1.

In a 24 years old patient first appeared intense pain in the epigastal

region, repeated vomiting after drinking alcohol. The attack occurred 2 hours
before the examination. Objectively: Respiratory rate increased to 30 per
minute. Pulse of 110 beats per minute, blood pressure 120/70 mm of Hg. Body
temperature of 37,7 º C, wet tongue. Stomach is not inflated, taking limited part in
breathing. Determined by the protective muscular tension in the proper epigastrium
and right hypochondrium. When the survey radiography of abdominal free gas
under the right dome of the diaphragm is not defined.

Indicate the most probable diagnosis and examination methods which may confirm
your diagnosis.

2. A 53 years old patient suffering in last 14 years from duodenal

ulcer. Throughout the period of the disease have repeatedly hospitalized due to
worsening of the ulcer. Suddenly raised the pain in the epigastric region & single
vomiting. Was in a forced position on its side with legs bent and given to her
stomach down. Over time, the pain has decreased, the patient's condition
improved. The next day, turned to a local doctor complaining of moderate pain in
the right upper quadrant, fever up to 37,8 º C. objectively : The overall condition of
the patient of moderate severity, the tongue is little dryish. Revealed a mild strain
protection hearing in the right upper quadrant and clearly expressed Shchetkin-
Blumberg symptom. Pulse 92 minutes. BP 120/70 mm of Hg .Leukocytosis 11,4 •
109, band neutrophils 14.
Indicate preliminary diagnosis, diagnostic program and treatment .

3. A 48 y.o patient with a history of ulcer for 16 years having intense pain
in sobstvennoepigastralnoy area, which then radiate in the back. Was single
vomiting. Objectively: the general state of a heavy, tongue dry, mild abdominal
distension in the upper half and moderately DEFENSE muscles in the epigastric
region. Symptom Spizharnov, Orlanki negative. BP 120/70 mm of Hg, pulse 112
per minute, body temperature 37,9 º C, leukocytosis 19,2 • 106 band neutrophils -
17. Suspected perforated ulcer on the posterior wall of the twelve duodenum.
Conduct differential diagnostics. On the basis of what methods of inspection it is
possible to verify the diagnosis indicated.

4.During operational interference in a 46 years old patient with the suspicion

down the perforated ulcer it is discovered edema in the region of hepatoduodenal
ligament with the stratifications of fibrin. There is no exudation in the abdominal
cavity. Gall bladder and pancreatic are not changed. During the hospitalization
with gastroduodenoscopy discovered the ulcer of the back wall of duodenum.
Diameter of ulcer -1,5 см. What actions must be accomplished to surgeon for
establishing of diagnosis and determining the volume of operational interference.
 5.In a 24 years old patient during operational interference it is established
the perforated ulcer of the front wall of the bulb of duodenum. Ulcerous anamnesis
is absent. During duodenoscopy of that produced during the hospitalization am
discovered the ulcer only of front wall of duodenum. Kray ulcers are not thickened,
there is no ulcerous infiltration.
What volume of operational interference it is expedient to produce in this
patient.

6.A 38 years old patient suffers from ulcer for last 12 years. There were
repeatedly the attacks of acute pancreatitis. After eating big amount of food he felt
intensive pains in the epigastral region. There was single vomiting. With the
inspection is determined the pain and the moderately expressed shielding muscle
tension before the epigastric region. The symptom Of Spijarnov is negative. Free
gas in the abdominal cavity is not revealed with the survey roentgenography. In
gastroduodenoscopy established “deep” ulcer of the rear wall of the pyloric
division of stomach. It is hospitalized beside the surgical department with the
diagnosis of acute pancreatitis, stomach ulcer. The conservative therapy of acute
pancreatitis before the flow of 4 hours was ineffective. Remains abdominal pain,
arose the symptoms of the irritation of peritoneum predominantly before right half
of stomach, temperature of the body of 38 ºC, leukocytosis 18,4·106, the stab
neutrophils - 19. to patient is produced the abdominal section, during which is
revealed a small quantity of stomach contents before by right the flank of stomach.
Stomach contents enter the abdominal cavity through foramen of
gastroepiploicum.

What clinical form of perforated ulcer in patient? What was the basic reason
for the late establishment of diagnosis? What operational interference have to be
done to patient?

7.the patient of 32 years is operated for perforated ulcer of the front wall of
duodenum. The operation of the taking in of perforated ulcer is produced. Down
the third day of postoperative period the abdominal pains arose. On the drainages
from the abdominal cavity are noted the isolations of stomach contents with the
admixture of the hemolyized blood of the nature “coffee sediment”. Is noted the
isolation of the analogous down intestinal contents nature “coffee sediment” during
sounding of stomach. Arose suspicion down the physical incompatibility of the
seams of the taken in perforated ulcer of duodenum that stomachic hemorrhage. In
connection with this it is executed pressing re laprotomy. The seams of the taken in
perforated ulcer are well-off. Stomach contents was “coffee sediment” enters the
free abdominal cavity through foramen of gastroepiploicum.
What pathology should be suspected? What actions should be carried out for
establishing the diagnosis? What volume of operational interference should be
carried out depending on the advanced diagnosis?
 8.The patient of 64 years old is hospitalized in the surgical department with
the diagnosis of ulcer of the duodenum, complicated with hemorrhage. State of the
patient of the average degree of gravity. BP 110/80 mm of Hg, pulse of 100 beats
in 1 min. stomach soft, painless, the symptoms of the irritation of peritoneum are
negative. With fibrogastroscopy it is discovered the ulcer of the rear wall of the
bulb of the duodenum, from walls of which reliable capillary hemorrhage.
Determine the most optimum therapeutic tactics in this patient.

9.In sick 32 years, ulcerous hemorrhages hospitalized with the diagnosis.

The state of patient is heavy. Skins are pale. Was repeated vomiting “coffee
sediment”. Arterial pressure 80/50 mm Hg, the pulse of 118 beats in 1 min.
hemoglobin of 80 gr/l .erythrocytes 2,6·1012, hematocrit 21 un. with
gastroduodenoscopy is established jet hemorrhage from the erosioned vessel on the
bottom of the ulcer of the rear wall of duodenum.
Determine therapeutic tactics in this patient.

10.The patient of 43 years is hospitalized beside the surgical department

with the complaints besides the general weakness, the vertigo, the vomiting
“coffee sediment”. BP 100/60 mm Hg, the pulse of 100 beats in min. hemoglobin
of 105 gr/l erythrocytes 3,2·1012, hematocrit 29 un. with gastroduodenoscopy
established the ulcer of the rear wall of the duodenum, on bottom of which the
existing thrombosed vessel. In the cavity of stomach was insignificant quantity
“coffee sediment” and of the arterial blood.
Determine therapeutic tactics.

11.Before the surgical department is hospitalized patient with the complaints

besides the general weakness, the vertigo. Was the day before vomiting “coffee
sediment”. General state of average gravity. Skins are pale, stomach during the
palpation soft, painless before all divisions. With a rectal study it is revealed
melene. BP 110/60 mm Hg, the pulse of 90 beats in min. hemoglobin 110 g/l,
erythrocytes 3,6·1012, hematocrit 27 un. with gastroduodenoscopy am established
the ulcer of the rear wall of the duodenum, whose bottom is covered for the sake of
fibrin. In the cavity of the stomach “coffee sediment” it is not established.
Prescribe treatment to this patient.

12.The patient of 72 years is operated for apropos ulcerous hemorrhage.

Associated pathology: atherosclerosis, the ischemic disease of heart, hypertonic
disease. The ulcer of the small curvature of stomach am discovered during
operational interference, the diameter of ulcer 2 см, edge of ulcer they bleed.
Hemostasis is realized via the broaching of ulcer. The relapse of hemorrhage based
on the same ulcer arose in 7 days in the hospital. The stoppage of hemorrhage was
realized by conservative methods.
 What reason for the relapse of hemorrhage? Sufficient whether was the
volume of executed operational interference? What operational benefit should have
been carried out patient?

13.In a 48 years old patient apropos of ulcerous hemorrhage is intra-

operating discovered the ulcer of the rear wall of the bulb of duodenum. Vessel on
the bottom of this ulcer was the source of hemorrhage.
What therapeutic tactics in patient? What volume of operational interference
should be carried out in this case?

14.The patient of 68 years old is hospitalized in the surgical department

with the diagnosis of stomachic hemorrhage. It suffers the ulcer of duodenum
before the course of 28 years. Associated diseases: atherosclerosis, hypertonic
disease. Hemostasis it is realized by conservative (by methods) measures. Patient is
transferred for further treatment beside the gastroenterology department. However,
down 5 days after hospitalization arose the relapse of ulcerous hemorrhage.
What reason for the appearance of the relapse of hemorrhage? Correct
whether was the tactics of treatment before the surgical department? If incorrect,
then what it had to be?

15.The patient of 74 years old is hospitalized in the surgical department

with the diagnosis of gastrointestinal hemorrhage. Ulcerous anamnesis is absent.
Associated diseases: the ischemic disease of heart, atherosclerosis, rheumatoid
polyarthritis. Unspecific antipyretic preparations assumed to the appearance of
hemorrhage in connection with the aggravations of rheumatoid polyarthritis of
patient. BP 120/70 mm Hg, the pulse of 98 beats beside min. hemoglubin of 92 g/l,
erythrocytes 2,9·1012. With gastroduodenoscopy are discovered the shallow ulcer
of the front wall of duodenum, capillary hemorrhage from the walls of ulcer.
What must be therapeutic tactics in this patient?

16.The patient of 54 years old is hospitalized beside the surgical department

with the complaints besides the general weakness, the vertigo, the vomiting
“coffee sediment”. Skins are pale, the stomach soft, painless. BP 90/50 mm Hg, the
pulse of 124 beats beside min. nV of 81 g/l, erythrocytes 2,1·1012. With
gastroduodenoscopy am discovered the ulcer of the rear wall of duodenum with the
erosioned vessel on the bottom and the jet hemorrhage.
You will determine the most expedient therapeutic tactics in this patient.
Base the expedience of the tactics of treatment selected you.

17.Patient against the age of 14 years complains the abdominal pain without
the clear localization, the vomitings, the liquid chair. It is ill before the flow of 12
hours. First pain arose in the epigastral region. Through 4 hours it is noted the
migration of pain beside the right epigastral division and propagations down entire
abdominal cavity. The language moist, stomach am not inflated with the
inspection, limitedly participates before the report of respiration. The symptoms of
the irritation of peritoneum are expressed illegibly. Temperature of the body of
37,6 ºC, the pulse of 90 beats beside min., BP 120/70 mm Hg, leukocytosis
12,4·109, the stab neutrophils - 9. with the survey roentgenography of stomach are
determined moderate [aeroenteriyu], free gas before the abdominal cavity it is not
established.
You will establish and base preliminary diagnosis. You will determine
further diagnostic and treating tactics.

18.In patient after drop based on the height the moderate abdominal pain
arose, there was single vomiting. The skins of usual color, language moist, the
stomach is moderately inflated with the inspection, during the palpation the pain
before its left half is determined, the symptoms of the irritation of peritoneum are
doubtful. Temperature of the body of 37,2 ºC, the pulse of 94 beats beside min., BP
120/70 mm Hg, leukocytosis 14,3·109, the stab neutrophils - 11. With the survey
roentgenography of stomach it is established moderate [aeroenterografiyu], free
gas before the abdominal cavity it is not established.
Indicate preliminary diagnosis. You will determine further diagnostic and
treating tactics in this victim.

19.In sick 57 years, that suffers cirrhosis of the liver as a result of the
chronic alcoholic intoxication, arose the moderate abdominal pain. The skins are
moderately icteric with the inspection of sclera. Stomach is increased before the
sizes due to ascites. Temperature of the body of 38,2 ºC the pulse of 104 beats
beside min., BP 110/60 mm Hg, leukocytosis 17,3·109, the stab neutrophils - 14.
with an ultrasonic study of the organs of abdominal cavity are determined the signs
of cirrhosis of the liver, significant amount of liquid in the free abdominal cavity.
You will establish preliminary diagnosis. You will determine the additional
methods of inspection for affirming this diagnosis.

20.The patient of 32 years, who suffers ulcer of duodenum, felt pain in the
epigastral region, whose intensity decreased 3 hours after appearance. By 3 days of
patient it began to complain the pain before by right subcostal area, the nausea, an
increase in the temperature of body to 38,0 ºC. During the palpation before as far
as right the subcostal area is determined the positive symptom of [Shchetkina]-
Blumberg. Pulse of 102 beats beside min., BP 112/70 mm Hg, leukocytosis
18,2·109, the stab neutrophils - 16.
Place the preliminary diagnosis of pathologic state and the possible reasons
for its appearance. You will determine the additional methods of inspection for
affirming this diagnosis and therapeutic tactics.

21.In the patient of 68 years, by the suffering gallstone disease, arose the
assault of acute cholecystitis. First conservative therapy with the application of
spasmolytics was effective. However, down 3 days from the beginning of disease
again arose pain before by right subcostal area, an increase in the temperature of
body to 38,1 ºC. During the palpation before as far as right the subcostal area is
determined infiltration. Pulse of 98 beats beside min., BP 130/80 mm Hg,
leukocytosis 17,4·109, the stab neutrophils - 15. With THE UZIS the presence of
[konkreagentov] beside cavity of gall bladder, edema of its wall with the
[podvoynymi] outlines.
You will establish diagnosis. You will determine therapeutic tactics.

22.The patient of 42 years is [operirovan] the apropos extended appendicular

to peritonitis down the 4th day from the beginning of disease. After middle
abdominal section are established gangrenous- perforated appendicitis, total
fibrinopurulent peritonitis.
You will determine the volume of operational interference and the method
of its completion.

23.The patient of 72 years 3 hours prior to hospitalization felt the unbearable

pain of below stomach. For a period of many years it suffers the [divertikulyarnoy]
disease of colon. During the palpation is determined the pain before lower half
stomach, the shielding tension of the muscles of front abdominal wall and the
positive symptom of Shchetkin- Blumberg. Temperature of the body of 38,1 ºC.
Pulse of 98 beats beside min., BP 130/80 mm Hg, leukocytosis 18,2·109, the stab
neutrophils - 19. with the survey roentgenography of the organs of abdominal
cavity is determined that moderated of aeroenterya
You will establish diagnosis. You will determine therapeutic tactics, volume
of operational interference and method of its completion.

24.In sick 37 years in 5 weeks from the beginning of the assault of acute
pancreatitis arose local pain before the left subcostal area, fever, temperature of the
body of 38,7 ºC. During the palpation the symptoms of the irritation of peritoneum
are absent. Before the left subcostal area moderately unhealthy infiltration is
determined. Pulse of 114 beats beside min., BP 120/70 mm Hg Of [lekotsitoz]
19,7·109, the stab neutrophils - 21. With THE UZIS in the section of the tail of the
pancreas is present liquid formation with its surrounding capsule.
You will establish diagnosis and you will determine therapeutic tactics in
this patient.

25.In sick after fulfilling of low front resection of rectum, forming of

colorectal anastomosis the 5th day after operating period arose the moderate pain
of below stomach. Stomach is inflated before its lower half, during the palpation
unhealthy, the symptoms of the irritation of peritoneum are expressed illegibly, the
exudate with the admixture of contents large intestine is separated on the drainages
from the cavity of small basin. Temperature of the body of 38,2 ºC, the pulse of
102 beats beside min., BP 100/60 mm Hg, erythrocytes 3,8·1012, hemoglobin 94
g/l, leukocytosis 17,8·109, the stab neutrophils - 18.
 You will establish diagnosis. Besides what does consist the special feature of
operational interference and method of its completion?