Management of angina

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Management of Angina

Angina is chest pain or discomfort caused by myocardial ischemia - an imbalance between oxygen supply and demand. Management differs by type (stable, unstable, vasospastic), but for stable angina the goals are: (1) relieve symptoms and improve quality of life, and (2) reduce disease progression, MI, and death. Absolute risk reduction in MI/cardiac death is achieved primarily through medical therapy, not revascularization.

1. Lifestyle Modification

The foundation of all angina management:

Smoking cessation - most impactful single intervention
Regular aerobic exercise (intensity guided by stress testing)
Weight loss and low-fat, low-cholesterol diet
Cardiac rehabilitation programs for diet, exercise, and risk factor education
Control of hypertension, diabetes (target HbA1c ≤7%), and dyslipidemia

2. Medical Therapy

Anti-ischemic / Antianginal Agents

Beta-Blockers (First-line)

Beta-blockers prevent catecholamine binding to beta-adrenergic receptors, reducing heart rate, myocardial contractility, and therefore myocardial oxygen demand. They raise the ischemic threshold and delay the onset of exertional angina.

Titrate dose to a resting heart rate of 50-60 bpm
All beta-blockers are roughly equally effective in stable angina
Avoid agents with intrinsic sympathomimetic activity (ISA)
Post-MI: reduce secondary events and sudden cardiac death
Goldman-Cecil Medicine, p. 633

Calcium Channel Blockers (CCBs)

CCBs reduce afterload via peripheral vasodilation, lower myocardial oxygen demand, reduce coronary vascular resistance, and inhibit coronary vasospasm.

Non-dihydropyridines (verapamil, diltiazem): also slow heart rate - preferred as monotherapy when beta-blockers are contraindicated; caution when combined with beta-blockers (risk of bradycardia)
Dihydropyridines (amlodipine, nifedipine): greater vasodilation, better for hypertensive patients with angina; short-acting dihydropyridines can reflexly increase HR, so add a beta-blocker
CCBs and beta-blockers are roughly equally effective in clinical trials for angina; CCBs have not been shown to reduce death or MI in stable IHD, so they serve as add-on or alternative therapy
Vasospastic (Prinzmetal) angina: CCBs are first-line; higher doses often required
Goldman-Cecil Medicine, p. 633

Dosing reference:

Drug	Dose
Nifedipine LA	30-180 mg daily
Amlodipine	5-10 mg daily
Diltiazem SR	120-360 mg daily
Verapamil SR	120-480 mg daily

Nitrates

Nitrates are metabolized to nitric oxide in vascular smooth muscle, causing vasodilation of coronary arteries and veins:

Venodilation reduces preload (LV end-diastolic pressure and wall tension), decreasing subendocardial oxygen demand
Coronary vasodilation improves blood flow

Important clinical points:

Sublingual nitroglycerin (0.3-0.6 mg) terminates an acute attack within 2-5 min; can also be used prophylactically before exertion
Long-acting nitrates (isosorbide di/mononitrate, transdermal patches) prevent angina and improve exercise tolerance
A nitrate-free interval of 8-12 hours daily is mandatory to prevent tolerance/tachyphylaxis
Absolute contraindication: concurrent use of PDE-5 inhibitors (sildenafil, tadalafil, vardenafil) - marked and prolonged hypotension
Long-acting nitrates are typically used as a second or third agent alongside beta-blockers/CCBs
Goldman-Cecil Medicine, p. 634

Nitrate preparations:

Preparation	Dose	Onset	Duration
Sublingual NTG	0.3-0.6 mg PRN	2-5 min	10-30 min
Aerosol NTG	0.4 mg PRN	2-5 min	10-30 min
Isosorbide dinitrate	5-40 mg tid	30-60 min	4-6 h
Isosorbide mononitrate	10-20 mg bid	30-60 min	6-8 h
Isosorbide mononitrate SR	30-120 mg daily	30-60 min	12-18 h
Transdermal NTG patch	5-15 mg daily	>60 min	12 h
IV nitroglycerin	10-200 mcg/min	<2 min	During infusion

Ranolazine

Inhibits the late inward sodium current, reducing intracellular calcium overload. It decreases angina and improves exercise tolerance without lowering blood pressure or heart rate - making it useful when hemodynamics limit uptitration of other agents. Used in combination with a beta-blocker for refractory symptoms.

Disease-Modifying Agents (Reduce MI and Death)

Agent	Indication / Role
Aspirin 81 mg daily	All patients with stable angina (absent contraindication); low-dose as effective as 325 mg with better adherence
Clopidogrel 75 mg	Alternative if aspirin intolerant; mandatory after PCI with stents
Low-dose rivaroxaban 2.5 mg bid + aspirin	Superior to aspirin alone for CV death/MI/stroke in stable CAD, but with more bleeding
High-intensity statin	All patients; reduces LDL and stabilizes plaque
ACE inhibitor / ARB	High-risk patients (diabetes, HF, LVEF <40%, vascular disease); reduces CV mortality and events
BP control	Target <130/80 mmHg
Glycemic control	HbA1c target ≤7%; refer to specialist if not achieved

Goldman-Cecil Medicine, p. 632-633; Washington Manual, p. 125-126

3. Management Flowchart

Stable Angina - Evaluation and Treatment Strategy

Stable angina management flowchart based on ISCHEMIA trial

Figure: Approach to stable ischemic heart disease based on the ISCHEMIA trial. Patients with severe limiting angina, clinical HF, or LV dysfunction go directly to coronary angiography. Others undergo medical optimization with GDMT first. (Washington Manual of Medical Therapeutics)

Lifestyle and Pharmacotherapy Algorithm

Lifestyle interventions and pharmacotherapy algorithm for angina

Figure: Stepwise approach - smoking cessation → lifestyle/cardiac rehab → ACE inhibitor → beta-blocker → glycemic control. (Goldman-Cecil Medicine)

4. Coronary Revascularization

Medical therapy with at least two classes of antianginal agents should be tried before revascularization is considered a failure in stable angina.

Key principle from COURAGE, BARI 2D, and ISCHEMIA trials: PCI improves anginal symptoms but does not reduce risk of death, MI, or major cardiovascular events compared to optimal medical therapy as an initial strategy in stable IHD - including patients with diabetes or chronic total occlusions.

PCI vs CABG Decision

Anatomic Situation	Preferred Strategy
Left main disease (>50% stenosis)	CABG preferred; PCI if poor surgical candidate (STS >5%) + low SYNTAX score
3-vessel severe disease	CABG
3-vessel moderate disease	Medical Rx or PCI²
Multivessel disease + diabetes	CABG (if LIMA to LAD possible); PCI if SYNTAX <22
2-vessel + proximal LAD disease	CABG
1-2 vessel disease, low risk	Medical therapy; PCI only for refractory symptoms or significant ischemia
Recurrent angina post-CABG	PCI (avoids repeat CABG morbidity)

SYNTAX Score: validated angiographic model; low/intermediate scores favor PCI outcomes comparable to CABG.

Graft patency: internal mammary artery ~90% at 10 years; saphenous vein graft 40-50% at 10 years; radial artery ~80% at 5 years. After 10 years, ~50% of patients develop recurrent angina.

Goldman-Cecil Medicine, p. 634; Washington Manual, p. 129

5. Unstable Angina

Unstable angina (new onset, rest angina, crescendo pattern) requires urgent management:

Immediate ASA (first drug given)
Nitrates for pain relief (sublingual or IV)
Beta-blockers (IV esmolol if safety uncertain)
Anticoagulation (heparin)
Early invasive strategy (coronary angiography + PCI) for high-risk features (elevated troponin, dynamic ECG changes, hemodynamic instability, GRACE score >140)
Dual antiplatelet therapy (aspirin + P2Y12 inhibitor: clopidogrel, prasugrel, or ticagrelor)

Rosen's Emergency Medicine

6. Vasospastic (Prinzmetal) Angina

Characterized by rest angina with transient ST elevation, often in the early morning. Associated with heavy smoking, migraine, and Raynaud phenomenon.

Acute attack: sublingual nitroglycerin within minutes
Prevention (first-line): calcium channel blockers (often at higher doses)
Adjuncts: long-acting nitrates combined with CCBs; statins, magnesium, alpha-blockers may help
Avoid: beta-blockers (can worsen spasm); smoking cessation essential
Fuster & Hurst's The Heart, 15th ed., p. 637

7. Refractory Angina

For patients failing maximal medical therapy who are not revascularization candidates, options include:

Coronary sinus reducer (Reducer device) - a 2025 systematic review/meta-analysis (PMID: 40684096) confirms efficacy and safety in refractory angina
Enhanced external counterpulsation (EECP)
Spinal cord stimulation
Transmyocardial revascularization

Summary Table

Category	Agent	Main Role
First-line antianginal	Beta-blocker	Reduce O₂ demand, HR, workload
Alternative / Add-on	CCB (non-DHP)	HR control + vasodilation
Vasodilation	CCB (DHP)	Vasodilation, hypertensive patients
Acute relief + prevention	Nitrates	Preload reduction + coronary dilation
Refractory angina	Ranolazine	No hemodynamic effect
Anti-thrombotic	Aspirin 81 mg	Plaque stabilization, reduce MI
Plaque stabilization	High-intensity statin	LDL lowering, plaque regression
High-risk patients	ACE inhibitor / ARB	CV mortality reduction
Post-PCI / ACS	DAPT (ASA + P2Y12)	Stent thrombosis prevention

Recent evidence note (2026): A meta-analysis of 28 RCTs (9,346 PCI vs. 9,503 medical patients; PMID: 41130952) confirmed PCI significantly reduces MI incidence (OR 0.84, p=0.01) but shows no difference in mortality, stroke, or freedom from angina vs. optimal medical therapy in stable angina - reinforcing that medical therapy remains the primary strategy for uncomplicated stable disease.

And management for unstable angina

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Management of Unstable Angina (UA) / NSTEMI

UA and NSTEMI are part of the acute coronary syndrome (ACS) spectrum. They are closely related - both involve partial coronary occlusion from plaque rupture, thrombus formation, or vasospasm. The key distinction: UA has no myocardial necrosis (negative biomarkers), while NSTEMI has positive troponin indicating necrosis. Management is largely the same, so guidelines typically address them together.

Epidemiology: ACS accounts for >780,000 events annually; 70% are NSTEMI/UA. At 1 year after UA/NSTEMI: ~6% mortality, ~11% recurrent MI, ~50-60% need revascularization. Long-term mortality of NSTEMI equals that of STEMI despite lower short-term mortality.

Definition of Unstable Angina

UA is defined as any of:

Rest angina lasting >20 minutes, occurring within 1 week of presentation
New-onset angina of at least CCS class II severity, within 2 months
Crescendo angina - previously stable angina that worsens by ≥1 CCS class to at least class III within 2 months

Rosen's Emergency Medicine; Textbook of Family Medicine 9e, p. 676

Step 1: Immediate Assessment

On arrival to ED:

ECG within 10 minutes of presentation (repeat every 5-10 min if pain continues)
Cardiac biomarkers: troponin I or T (preferred; remains elevated for days); serial measurements at 0 and 3-6 hours. CK-MB is no longer the recommended primary marker
CBC, metabolic panel, BNP, lipid profile, fasting glucose
Chest X-ray
Supplemental oxygen only if SpO₂ <90% or respiratory distress

ECG Patterns to Recognize

Finding	Significance
ST depression (multiple leads) + ST elevation in aVR/V1	Multivessel or left main disease
Biphasic/deeply inverted T waves V2-V4 + stuttering pain	Wellens syndrome - critical LAD stenosis
New LBBB	High-risk - treat as STEMI equivalent
ST depression in anterior leads with ST elevation inferiorly	Posterior MI

Step 2: Risk Stratification

High-Risk Features - Prompt Urgent Angiography (<2 hours)

Refractory/accelerating angina despite adequate medical therapy
Hemodynamic instability or cardiogenic shock
Signs of new HF or pulmonary edema (high Killip class)
New or worsening mitral regurgitation
Sustained VT or VF
New LBBB

TIMI Risk Score (1 point each - higher = worse prognosis)

Age >65 years
Known CAD (stenosis >50%)
≥2 anginal episodes in 24 hours
ST-segment or T-wave changes
Elevated cardiac biomarkers
ASA use in the last 7 days
≥3 CAD risk factors (family history, DM, HTN, hyperlipidemia, smoking)

GRACE score >140 = high risk; <109 = low risk.

Step 3: Acute Pharmacologic Management (MONA + Anticoagulation + DAPT)

A. Anti-ischemic Therapy

Drug	Dose / Notes
Aspirin	162-325 mg chewed immediately (non-enteric coated); then 81 mg daily
Nitrates	Sublingual NTG 0.3-0.6 mg q5min x3; IV nitroglycerin for ongoing pain or hypertension. Contraindicated with PDE-5 inhibitors and in hypotension/RV infarct
Beta-blockers	Oral within 24h (e.g., metoprolol 25-50 mg); IV if ongoing ischemia or severe hypertension. Titrate to HR 50-60 bpm. Avoid in acute decompensated HF, bradycardia, AV block, or bronchospasm. IV esmolol useful if safety uncertain
Morphine	For acute pain unresponsive to antianginal therapy; use cautiously (some evidence of harm in ACS with routine use)
Oxygen	Only if SpO₂ <90%

B. Antiplatelet Therapy

Dual antiplatelet therapy (DAPT) is a cornerstone - aspirin alone provides only partial platelet inhibition (COX pathway only); P2Y12 inhibition blocks the ADP pathway.

Drug	Loading Dose	Maintenance	Notes
Aspirin	162-325 mg	81 mg daily	Give to all patients immediately
Clopidogrel	600 mg	75 mg daily	Preferred if CABG possible (stop 5 days pre-CABG)
Ticagrelor	180 mg	90 mg twice daily	More potent, faster onset; preferred over clopidogrel in most ACS (if no contraindication)
Prasugrel	60 mg	10 mg daily	Most potent P2Y12 inhibitor; contraindicated in prior stroke/TIA; avoid in age >75, weight <60 kg

After 600 mg clopidogrel load, steady-state platelet inhibition reached in 2-3 hours (vs. days with 75 mg daily dosing).

GP IIb/IIIa inhibitors (tirofiban, eptifibatide): Consider in patients with high-risk features, ongoing ischemia, or delay to revascularization. Not used if bivalirudin is chosen as anticoagulant (except bail-out). Textbook of Family Medicine 9e, p. 677

C. Anticoagulation

Both UFH and LMWH have Level A evidence. LMWH (enoxaparin) is generally preferred in patients managed conservatively due to more predictable pharmacokinetics, resistance to platelet factor 4, lower HIT risk, and greater anti-Xa activity.

Drug	Dose	Route	Notes
Enoxaparin (LMWH)	1 mg/kg SC twice daily	SC	Preferred in conservative strategy; ESSENCE trial: superior to UFH for death/MI/recurrent angina at 1 month
UFH	70 units/kg bolus IV, then ~1000 units/hr	IV	Adjust to aPTT; preferred if urgent CABG planned or if creatinine clearance <30 mL/min
Bivalirudin	Weight-based IV infusion	IV	Direct thrombin inhibitor; alternative to UFH + GP IIb/IIIa at time of PCI; lower bleeding risk
Fondaparinux	2.5 mg SC daily	SC	Lower bleeding risk; avoid if eGFR <30

D. Statins

Start high-intensity statin immediately regardless of baseline LDL. In-hospital initiation improves long-term compliance.

Atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily
LDL goal: <70 mg/dL
If LDL remains >70 despite statin: add ezetimibe 10 mg daily; if still not at goal, add a PCSK9 inhibitor (alirocumab 300 mg or evolocumab 320 mg SC every 4 weeks)

E. ACE Inhibitor / ARB

Start early in patients with LVEF <40%, HF, hypertension, or diabetes
ARB if ACE inhibitor intolerant

F. Aldosterone Antagonist

Add if patient is on both ACE inhibitor and beta-blocker AND has EF <40% with either symptomatic HF or DM

Step 4: Revascularization Strategy

ACS Management Flowchart

Figure: ACS management pathway - UA/NSTEMI patients stratified to routine invasive vs. ischemia-driven strategy based on risk. (Washington Manual of Medical Therapeutics)

Unlike stable angina, in ACS a routine invasive approach with PCI has been shown to reduce recurrent MI, hospitalizations, and death. All patients receive antithrombotic + antiplatelet + anti-ischemic therapy regardless of revascularization strategy.

Timing of Coronary Angiography

Strategy	Timing	Indications
Immediate/Urgent invasive	<2 hours	Refractory angina, hemodynamic instability, shock, sustained VT/VF, new MR/HF
Early invasive	<24 hours	TIMI ≥3 or GRACE >140; rapid rise in biomarkers; new or presumed new ST depressions
Delayed invasive	24-72 hours	Diabetes; renal insufficiency (GFR <60); LVEF <40%; early postinfarction angina; prior PCI <6 months; prior CABG; TIMI ≥2 or GRACE 109-140
Ischemia-driven (conservative)	Elective if triggered	Low-risk (TIMI ≤1 or GRACE <109); biomarker-negative; patient preference; no high-risk features

Washington Manual of Medical Therapeutics, p. 136-138

Ischemia-Driven (Conservative) Strategy

If no high-risk features develop, biomarkers remain negative, and symptoms respond to medical therapy:

Patient should be angina-free for ≥12 hours before noninvasive stress testing
If EF <40% or new wall motion abnormality → proceed directly to angiography
If stress test positive or angina at low workload → angiography and revascularization

Refractory/Recurrent Angina Despite Medical Therapy

Urgent cardiac catheterization and revascularization
Intra-aortic balloon pump (IABP): bridge to revascularization in hemodynamically unstable patients; inflates in diastole (augments coronary perfusion) and deflates in systole (reduces afterload). Complication: lower limb ischemia ~3%
Revascularization (PCI or CABG) relieves refractory angina in ~90% of patients

Goldman-Cecil Medicine, p. 648

Step 5: Post-Discharge / Long-Term Management

Following stabilization (identical to post-ACS care):

Intervention	Details
DAPT	ASA + P2Y12 inhibitor for minimum 12 months post-ACS (or post-stenting); longer if tolerated
High-intensity statin	Indefinitely; target LDL <70 mg/dL
Beta-blocker	Especially post-MI; reduces sudden cardiac death
ACE inhibitor / ARB	Especially with EF <40%, DM, HF, HTN
Lifestyle modification	Smoking cessation, cardiac rehabilitation, diet, exercise
Glycemic control	HbA1c ≤7% in diabetics
Avoid NSAIDs	Except aspirin (increase CV risk)
Annual influenza vaccination	Recommended
Screen for depression	Common post-ACS; worsens outcomes

Summary: UA/NSTEMI Acute Management at a Glance

1. ECG within 10 min + serial troponins
2. Aspirin 162-325 mg chewed immediately
3. Anticoagulate: enoxaparin 1 mg/kg SC q12h (or UFH/bivalirudin)
4. Add P2Y12 inhibitor (ticagrelor 180 mg or clopidogrel 600 mg)
5. Beta-blocker (oral within 24h)
6. Nitrates (sublingual / IV) for ongoing pain
7. High-intensity statin (atorvastatin 40-80 mg)
8. ACE inhibitor (if EF <40%, DM, HF, HTN)
9. Risk stratify → timing of angiography (urgent/early/delayed/conservative)
10. Long-term DAPT + statin + ACE-I + lifestyle modification

Key distinction from stable angina: In UA/NSTEMI, a routine invasive strategy is the default for moderate-to-high risk patients and improves outcomes. In stable angina, medical therapy is the initial default and revascularization is reserved for refractory or high-risk anatomic disease. Washington Manual of Medical Therapeutics, p. 138

Explain all cases for exam

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State Interdisciplinary Exam - All 37 Clinical Cases Explained

CASE 1 - Contrast-Induced Nephropathy (AKI Stage 3)

Clinical picture: 58-year-old post-coronary stenting (5 days earlier). Develops anuria (<100 mL/2 days), leg edema, BP 160/110. Creatinine 589 µmol/L, urea 50 mmol/L, K+ 6.5, pH 7.19.

Diagnosis:

Main: Contrast-induced nephropathy → AKI Stage 3 (anuria + creatinine 589)
Background: CAD + stenting, CHF FC II, HTN Stage III Risk 4, T2DM, Obesity II

Life-threatening complications: Hyperkalemia (6.5 mmol/L), severe metabolic acidosis (pH 7.19), uremia

Emergency management:

ICU admission
Urgent decision on renal replacement therapy (indication: anuria, urea >30, K+ elevated, pH <7.25)
Hyperkalemia correction: IV calcium gluconate 10% - 30 mL bolus; IV 40% glucose + insulin (2 units/5g glucose); furosemide 40-60 mg IV; sodium/calcium polystyrene sulfonate 15g x4/day orally or rectally

Prevention before contrast studies:

Stop nephrotoxic drugs 3-4 days before
Hydration: 0.9% NaCl 1-1.5 mL/kg/h for 6-12h before AND after procedure
Use minimum contrast volume
Monitor creatinine at 48 and 72h post-procedure
Use rosuvastatin 40/20 mg or atorvastatin 80 mg in CKD patients

CASE 2 - Acute Gouty Arthritis + CKD

Clinical picture: 50-year-old male, uric acid 895 µmol/L (12 years), attacks of arthritis at multiple joints, tophi, HTN refractory to enalapril+amlodipine. Creatinine 200 µmol/L. Urinalysis: uric acid crystals, casts, low SG.

Diagnosis:

Main: Acute gouty arthritis (1st MTP joint), tophi, chronic tubulo-interstitial nephritis, CKD C3b
Comorbidity: HTN Stage II uncontrolled, Risk 4

Acute treatment:

Nimesulide 200-400 mg/day; if ineffective → Colchicine 0.5 mg start, then 1 mg x3/day (adjust dose for GFR)
Allopurinol is contraindicated in acute attack; target uric acid <360 µmol/L
Anti-gout diet, alcohol prohibition

HTN management in gout+CKD:

Losartan 100 mg/day (uricosuric effect) + amlodipine 10 mg/day
Thiazide diuretics contraindicated (raise uric acid)
CKD C3b management: low-protein diet, phosphorus-calcium correction, anemia prevention

Differential diagnosis: Rheumatoid arthritis, osteoarthritis, drug nephropathy

Classic gout features: Nocturnal joint attacks (1st MTP), tophi, "punch-out" lesions on X-ray, hyperuricemia, gouty nephropathy

CASE 3 - Chronic Glomerulonephritis, Nephrotic Syndrome

Clinical picture: 23-year-old male with chronic tonsillitis. Massive edema, oliguria, after sore throat. BP 140/95. Protein 5.4 g/L in urine, daily proteinuria 7.3 g/day, cholesterol 9 mmol/L, albumin 33%, total protein 45.6 g/L.

Main syndrome: Nephrotic syndrome - hypoalbuminemia + hypo-oncotic edema + hypercholesterolemia + proteinuria >3.5 g/day

Diagnosis: Chronic glomerulonephritis, nephrotic syndrome, exacerbation (after tonsillitis trigger)

Life-threatening complication: Interstitial pulmonary edema (basal rales bilaterally)

Emergency:

ICU hospitalization
IV furosemide 40 mg (control water balance)
If diuresis <200 mL/12h, urea >30, hyperkalemia, pH <7.25 → renal replacement therapy (hemodialysis/ultrafiltration)

Treatment:

Morphological variant guides therapy (nephrobiopsy needed)
Immunosuppression: GCS alternating with alkylating cytostatics (cyclophosphamide, chlorambucil) as 1st line; alternative: calcineurin inhibitors
Edema: Loop diuretics + IV albumin, water balance monitoring, salt restriction ≤5 g/day
VTE prevention: Enoxaparin 1 mg/kg SC x2/day or UFH 5000 IU x4/day SC (monitor aPTT)
RAAS blockade: ACE inhibitor or ARB (if no hyperkalemia, adequate GFR)

CASE 4 - Chronic Pyelonephritis Exacerbation + DM + HTN

Clinical picture: 50-year-old male, T2DM (metformin), HTN (valsartan). Fever 37.8°C, lumbar heaviness, urinalysis: leukocytes 20-30/hpf, specific gravity 1.012, traces of protein. Leukocytosis 11×10⁹, stabs 8%. Kidney ultrasound: deformed pelvis bilaterally.

Diagnosis: Chronic bilateral complicated pyelonephritis, exacerbation; CKD C? (calculate GFR)

Features in elderly pyelonephritis:

Bilateral forms predominate (unilateral rare by 8th decade)
Purulent forms more frequent (up to 25% men)
Minimal typical symptoms (no fever, no lumbar pain)
Atypical: confusion, falls, incontinence, normochromic anemia, HTN
Common organisms: E. coli, Enterococcus; with obstruction: anaerobes
Possible false-negative urine culture

Work-up: Urine per Nechiporenko, Zimnitsky test, GFR calculation, urine culture, prostate/bladder ultrasound, PSA, urology referral if obstruction

Treatment:

Levofloxacin 500 mg x1/day for 10 days + adequate hydration

After normalization (10 days):

Transition to herbal uroseptics for 6 months
Avoid hypothermia
If E. coli isolated: Urovaxom (OM-89) 1 capsule/day x 3 months (immunoprophylaxis)

CASE 5 - Rheumatoid Arthritis + Multiple Comorbidities

Clinical picture: 42-year-old female manager, 6 months of symmetric polyarthritis (PIP, MCP, wrist, knee joints), morning stiffness until midday, 4 kg weight loss, RF+ 120, ACCP+ 320, ESR 45, anemia (Hb 95), X-ray: periarticular osteoporosis, erosions. Also: heartburn/epigastric pain on NSAIDs, shortness of breath on exertion.

Diagnosis:

Main: Rheumatoid arthritis, seropositive (RF+, ACCP+), advanced stage, Activity Grade 3, Radiological Stage II, FC II
Comorbidities: NSAID-induced interstitial nephritis, Chronic erosive gastritis HP+, Anemia of chronic inflammation

Immediate symptomatic therapy (before workup results): Prednisolone 5-30 mg/day (until DMARD takes effect)

After workup (serum iron low, ferritin low, FGDS shows erosive gastritis HP+, hypostenuria on Zimnitsky):

Iron supplements (IDA confirmed)
4-component HP eradication therapy
Methotrexate 15 mg/week + folic acid (avoid MTX side effects) as DMARD
Stop NSAIDs (interstitial nephritis)
Dose adjust MTX after 3 months

Biologic DMARDs for RA:

TNF-α inhibitors: infliximab, adalimumab, golimumab, certolizumab pegol, etanercept
Other mechanisms: rituximab (anti-CD20), abatacept (CTLA4-Ig), tocilizumab (anti-IL-6)

CASE 6 - Systemic Lupus Erythematosus (SLE)

Clinical picture: 25-year-old, 1 year of disease. Started with fever, malar rash, macrohematuria → irregular prednisolone → arthritis, lymphadenopathy, pericarditis, bilateral exudative pleurisy. CBC: Hb 84, leukocytes 3.2×10⁹, platelets 140×10⁹. Urinalysis: proteinuria 2.2%, hematuria 40/hpf. Creatinine 144 µmol/L.

Diagnosis: SLE with nephritis, skin involvement, lymphadenopathy, pericarditis, pleuritis (polyserositis), arthritis, pancytopenia (three-lineage cytopenia), subacute course

Work-up: LE cells, ANA (antinuclear factor), anti-dsDNA, anti-Sm antibody, CIC, antiphospholipid panel (lupus anticoagulant, anti-cardiolipin antibodies), RF

Pathomechanism: SLE = hyperproduction of non-organ-specific autoantibodies (especially anti-dsDNA) → immune complex deposition → immunoinflammatory damage to organs → nephrotic syndrome + 3-lineage cytopenia

Differential diagnosis: Drug-induced lupus, granulomatous polyangiitis, HIV, primary CGN, RA

Treatment:

Hydroxychloroquine + glucocorticoids
High activity: pulse therapy methylprednisolone 500-1000 mg IV x3 days
Lupus nephritis: cyclophosphamide (induction); azathioprine or mycophenolate mofetil (maintenance)
Antihypertensives: ACE inhibitors, calcium antagonists
Biologic: abatacept 125 mg SC weekly
Plasmapheresis for refractory disease

CASE 7 - SLE with CNS Involvement (Neurovasculitis)

Clinical picture: 24-year-old female, 3 months: polyarthritis, malar + discoid rash, oral ulcers, peripheral + cavitary edema, stupor, neurological deficit (neurovasculitis). Pancytopenia, ESR 68, proteinuria 2.2 g/L, casts, hematuria, high-titer ANA, anti-dsDNA, anti-Sm antibodies. CRP 9.

Diagnosis: SLE, acute course, Activity Grade 3, with skin + joints + kidneys + CNS involvement + pancytopenia

Justification: Arthritis + malar rash + nephritis + cytopenia + lupus neurovasculitis + ANA + anti-native DNA + anti-Sm Ab + ESR 68

Differential: RA, primary glomerulonephritis, bone marrow disorders

Work-up: CXR, Echo, abdominal + renal US, kidney biopsy, daily proteinuria, brain MRI, LFTs, RFTs, electrolytes, lipid fractions, total protein + fractions, APS panel

Pulse therapy dose for neurovasculitis emergency: Methylprednisolone 1000 mg IV x 3 days

CASE 8 - Infective Endocarditis (IE)

Clinical picture: 53-year-old artist. Tooth extraction 2.5 months ago. Fever 39.5°C, sweating, chills, 10 kg weight loss, dyspnea, dizziness. Alcohol abuse + heavy smoker. Echo: vegetation 0.8×0.8 cm on aortic valve, aortic regurgitation Grade III, mitral regurgitation Grade II, LV dilation (EDD 6 cm, LA 5.5 cm). BP 130/40 (wide pulse pressure). Soft protodiastolic murmur at Botkin-Erb point and 2nd ICS right.

Syndromes:

Inflammatory/septicemic (fever, chills, acute phase reactants)
Intoxication (weakness, sweating, anorexia, weight loss, arthralgia, anemia)
Valvular damage (aortic insufficiency)
Thromboembolic disorders (Janeway lesions)
Immune disorders (glomerulonephritis, hepatitis, splenomegaly, RF+)
Heart failure

Diagnosis (DUKE criteria):

Major: Echocardiographic evidence of intracardiac mass on valve
Minor: Fever >38°C, predisposing heart condition, septic infarct pneumonia
Sufficient: 1 major + 3 minor criteria

Complications: CHF Stage IIA, NYHA FC IV; glomerulonephritis; moderate anemia

Work-up: Blood cultures x3 (before antibiotics if possible) to identify organism and sensitivity

Treatment: Empirical antibiotics given severity; Grade III aortic regurgitation + large vegetation = indication for valve replacement → urgent cardiac surgery consultation

CASE 9 - Rheumatoid Arthritis + Secondary Amyloidosis

Clinical picture: 52-year-old female with 16-year RA history. Now: fever 38°C, wrist/MCP/PIP joint inflammation + stiffness. Proteinuria 6.6 g/L, daily proteinuria 9 g/day, hypoalbuminemia (albumin 30), total protein 50, creatinine 120 µmol/L (GFR ~45 ml/min = CKD C3a), cholesterol 7 mmol/L. RF+ 1:160.

Main syndromes: Articular, nephrotic, immunoinflammatory

Diagnosis:

Main: RA, seropositive, late stage, erosive, Ro Stage II
Complication: Secondary systemic AA amyloidosis (most likely cause of nephrotic syndrome in long-standing RA), CKD C3a A4

Differential for nephrotic in RA: Systemic vasculitis, amyloidosis, paraneoplastic nephrotic syndrome including myeloma

Work-up: ACCP, nephrobiopsy (verify amyloidosis + typing), abdominal + renal + cardiac US, ECG, coagulogram, LFTs, GFR calculation

Treatment:

Urgent hospitalization (nephrotic syndrome + high RA activity)
Correct DMARD therapy to reduce RA activity
Edema: loop diuretics + IV albumin, fluid balance, salt ≤5 g/day
VTE prevention: enoxaparin 1 mg/kg SC x2/day or UFH 5000 IU x4/day
RAAS blockade: ACE inhibitor or ARB

CASE 10 - Isolated Systolic Hypertension in the Elderly

Clinical picture: 72-year-old retired woman, 20-year HTN history, irregular therapy. BP 162/62 → pulse pressure = 100 mmHg. BMI 30.5 (Obesity I), WC 102 cm. Insomnia, memory loss.

Diagnosis: HTN Stage II, Isolated Systolic AH (ISAH), Risk 3 (high). LVH. Obesity I.

Justification of ISAH: Pulse pressure ≥60 mmHg in elderly = sign of arterial wall stiffness. PP = 162 - 62 = 100 mmHg.

Preferred antihypertensive combination for elderly ISAH: Calcium channel blocker + thiazide diuretic (per current national recommendations). Alternative if CCB intolerant: ACE inhibitor or ARB.

After 3 months (BP 140-150/65, LDL 3.6, GFR 63, ALT 50):

For age ≥70: target SBP 130-139 mmHg (subject to good tolerance), DBP 70-79 mmHg
Intensify to triple fixed combination (ACE/ARB + diuretic + calcium antagonist) for better adherence

Hypertensive episode emergency (BP 180/100 + symptoms):

Captopril 25 mg sublingual, BP check after 30-40 min
If persistent: repeat captopril 25 mg sublingual, recheck 30-40 min
If ineffective: call ambulance (EMS)

CASE 11 - Post-MI, Post-Stenting + Uncontrolled HTN + Dyslipidemia

Clinical picture: 75-year-old male, 3 months post-inferior STEMI (RCA stented with DES). Now: headache, dizziness, BP 190/100 on lisinopril 20 mg. LDL 3.6 mmol/L (target <1.4). Rosuvastatin 10 mg only.

Diagnosis: IHD. Post-infarction cardiosclerosis (inferior wall). RCA stenting (DES). HTN Stage III, uncontrolled, Risk 4 (very high). Dyslipidemia Type IIa (Fredrickson).

Drug groups for ongoing therapy:

DAPT: ASA 75 mg + ticagrelor 90 mg twice daily until 1 year post-event (until June 18, 2024). Note: uncontrolled HTN increases bleeding risk → urgent BP correction
Antihypertensives: Add calcium antagonist and/or diuretic to lisinopril
Target BP for age + comorbidity: 130-139/70-79 mmHg
Statin: Increase rosuvastatin dose (10 mg insufficient)

LDL target: <1.4 mmol/L (very high CV risk: established CAD)

Current LDL 3.6 → increase statin + add ezetimibe 10 mg/day

CASE 12 - Stable Angina FC II + HTN + Dyslipidemia → STEMI

Clinical picture: 68-year-old driver, 2 months of exertional chest pain (>500m, relieved by rest). Misdiagnosed as intercostal neuralgia. HTN 5 years untreated. BMI 33.9, heredity positive (father+brother MI <55y). BP 170/100. LDL 3.57. ECG: LVH.

Diagnosis: IHD. Angina FC II. HTN Stage III, uncontrolled, Risk 4 (very high). LVH. Dyslipidemia Type IIb. Obesity I.

Work-up: OAM, CBC, biochemistry, GFR, lipid profile, ECG, Echo, carotid duplex (BCA), Holter ECG. Determine pretest probability → stress test or direct CAG if high probability.

Drug groups: Beta-blocker (1st line antianginal); short-acting nitrates PRN; antiplatelet (aspirin); high-intensity statin; RAAS blocker + diuretic or CCB (target BP <130/80)

CV risk and LDL target: Very high risk (established CAD) → LDL target <1.4 mmol/L

Emergency scenario (ST elevation V1-V4, nitrates x2 ineffective → STEMI):

Prehospital: nitrates, morphine, oxygen, DAPT loading, anticoagulant SC
Emergency transfer to PCI center; if delivery >120 min impossible → thrombolysis
PCI + stenting of culprit artery
Troponin to confirm MI

CASE 13 - Post-STEMI + Permanent Atrial Fibrillation + Dyslipidemia

Clinical picture: 75-year-old woman, 3 months post-inferior STEMI (RCA stented with DES). Permanent AF for 3 years (2 failed electrical cardioversions). HR 140, pulse 110, BP 110/80. Ankle swelling. LDL 3.2 (above target). CHA₂DS₂-VASc = 6, HAS-BLED = 2.

Diagnosis: IHD + PICS (inferior wall). RCA DES stenting. Permanent AF (EHRA 2b, CHA₂DS₂-VASc 6, HAS-BLED 2). CHF IIA.

Anticoagulation in AF (modern approach):

CHA₂DS₂-VASc ≥2 in men / ≥3 in women → continuous anticoagulation indicated
Preferred: Direct oral anticoagulants - apixaban, rivaroxaban, or dabigatran
If no contraindications to NOACs, preferred over warfarin

Drug plan:

Antiplatelet + NOAC: Clopidogrel 75 mg + NOAC (up to 12 months post-MI); then NOAC monotherapy
Statins (indefinitely) - intensify to reach LDL <1.4
Beta-blockers (rate control for AF + post-MI benefit, indefinitely)
ACE inhibitor or ARB (indefinitely)

LDL target: <1.4 mmol/L (very high CV risk)

CASE 14 - Stable Angina FC II + HTN + Dyslipidemia

Clinical picture: 55-year-old mechanic, 2 years of exertional retrosternal pain (fast walk, stairs >2 flights), relieved by 1 sublingual NTG. HTN 5 years untreated. Heavy smoker (2 packs/day). BMI 33.9. LDL 4.2 (severely elevated). LVH on ECG.

Diagnosis: IHD. Angina FC II. HTN Stage III, uncontrolled, Risk 4 (very high). LVH. Dyslipidemia Type IIb. Obesity I.

Work-up: Per stable CAD guidelines - CBC, OAM, biochemistry, GFR, lipid profile, ECG, Echo, carotid duplex, Holter ECG. Stress test (if no contraindications) or CAG if high pretest probability.

Drug groups:

Aspirin
High-intensity statin (lipid-lowering)
Beta-blocker and/or CCB and/or organic nitrates (antianginal)
RAAS blocker (ACE/ARB) in combination for BP control

LDL target: <1.4 mmol/L (established CAD = very high risk)

CASE 15 - Permanent AF + Post-STEMI → GI Bleeding on Anticoagulant

Clinical picture: 75-year-old woman, 6 years post-inferior STEMI (RCA DES). Permanent AF 2 years. HR 140, pulse 110, BP 110/80. LDL 3.9. Irregular therapy.

Diagnosis: IHD + PICS (inferior wall). Permanent AF (tachysystolic, EHRA IIb, CHA₂DS₂-VASc 6, HAS-BLED 2). CHF IIA/FC II.

Work-up: CBC, OAM, biochemistry, GFR, lipid profile, TSH, ECG, Echo, Holter ECG

Anticoagulation: Preferred: NOAC - rivaroxaban 20 mg once daily; or warfarin (INR target 2.0-3.0)

Warfarin INR monitoring:

At target INR: check at least monthly
If out of range: check every 3 days; when INR 2-3, then weekly, then twice monthly, then monthly

GI bleeding emergency (black stool, weakness, abdominal pain on anticoagulant):

Stop anticoagulant immediately
Hospitalization in surgical department
Assess degree of blood loss
Urgent EGDS (EGD)
Conservative hemostasis therapy
Reassess risk/benefit of resuming anticoagulation; adjust regimen

CASE 16 - Bronchial Asthma (First Episode)

Clinical picture: 25-year-old driver, 3 months of episodes of suffocation with expiratory difficulty, hard sputum, attacks 2-3x/week especially at night, resolve spontaneously in ~1 hour. Scattered dry high-pitched rales. Mother has asthma.

Diagnosis: Bronchial asthma, allergic, first detected, exacerbation (not severe)

Work-up: CBC, OAM, biochemistry, total IgE, CXR, spirometry with salbutamol 400 mcg reversibility test (key diagnostic test), ECG, pulse oximetry

Acute treatment:

Hospitalization, smoking cessation
Inhaled bronchodilators (fenoterol/ipratropium bromide 1 mL) via nebulizer x3-4/day
Inhaled GCS (beclomethasone or budesonide) 1000-2000 mcg/day
After exacerbation control: asthma school education + basic therapy

Basic therapy in remission: According to Step 3 clinical guidelines for BA

CASE 17 - Community-Acquired Pneumonia → Deterioration

Clinical picture: 50-year-old non-smoker, 3-day history of fever 38°C, malaise, cough with light sputum. Breath weakened in lower right lung, crepitus, dullness. RR 20, HR 100.

Diagnosis: Community-acquired pneumonia, right-sided, non-severe

Work-up: CBC, CRP, CXR in 2 projections, SpO₂

Risk stratification (CRB-65): No confusion (0), RR <30 (0), BP >90/60 (0), age <65 (0) = Score 0 → outpatient treatment

Treatment: Amoxicillin 1000 mg x2/day orally + mucolytics (ambroxol or acetylcysteine) + oral rehydration + antipyretics for fever >38.5°C

After 3 days: condition worsened, green sputum, leukocytes 3.0×10⁹ (leukopenia!), lymphocytes 86%, ESR 30:

This suggests viral etiology (lymphocytosis, leukopenia) or inadequate treatment
Hospitalize in pulmonology/therapeutic department
Change antibiotic to IV: amoxicillin/clavulanic acid 1.2 g x3/day or 3rd-gen cephalosporin (ceftriaxone 2-4 g/day) + macrolide (azithromycin 500 mg/day) or respiratory fluoroquinolone monotherapy (levofloxacin 1000 mg/day or moxifloxacin 400 mg/day)

CASE 18 - Community-Acquired Pneumonia

Clinical picture: 44-year-old smoker, preceded by URTI. Sudden fever 39°C, chills, dry then productive cough, right-sided chest pain. Bronchial breathing + crepitus in lower right lung, increased bronchophony, vocal fremitus. SpO₂ 99%, RR 22.

Diagnosis: Community-acquired pneumonia, right-sided, non-severe

Work-up: CBC, CRP, CXR in 2 projections

Outpatient treatment (age <60, no comorbidities, no respiratory failure, clear mind, stable hemodynamics)

Treatment: Amoxicillin or macrolide (clarithromycin/azithromycin) orally + ambroxol + oral rehydration + antipyretics >38.5°C

Severe pneumonia criteria:

Major ("big") criteria: Severe respiratory failure (requiring ventilation), septic shock (requiring vasopressors)
Minor ("small") criteria: RR >30/min; PaO₂/FiO₂ ≤250; multilobar infiltration; confusion; uremia (BUN ≥20 mg/dL); leukopenia <4×10⁹; thrombocytopenia <100×10¹²; hypothermia <36°C; hypotension requiring IV fluids

CASE 19 - CAP in Diabetic Patient + Antibiotic Assessment

Clinical picture: 51-year-old engineer with T2DM (diet-controlled). 2 days of weakness, mucopurulent sputum, fever 38.5°C. Smoking 30 pack-years. Decreased percussion + crepitus right lower lobe. CXR: S9 infiltration heterogeneous. Local doctor prescribed azithromycin 500 mg x1/day x3 days outpatient.

Q1. Was the diagnosis correct? Yes - CAP right-sided, non-severe ✓

Q2. Was outpatient treatment correct?

CRB-65: confusion 0, RR <30 0, SBP >90 0, age <65 → Score 0 → outpatient acceptable
However, with DM inpatient is preferable (comorbidity). Outpatient acceptable per score but borderline.

Q3. Was azithromycin correct? Yes - in mild CAP, azithromycin covers all major pathogens of CAP (Streptococcus pneumoniae, atypicals)

Q4. Criteria for antibiotic effectiveness:

Temperature persistently <37.2°C for ≥48 hours
No intoxication syndrome
RR <20/min (without chronic DN)
No purulent sputum (except chronic producers)
CBC: leukocytes <10×10⁹, neutrophils <80%, juvenile forms <6%

Severe pneumonia criteria: (same as Case 18 above)

CASE 20 - COPD Gold 4 + Cor Pulmonale Decompensated

Clinical picture: 57-year-old heavy smoker (37 pack-years). FEV1 = 30% predicted, FEV1/FVC = 0.6. SpO₂ 87%. CAT score 28. Exacerbations 2-3x/year, 1 hospitalization last year. Right heart hypertrophy on ECG. Cyanosis, leg edema, liver 2 cm below costal margin, distended neck veins. Polycythemia (Hb 168).

Diagnosis: COPD, GOLD Stage 4 (extremely severe), Group D, exacerbation. Chronic cor pulmonale (decompensated). Respiratory failure Grade 2.

Treatment:

Hospitalize, smoking cessation
Low-flow oxygen 2-4 L/min (maintain SpO₂ >94%)
Nebulizer bronchodilators (fenoterol/ipratropium, salbutamol) x2-3/day
Inhaled GCS (beclomethasone/budesonide) 1000 mcg/day
Theophylline 100-300 mg/day
Mucolytics (ambroxol, ACC)
Diuretics: loop (torasemide) + potassium-sparing (spironolactone) for edema
Heparin (thrombosis prevention in cor pulmonale)

Indications for long-term low-flow O₂ therapy (LTOT):

Absolute: pO₂ ≤55 mmHg or SpO₂ ≤88%
Relative (special conditions): pO₂ 55-59 mmHg or SpO₂ 89% WITH: cor pulmonale, edema, polycythemia (Ht >55%)
No indication: pO₂ ≥60 mmHg, SpO₂ ≥90% (without special conditions)

Respiratory failure definition & grades:

DN = PaO₂ <60 mmHg and/or PaCO₂ >45 mmHg
Grade 1: PaO₂ 60-79 / SpO₂ 90-94%
Grade 2: PaO₂ 40-59 / SpO₂ 75-89%
Grade 3: PaO₂ <40 / SpO₂ <75%

CASE 21 - COPD (Emphysematous Type)

Clinical picture: 52-year-old typesetter, 30 cigarettes/day since age 20. Progressive dyspnea + weight loss for 2 years. Barrel-shaped chest, box percussion sound, diffusely weakened vesicular breathing. SpO₂ 96%. Liver +4 cm (cor pulmonale). Accent II tone over PA.

Diagnosis: COPD (emphysematous/"pink puffer" type)

Justification: Smoking history (HCI >10 pack-years), broncho-obstructive syndrome, gradual progressive course, emphysema signs on exam

Work-up: CBC, OAM, biochemistry (creatinine, glucose, bilirubin, ALT, AST, CRP), spirometry + salbutamol reversibility test, CXR, ECG

Treatment:

Smoking cessation
Basic therapy: Long-acting M-anticholinergic (tiotropium bromide, aclidinium bromide, glycopyrronium) - preferred in GOLD C/D emphysema
Short-acting inhaled bronchodilator PRN (fenoterol/ipratropium, salbutamol)

LTOT indications: Same as Case 20

CASE 22 - Duodenal Ulcer + HP + GI Bleed Complication

Clinical picture: 45-year-old engineer, 3-year history of epigastric pain (hunger pain, nocturnal pain), constant heartburn, heaviness after eating, nausea. Smokes, coffee abuse, irregular meals. EFGDS: ulcer defect 0.5 cm on posterior wall of duodenal bulb, white fibrin base, urease test positive.

Diagnosis: Peptic ulcer of duodenal bulb, HP-associated, subacute phase, with pain and dyspeptic syndromes, moderate severity

Work-up: X-ray (niche sign, convergence of folds), endoscopy (visual + targeted biopsy), intragastric pH-metry, electrogastrography, HP detection (breath test, PCR of feces, morphological biopsy)

Treatment (4-component eradication):

PPI (omeprazole 20 mg x2/day) + clarithromycin 500 mg x2/day + amoxicillin 1000 mg x2/day x14 days
Gastroprotector: De-Nol (bismuth subcitrate)
Antacids (Maalox/Almagel) or alginates (Gaviscon)

GI bleeding complication (coffee-ground vomiting, weakness, dizziness):

Lay patient flat, lower head if hemodynamically unstable
Cold compress to epigastric region, NPO (nothing by mouth or water)
Etamsylate 12.5% 2-4 mL IV
Urgent hospitalization to surgical department

CASE 23 - Cholelithiasis + Chronic Calculous Cholecystitis → Biliary Colic

Clinical picture: 48-year-old obese woman, mother had cholecystectomy. 10-15 years of biliary pain after fatty food, stops with drotaverine. Now 2 weeks of constant pain + nausea + chills. Murphy+, Lepene+, Ortner+. US: gallbladder enlarged, walls 4 mm, multiple calculi up to 2.5 cm. CBD 6 mm.

Diagnosis: GSD. Chronic calculous cholecystitis, without exacerbation. Hypomotor GB dysfunction. Chronic reflux gastritis (type C), exacerbation. Chronic duodenitis. Duodeno-gastric reflux.

Additional work-up:

Fecal elastase-1 (exocrine pancreatic function)
Pancreatic amylase + lipase (exclude pancreatitis)
MR-pancreatocholangiography or endo-US (CBD stones, pancreatobiliary zone)
Duodenal sounding (biliary dyskinesia type + bile culture)

Treatment:

Planned laparoscopic cholecystectomy
UDCA (Ursofalk, Ursosan) courses under US control
Antispasmodics (Odeston, Buscopan)
Prokinetics (metoclopramide, domperidone)
Diet: no fatty, fried, smoked, flour

Biliary colic emergency (acute pain, nausea, vomiting):

Myotropic antispasmodics IV/IM (drotaverine) or selective antispasmodics (Odeston, Buscopan)
If persistent: hospitalize in surgical department

CASE 24 - Chronic Alcoholic Pancreatitis Exacerbation

Clinical picture: 46-year-old driver, alcohol abuse 7 years. After celebration: constant epigastric pain radiating to back/left abdomen, nausea, vomiting, bloating, steatorrhea x3/day (greasy, fetid). US: heterogeneous pancreas, calcifications, dilated duct, head 5 cm. Liver enlarged (alcoholic steatosis). Gallstone 8 mm.

Diagnosis: Chronic alcoholic pancreatitis, pain form, with exocrine insufficiency, exacerbation. Alcoholic hepatic steatosis. GSD, chronic calculous cholecystitis, latent.

Work-up: Biochemistry (glucose, lipase, amylase, LFTs, bilirubin, alkaline phosphatase), urinary diastase, fecal elastase-1, glycemic profile + HbA1c (exclude DM), abdominal CT (exclude cysts/tumors), EGDS (exclude duodenal ulcer), surgical consultation

Treatment:

Hospitalize, absolute alcohol abstinence, diet #5
Antispasmodic: drotaverine 80 mg IM x2/day
Analgesics: baralgin, paracetamol
Enzyme replacement therapy (Creon) for exocrine insufficiency
Glycemia correction if needed

Refractory pain management:

If NSAIDs insufficient: narcotic analgesics (promedol, morphine) or tramadol
Antioxidant therapy
Tricyclic antidepressants (amitriptyline) as pain modulators

CASE 25 - Chronic Biliary-Dependent Pancreatitis + Pancreatogenic Diabetes

Clinical picture: 47-year-old, post-cholecystectomy (age 40). 6 months post-op: persistent upper abdominal pain, radiating to back, worse with diet errors. Last 1.5-2 years: chronic loose stool, 8 kg weight loss, perineal itching, polydipsia, polyuria. Positive Kerte's sign, Mayo-Robson's sign (head of pancreas involvement).

Diagnosis: Chronic biliary-dependent pancreatitis, pain form, with exocrine AND endocrine insufficiency, exacerbation. Pancreatogenic diabetes mellitus (mild course)

Work-up: CBC, OAM, urine amylase, biochemistry including lipase, amylase, glucose, C-peptide, coprogram, fecal elastase-1, abdominal US, endoscopic US, MR-cholangiopancreatography, CT abdomen

Treatment:

Diet #5p (fasting x3 days initially)
PPIs (suppress gastric secretion)
Enzyme preparations (Creon, Micrasim)
M-anticholinergics (platyphylline)
Myotropic antispasmodics (mebeverin, drotaverine)
Insulin therapy in low doses (pancreatogenic DM)

Differential diagnosis: Gastric ulcer, GSD/chronic cholecystitis, inflammatory bowel disease, abdominal ischemic syndrome, pancreatic cancer, duodenitis with SIBO

Pathogenesis: Biliary tract disease → ↑pressure in CBD → biliary-pancreatic reflux of infected bile → partial activation of pancreatic enzymes in ducts → edema-hemorrhage-destruction → fibrosis → exo- and endocrine insufficiency

CASE 26 - Chronic Atrophic Gastritis Associated with H. pylori

Clinical picture: 45-year-old woman, 20-year chronic gastritis, exacerbations 1-2x/year, never had eradication therapy. Current exacerbation after diet error. EFGDS: atrophic mucosa in antrum, rapid urease test positive. Biopsy: atrophy + chronic polymorphocellular infiltration.

Diagnosis: Chronic atrophic gastritis, HP-associated, exacerbation

Additional work-up: CBC, abdominal US, GI fluoroscopy, coprogram, stool for dysbiosis

Treatment:

Nolpaza (pantoprazole) 40 mg morning x3 weeks
De-Nol 120 mg x4/day x3 weeks
Ganaton (itopride) 50 mg x3/day x3 weeks (prokinetic)
If patient consents: eradication - clarithromycin 500 mg x2/day + amoxicillin 1000 mg x2/day x14 days + PPI

Role of H. pylori: Central etiopathogenetic factor in: chronic gastritis type B, duodenitis/gastroduodenitis, peptic ulcer (gastric and duodenal), MALT lymphoma, non-cardiac gastric cancer. HP pathogenicity factors: colonization (motility, adhesins, urease), persistence (enzymes, LPS, coccal forms), disease-causing (vacuolating cytotoxin VacA, CagA antigen, pro-inflammatory factors)

CASE 27 - GERD with Erosive Esophagitis

Clinical picture: 45-year-old woman, 3 months of heartburn + acid regurgitation, worse lying down + bending after meals. Smoker (10 cigarettes/day). BMI 31. EGDS: multiple areas of mucosal hyperemia + non-confluent erosions of distal esophagus <5 mm.

Diagnosis: GERD, endoscopically positive form, Stage II (Grade A), with typical symptoms

Work-up: 24h esophageal pH-metry; EGDS + biopsy; barium fluoroscopy; PPI diagnostic test. Additional: manometry (LES tone), esophageal impedancemetry, scintigraphy, genetic screening for Barrett's esophagus

Treatment (combination):

PPIs (rabeprazole, dexlansoprazole)
Antacids
Prokinetics (itopride)

Lifestyle recommendations:

Fractional meals in small volumes, 2-3h intervals; no food 2-3h before bed
Exclude: canned food, smoked meats, fatty/fried food; reduce coffee
Weight loss
Avoid: excessive physical exertion, bending forward, lying down <30-60 min after eating
Sleep with elevated head of bed
Smoking cessation

Pathogenesis: ↓LES pressure → ↓esophageal peristalsis → delayed gastric emptying → duodenogastric + gastroesophageal reflux → mucosal exposure to acid/pepsin → esophagitis

CASE 28 - Chronic Alcoholic Hepatitis + Intrahepatic Cholestasis

Clinical picture: 48-year-old, 13 years heavy alcohol use (>60 g ethanol/day). Jaundice, telangiectasias (chest/back/shoulders), palmar erythema, right hypochondrium pain. ALT 203, AST 214, GGTP 89, ALP 298, total bilirubin 25. Indirect bilirubin elevated (22.5). Hepatitis B and C markers negative. Elastometry: F2 fibrosis (METAVIR). No varices findings.

Diagnosis: Chronic alcoholic hepatitis, moderate activity, moderate fibrosis (F2). Intrahepatic cholestasis.

Work-up: EGDS (assess esophageal varices, assess mucosa), abdominal US (other organs, gallbladder, pancreas), MR liver + MR-cholangiopancreatography

Treatment:

Alcohol abstinence (primary etiological treatment) + narcologist consultation
Antispasmodic for pain: mebeverine 200 mg x2/day
Hepatoprotector: S-adenosylmethionine (Heptral) 400-1600 mg/day x1 month
UDCA 8-10 mg/kg/day x3 months (cholestasis + hepatoprotection)

After 1 month (improvement, normalized LFTs):

Abdominal US every 6 months
Hepatoprotector courses x2/year
Long-term UDCA 2 tablets (600 mg)/day

Pathogenesis: Ethanol → acetaldehyde accumulation → ↓β-oxidation of fatty acids → lipid peroxidation → disruption of phospholipid cell membranes → alcoholic hyaline → disruption of intracellular transport → balloon dystrophy → hepatocyte necrosis → fibrosis. Cytolysis: ↑ALT, ↑AST.

CASE 29 - GERD + Erosive Gastritis + Possible HP + GI Bleed

Clinical picture: 48-year-old welder, shift worker, smoker (20 cigarettes/day since age 13). 2 years of severe heartburn, acid regurgitation especially lying down/bending. Episode of black liquid stool 3 days ago (resolved). EGDS: multiple small erosions lower third esophagus (up to 50% circumference), cardia incompetent, gastric mucosal prolapse into esophagus, multiple flat erosions in antrum. Occult blood positive.

Diagnosis: GERD. Chronic erosive reflux esophagitis Stage II, exacerbation. Chronic erosive antral gastritis, HP-associated(?), exacerbation, complicated by mild bleeding.

Work-up: 24h intraluminal esophageal pH-metry, esophageal manometry, barium fluoroscopy (with lateroposition), mucosal biopsy (esophagus + stomach), HP blood test

Treatment plan:

Non-drug: fractional meals, no lying 3h post-meal, elevated headboard, no tight clothes, smoking cessation, avoid heavy loads
Rabeprazole 20 mg x1/day before meals x8 weeks, then maintenance 20 mg/day x52 weeks
Itopride (Ganaton) 1 tab x3/day before meals x4 weeks
Maalox 1 tab x3/day 40-60 min after meals
UDCA 250 mg x2/day x4 weeks (for bile reflux)

Eradication if HP confirmed:

Rabeprazole 20 mg x2/day + amoxicillin 1000 mg x2/day + clarithromycin 500 mg x2/day x10-14 days
Add bismuth subcitrate 2 tabs x2/day or rebamipide for mucosal protection

Control endoscopy: annually; gastroenterologist review every 6 months; disability certificate 21-28 days (complicated form up to 2.5 months)

Pathogenesis: ↓LES function + ↓esophageal clearance + damaging refluxant (acid/bile/pepsin) + esophageal hypersensitivity → esophagitis/erosions/Barrett's/strictures

CASE 30 - Peptic Ulcer + Accomplished GI Bleeding + IHD (Complex Comorbidity)

Clinical picture: 69-year-old with post-MI (1.5 years ago), post-stenting (10 months), on aspirin + clopidogrel (stopped rosuvastatin 5 months ago). 4-5 weeks epigastric pain, black stools for 2 days a week ago (resolved). Anemia: Hb 103, MCV 22 (microcytic, hypochromic). Cholesterol 7.8, TG 2.6. ECG: old anterior MI (Q waves V1-V4, negative T).

Diagnosis: Peptic ulcer of stomach/duodenum, exacerbation. Accomplished GI bleeding. Posthemorrhagic anemia (mild). Possible NAFLD, chronic pancreatitis. IHD, PICS, post-stenting, angina FC II, CHF IIA. Dyslipidemia.

Work-up: OAM, biochemistry (LFTs, bilirubin, alkaline phosphatase, GGTP, amylase, total protein, glucose), abdominal US, EGDS, colonoscopy, anti-HP antibodies, cardiologist consultation

Management:

Diet 4-5x/day, avoid spicy/salty/fried/smoked
De-Nol, Duspatalin, fibrate (Trakor for high TG), iron preparations
PPI, HP eradication if confirmed

PPI choice for this patient:

Pantoprazole or rabeprazole - these are NOT metabolized via CYP450 system → less liver burden + less interaction with clopidogrel (unlike omeprazole/esomeprazole which reduce clopidogrel efficacy)
PPI standard dose x2/day + bismuth subcitrate 120 mg x4/day + clarithromycin 500 mg x2/day + amoxicillin 1000 mg x2/day (or metronidazole 500 mg x2/day)

Pathogenesis of PUD: Imbalance between aggressive factors (HCl, pepsin, HP, bile, NSAIDs, smoking) and mucosal protective factors (mucus, bicarbonate, prostaglandins, blood flow, cell regeneration). HP + blood group 0 are key risk factors for duodenal ulcer.

CASE 31 - Ulcerative Colitis, Left-Sided, Moderate Attack

Clinical picture: 29-year-old programmer, 5 months of progressive diarrhea 5-6x/day (including at night) with blood and mucus, tenesmus, left flank pain, 5 kg weight loss. Worsened after self-treatment with chloramphenicol. Sigmoidoscopy: diffuse hyperemia, edema, contact bleeding, confluent erosions, fibrin, blood-mucus. Fecal calprotectin 532 µg/g. CRP 95 mg/L.

Diagnosis: Ulcerative colitis, acute course, left-sided lesion, moderate severity attack

Work-up: Bacterial stool culture, abdominal X-ray, colonoscopy with biopsy (full extent assessment), irrigoscopy, abdominal US, CT with bowel contrast

Treatment:

Non-drug: Diet #4, psychological support
5-ASA (mesalazine): 3-4.8 g/day orally + 2-4 g/day as enemas x6-8 weeks
Remission maintenance: mesalazine 1.2-2.4 g/day orally + 2 g x2/week enemas
If 5-ASA insufficient: GCS budesonide 9 mg/day x8 weeks

Disability assessment: Moderate disease in exacerbation phase = temporary disability 1.5-2 months

Pathogenesis: Immune dysregulation (genetic factors, food allergy, stress, dysbiosis) → activation of pro-inflammatory cytokines → lymphoplasmacytic infiltration of colonic mucosa

CASE 32 - B12 Deficiency Anemia, Severe (Funicular Myelosis + CHF)

Clinical picture: 65-year-old woman, 6 months progressive weakness, difficulty swallowing, dyspnea, leg swelling. Bright red smooth cracked tongue (Hunter's glossitis). Pancytopenia: Hb 40, erythrocytes 1.0×10¹², MCV 110, MCH 40, reticulocytes 0.1%. Macro- and anisocytosis, megalocytes, Jolly bodies, Cabot rings. Neurological: distal hyperesthesia, ↑deep tendon reflexes, ↓muscle strength (funicular myelosis).

Diagnosis:

Main: Chronic DNA/RNA-dependent hyperchromic macrocytic anemia, severe
Complications: Leukopenia; funicular myelosis (subacute combined degeneration of spinal cord); myocardial dystrophy, LVH, CHF Stage IIB, FC III-IV

Work-up: Biochemistry (bilirubin fractions - to type jaundice); Echo (CHF verification); EGDS + colonoscopy (exclude GI pathology); stool for helminth ova (exclude Diphyllobothrium latum); serum B12 + folic acid + methylmalonic acid levels; antibodies to parietal cells + Castle's intrinsic factor; bone marrow aspirate (exclude leukemia)

Differential:

Folic deficiency anemia - no funicular myelosis
IDA - microcytic, ↓serum iron
Hemolytic anemia - reticulocytosis, not macrocytic
Acute leukemia - no thrombocytopenia here, no blast cells

Treatment:

Cyanocobalamin 500 mcg IM daily x1 week (neurological symptoms = higher dose); then 500 mcg every 5-7 days until Hb/WBC normalize; then 500 mcg weekly x2 months (depot formation)
Given severity of anemia + myocardial dystrophy: erythrocyte suspension transfusion indicated
Efficacy: reticulocyte rise at days 5-7; Hb rise after 1-1.5 weeks; LDH/bilirubin normalization

CASE 33 - Iron Deficiency Anemia, Severe (Sideropenic Syndrome)

Clinical picture: 21-year-old disabled female (cerebral palsy), never ate meat, frequently ate soil (pica/geophagia). Fatigue, hair loss, cheilitis, taste perversion. Hb 60 g/L, color index 0.63, MCV ↓ (microcytic, hypochromic). Serum iron 4.1 µmol/L (low), TIBC 103 µmol/L (↑ = unsaturated), occult blood negative x3.

Diagnosis: Chronic iron deficiency anemia, severe (Hb 60 g/L)

Justification:

Anemic syndrome: fatigue, anorexia, functional cardiac murmur
Sideropenic syndrome: hair loss, cheilitis, taste perversion (geophagia), ↓serum iron, ↑TIBC, low color index

Work-up: LFTs (hepatomegaly); stool for helminth ova (eats soil → Ascaris, Toxocara); stool occult blood; EGDS + sigmoidoscopy/colonoscopy; ferritin (exclude relative iron deficiency); abdominal + pelvic US; gynecology consultation

Differential: B12-deficiency anemia (exclude - hypochromic, ↓iron, ↑TIBC = opposite of B12); anemia of chronic disease (no sideropenic syndrome); thalassemia (↑reticulocytes, target cells, normal/elevated iron, splenomegaly, bilirubin)

Treatment:

Oral iron preparations (ferrous or ferric), 100-120 mg elemental iron/day in 1-2 doses (polymaltose complex preferred - good absorption, fewer side effects)
Continue until Hb normalizes, then maintenance 50-60 mg/day x3-4 months to replenish depot
Efficacy: clinical improvement days 5-6; reticulocytes rise days 8-12; Hb rises after 2.5-3 weeks
Consider IV iron (iron carboxymaltose, iron hydroxide sucrose) given cognitive deficit and need for compliance
Transfusion NOT indicated (no cardiovascular compromise, no circulatory-hypoxic syndrome meeting transfusion threshold)

CASE 34 - Acute Leukemia (First Attack)

Clinical picture: 35-year-old male, 1 month of severe weakness, dyspnea, bruising all over, nosebleeds, gingival bleeding, fever 38.1°C. CBC: Hb 76, leukocytes 35×10⁹, blasts 21%, platelets 21×10⁹. No lymphocytes/monocytes/stabs. Hepatomegaly to navel level. Splenomegaly. Elevated bilirubin 48.8, prolonged aPTT 50s.

Clinical syndromes:

Hemorrhagic (bruising, nose/gum bleeding, thrombocytopenia)
Circulatory-hypoxic (weakness, dyspnea, anemia)
Hyperplastic (hepatosplenomegaly, leukemic infiltration)
Intoxication (fever, weakness)

Diagnosis: Acute leukemia (unspecified), 1st attack, extended phase. Metaplastic anemia (moderate). Metaplastic thrombocytopenia with hemorrhagic syndrome. Leukemic liver infiltration.

Work-up:

Sternal puncture (cytological bone marrow exam - confirm blast cell dominance)
Cytochemical reactions on blast cells (lineage determination)
Immunophenotyping - most informative (distinguish AML vs ALL)
Cytogenetic/molecular biology (prognosis, targeted therapy eligibility)
Biochemistry: bilirubin fractions, GFR, LDH, AST, ALT, urea, uric acid
Viral hepatitis markers
Abdominal US, ECG, Echo, CXR

Treatment:

Admit to hematology department
Specific chemotherapy depends on AML vs ALL variant
Blood component therapy:
- Anemia correction: erythrocyte suspension transfusion
- Hemorrhagic syndrome: FFP (fresh frozen plasma) + platelet concentrate transfusion
Hepatoprotectors (UDCA) for hyperbilirubinemia/liver involvement
Infusion therapy + forced diuresis + xanthine oxidase inhibitors (allopurinol) for tumor lysis nephropathy prevention

CASE 35 - IDA in Young Woman + Menorrhagia (Mild, then Follow-up)

Clinical picture: 28-year-old woman, anemia since age 16, irregular iron therapy. Profuse menstruation x5-7 days every 21 days. 2 pregnancies. Weakness, palpitations (HR 110), dizziness, taste perversion (dry pasta, buckwheat), sore throat. Hb 94 g/L, MCH 25 pg, MCV 76 fl (microcytic), serum iron 7.6, ferritin 8.8 µg/L.

Diagnosis: Chronic IDA, mild degree (Hb >90 g/L). Circulatory-hypoxic + sideropenic syndromes confirmed by lab.

Work-up: Gynecologist consultation; stool for occult blood; abdominal + pelvic US; EGDS; sigmoidoscopy (exclude GI blood loss source)

Drug choice: Oral iron (polymaltose iron complex) 200 mg/day until Hb normalizes

After 2 months (Hb normalized to 122, but ferritin still low at 12 µg/L):

Continue therapy at reduced dose 100 mg/day for 4-6 months to replenish iron depot
Monitor ferritin every 6 months while menorrhagia persists

CASE 36 - B12 Deficiency Anemia, Severe (Elderly + Anginal Symptoms)

Clinical picture: 67-year-old woman, 6 months progressive weakness, "shaky gait," tingling in limbs (funicular myelosis). New: pressing retrosternal pain + dyspnea on exertion (last 2 months). Jaundiced + pale skin. Splenomegaly. Hb 68 g/L, MCV 104.6, MCH 40.6, reticulocytes 0.8%, thrombocytopenia (70×10⁹), leukopenia (2.3×10⁹). Macrocytosis, hypersegmented neutrophils, Jolly bodies, Cabot rings. Indirect bilirubin 38.4 µmol/L (hemolytic component). Bone marrow: megaloblastic hematopoiesis.

Diagnosis: Chronic hyperchromic macrocytic anemia, severe (Hb <70 g/L). Circulatory-hypoxic syndrome, neurological deficit (unsteadiness, hyperesthesia, tingling) = funicular myelosis.

Work-up: Serum B12 + folic acid; antibodies to helminths; stool for helminths; abdominal US; EGDS + colonoscopy

Expected EGDS finding: Atrophy of gastric mucosa (autoimmune atrophic gastritis → ↓intrinsic factor → ↓B12 absorption)

Transfusion indications:

Age + increasing anginal symptoms on exertion + Hb <70 → erythrocyte suspension transfusion indicated

Treatment:

If B12 deficiency: cyanocobalamin 500 mcg/day IM x1 month, then 500 mcg IM x1/week x2 months
If folic acid deficiency: folic acid 1-2 mg/day x1 month

CASE 37 - B12 Deficiency Anemia, Severe + Cognitive Decline + Atrophic Gastritis

Clinical picture: 63-year-old woman, HTN on lisinopril+amlodipine. 6 months of severe weakness + cognitive impairment (forgetfulness, word-finding difficulty). Crimson tongue (Hunter's glossitis). Pale + mucous membranes. Epigastric sensitivity. Liver +2 cm. CBC: Hb 52 g/L, MCV 108, MCH 36.1, thrombocytopenia (PLT 76×10⁹), leukopenia (WBC 2.8×10⁹). Macrocytosis.

Diagnosis: DNA/RNA-dependent anemia (B12 deficiency, folic acid deficiency), severe (Hb <60 g/L = emergency hospitalization)

Management:

Emergency hospitalization in therapeutic hospital (Hb <60 g/L + moderate thrombocytopenia = urgent)
EGDS → atrophic gastritis found (confirms mechanism of B12 deficiency)
Cyanocobalamin 500 mcg/day IM started

After 1 month (Hb improved to 96, but cognitive symptoms remain):

Atrophic gastritis confirmed → continue cyanocobalamin 500 mcg IM every 2 weeks
Add folic acid (atrophic gastritis impairs folate absorption also)
Cognitive symptoms may be slow to resolve (neurological damage is slower to reverse than hematological)

Q4 - Can diet increase Hb?

No - because atrophic gastritis impairs intrinsic factor production → B12 cannot be absorbed from food or oral multivitamins regardless of diet quality. Only parenteral B12 is effective. Dietary advice alone is ineffective in pernicious anemia.

Quick Reference Summary Table

Case	Diagnosis	Key Drug(s)
1	Contrast-induced nephropathy, AKI Stage 3	Calcium gluconate IV, glucose+insulin, furosemide
2	Acute gouty arthritis + CKD	Nimesulide/colchicine; losartan (not thiazides!)
3	CGN nephrotic syndrome	GCS + cyclophosphamide; furosemide + albumin; enoxaparin
4	Chronic pyelonephritis exacerbation	Levofloxacin 500 mg x10 days; urovaxom maintenance
5	Rheumatoid arthritis	Prednisolone bridge → methotrexate 15 mg/week + folic acid
6	SLE + nephritis + polyserositis	Hydroxychloroquine + GCS; pulse methylprednisolone; cyclophosphamide
7	SLE + neurovasculitis	Methylprednisolone 1000 mg IV x3 days
8	Infective endocarditis (aortic valve)	Empiric antibiotics; valve replacement surgery
9	RA + secondary AA amyloidosis	DMARD correction; diuretics + albumin; enoxaparin; RAAS blockade
10	ISAH elderly	CCB + thiazide diuretic; captopril SL for crisis
11	Post-STEMI + HTN uncontrolled	DAPT (ASA + ticagrelor 90 mg x2); add CCB/diuretic; statin ↑ + ezetimibe
12	Stable angina II + HTN	Beta-blocker; aspirin; statin; RAAS+diuretic/CCB; STEMI→PCI
13	Post-MI + permanent AF	Clopidogrel + NOAC (12 months) → NOAC monotherapy; statins; beta-blocker
14	Stable angina II + HTN + dyslipidemia	Aspirin; statin; beta-blocker ± CCB ± nitrates; RAAS + diuretic
15	Permanent AF + post-MI → GI bleed	Rivaroxaban or warfarin (INR 2-3); surgical admission for GI bleed
16	Bronchial asthma (first episode)	Fenoterol/ipratropium nebulizer + inhaled GCS; step 3 basic therapy
17	CAP right non-severe → deterioration	Amoxicillin → if deterioration: IV amoxiclav or cephalosporin + macrolide
18	CAP right non-severe	Amoxicillin or macrolide orally
19	CAP (diabetic, outpatient)	Azithromycin appropriate for mild CAP
20	COPD GOLD 4 + cor pulmonale	O₂ therapy; nebulized bronchodilators; inhaled GCS; diuretics; heparin
21	COPD (emphysematous)	Long-acting anticholinergic (tiotropium); SABA PRN
22	Duodenal ulcer HP+	PPI + clarithromycin + amoxicillin x14 days; De-Nol; GI bleed: surgery
23	Calculous cholecystitis	Laparoscopic cholecystectomy; UDCA; antispasmodics
24	Alcoholic pancreatitis exacerbation	Abstinence; drotaverine; analgesics; enzymes; insulin if DM
25	Biliary-dependent pancreatitis + pancreatogenic DM	PPIs; Creon; anticholinergics; antispasmodics; insulin
26	Atrophic gastritis HP+	PPI + De-Nol + prokinetic; eradication (clarithromycin + amoxicillin)
27	GERD erosive esophagitis Stage II	PPI (rabeprazole) + prokinetics + antacids; lifestyle modification
28	Alcoholic hepatitis + cholestasis	Abstinence; S-adenosylmethionine; UDCA
29	GERD + erosive gastritis + HP	Rabeprazole x8 weeks; itopride; UDCA; HP eradication
30	PUD + GI bleed + post-MI (complex)	Pantoprazole/rabeprazole (not CYP450-metabolized); De-Nol; iron; EGDS
31	Ulcerative colitis moderate left-sided	Mesalazine 3-4.8 g/day oral + enemas; GCS if refractory
32	B12 deficiency anemia severe + funicular myelosis	Cyanocobalamin 500 mcg IM daily x1 week; blood transfusion
33	IDA severe (pica)	Oral iron 100-120 mg/day; consider IV iron
34	Acute leukemia	Bone marrow biopsy + immunophenotyping → chemotherapy; blood products
35	IDA mild + menorrhagia	Iron polymaltose 200 mg/day → reduce to 100 mg/day x4-6 months
36	B12 deficiency severe + angina	Cyanocobalamin 500 mcg IM; erythrocyte transfusion (anginal symptoms)
37	B12 deficiency + atrophic gastritis + cognitive decline	Cyanocobalamin 500 mcg IM x2 weeks; add folic acid; diet alone ineffective

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