
Oxygen therapy 
IV fluid NaCl 400ml 
Diclofenac Sodium: 2,5%-3ml 1t/d IM 
Broad spectrum antibiotic: Meropenem 1g IV 3t/d 
Additional info: sanitation 

26. A 36-years-old man complains of a fever (up to 39.9°C), pain in throat at swallowing, pain in
neck and breast, chills, weakness. For two weeks, it is being treated for tonsillitis; despite the
therapy, feeling worsens. The man smokes during 30 years, about half a packet of cigarettes a
day, consumes alcohol episodically. There was an allergy to penicillin in the past.
Patient is grave. BP: 118/82; RR: 29/min.; P: 128/min.; SpO2: 92%, Auscultation finds vesicular
breath sounds. Cardiac sounds are rhythmic, clear. The abdominal wall is soft and painless on
palpation. Intestinal sounds are as usual. There is a swelling of tissues and hyperemia of the skin
of the neck to the right, in supraclavicular area.
Applications:
* Chest CT
° Results of laboratory tests.
Questions
1. Formulate a clinical diagnosis.
2. Give the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest a surgical tactics.
5. Prescribe medications.

1. Phlegmon of the neck. Acute purulent descending mediastinitis

2. CT scan: signs of mediastinitis( widen mediastinum with pus in the right
and left)
3. Lab data: Neutrophil leukocytosis with shift to the left
4. Hospitalization in the surgical department
Disclosure and drainage of the phlegmon of the neck, mediastinitis 
5. Medication
Broad spectrum Antibiotics( Meropenem 1g 3t/d IV)
(cephalosporins, macrolides, flourquinolones, aminoglycosides)
Diclofenac sodium 2,5%-3ml 1t/d
Infusion therapy 400ml IV NaCl

27. A 25-year-old man is brought to the emergency department after being stabbed in the chest
during a bar fight. The patient was given 2 liters of normal saline en route to the hospital due to
hypotension.
T: 35.9°C; BP: 85/40; RR: 25/min.; P: 138/min. The patient is in moderate respiratory distress
and appears pale. His skin is clammy, and you notice marked jugular venous distension. The stab
wound is deep, to the left of the sternum in the Sth intercostal space. Breath sounds are
normal and clear bilaterally. His chest is resonant to percussion bilaterally. Heart sounds are
faint and distant. Peripheral pulses are weak. He is disoriented and unable to answer questions.
Applications:
* Radiogram of the thorax
* Result of blood tests.
Questions
1. Determined a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. What is the first aid?
6. Propose the medication (in the form of prescriptions or appointments)

1. Penetrating wound of the left half of the chest. Hemopericardium (Tension

pneumothorax of the left lung)
2. X-ray: presence of fluid in the pericardial cavity
3. Lab dat: Anemia of mild degree.
4. Hospitalization in the surgical department
Emergency Needle thoracotomy/needle decompression, or pleural
drainage
Suture of the cardiac wound
Secondly, the primary surgical treatment of the chest wound

5. First aid: Yes, at progressing of tamponade of the pericardium(progressive

arterial hypotension and an increase in CVP),Pericardiocentesis is necessary
6. Medication
Infusion therapy 400ml NaCl IV; FFP 200ml IV
Analgesic: Ketorolac 3%-1ml 3t/dIM
 Antibiotics prophylaxis: Ceftriaxone 1g 2t/d IM
 Emergency prophylactic of Tetanus.

28. A 32-year-old man presents with a chief complaint of difficulty swallowing. His dysphagia
has become gradually worse over the last 6 months and is equal for solids and liquids. He
also mentions bouts of severe chest pain when drinking ice water. He denies heartburn, fever,
exertional chest pain, and dyspnea, but does admit to a 5-pound weight loss during the last 6
months, primarily due to eating less because of the difficulty and chest pain he has when
attempting to eat. He also mentions occasional regurgitation of undigested food when lies down
to go to sleep at night.
T: 36.8°C; BP: 118/75; RR: 14/min.; P: 62/min. The physical exam is unremarkable. Specifically,
lymphadenopathy, skin changes, heart murmurs, and abdominal tenderness are not present.
Applications:
* Esophagogram
* Results of laboratory tests.
Questions
1. Formulate a clinical diagnosis.
2. Give the conclusion of the ultrasound examination.
3. What diagnostic methods should be used to confirm the diagnosis
4, Give an assessment of the laboratory parameters.
5. Suggest a surgical tactics.
6. Prescribe medications.

1. Achalasia of the esophagus

2. US: symmetric narrowing of the terminal part if the esophagus with
smooth contour and moderate suprastenotic expansion
3. FEGDS Esophagomanometry, Sonography
4. Lab Data: Hyperbilirubinemia
5. Cardiac dilatation(Balloon endoscopic procedure),
surgery at ineffectiveness (esophagocardiomyotomy)
6. Medication
Spasmolytics (Drotaverin 40mg IM)
PPI:Pantoprazole 40mg 2t/d
Calcium antagonist
Sedatives

29, A 35-year-old man is brought to the emergency department after a severe auto accident in
which he was a restrained passenger. The man complains of severe abdominal pain with some
radiation to the shoulder area and some mild shortness of breath. He has no significant past
medical history, takes no medications, and denies using alcohol or other drugs.
T: 36.6°C; BP: 125/85; RR: 18/min.; P: 84/min.The patient is healthy appearing. He has mild
tachypnea, and bowel sounds can be heard in the left lower thorax. Head and neck exam is
normal. Abdominal exam is remarkable for minimal diffuse tenderness to deep palpation and
normal bowel sounds. On extremity exam, there is no pain with palpation or limitation of active
and passive motion of the left arm and shoulder. Stool is negative for occult blood.
Applications:
* Radiogram of the chest
* Result of blood tests.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Blunt thoracic-abdominal trauma, rupture of the diaphragm to the left

2. X-ray: Dislocation of the abdominal organs in left pleural cavity
3. Lab dat: Anemia of mild degree
4. Hospitalization to a surgical department
Urgent thoracotomy
- Suture of the left diaphragm

5. Medication
Analgesics: Ketorolac 3%-1ml 3t/d IM
Antibiotic prophylaxis: Ceftriaxone 1g 2t/d IM
- Infusion therapy with normal saline 400ml IV

30. A 52-years-old man complains of periodic abdominal pain, heartburn, which is significantly
enhanced in the position of lying, at bending; bouts of air, sometimes - with food or bile. He is ill
for about two years. Patient takes antacids occasionally, which gives a short-term reduction of
heartburn. He was examined 2 months ago with esophagoscopy, redness of the esophageal
mucosa with crosions in its terminal part; reflux of the gastric content was revealed. The man is a
driver; sometimes he lifts some heaviness. He smokes over 30 years, at least a pack of cigarettes
a day; docs not use alcohol; takes 3-4 cups of coffee daily.
The man is of high nutrition, body mass index is 34.2. Skin and mucous are common. Peripheral
lymph nodes are not enlarged. T: 36.6°C; BP: 125/85; RR: 18/min.; P: 64/min. The physical
exam is unremarkable.
Applications:
* Barium X-rays of esophagus and stomach.
* Result of laboratory test.
Questions
1. Determine a clinical diagnosis.
2. Formulate the conclusion of the radiological examination.
3. Give an assessment of the laboratory parameters.
4. Suggest surgical tactics.
5. Propose the medication (in the form of prescriptions or appointments)

1. Axial hernia of the diaphragm (don’t know why it’s hernia) GERD
(gastroesophageal reflux disease)( thought is reflux)
2. X-ray: Dislocation of the proximal part of the stomach into the chest along
the axis of the esophagus.
3. Lab data: Anemia,hypercholesterolemia
4. Hospitalization to a surgical department
Surgical intervention (Anti reflux surgery): Crurorraphia, Nyssen
fundoplasty
5. Medication

PPI: Pantoprazole 40mg 2t/d, in postoperative period: Analgesic(eg
Ketorolac 3%-1ml 3t/d IM);
Antibiotics prophylaxis: Ceftriaxone 1g 2t/d IM
Infusion therapy: Glucose solution 5%-200ml IV