ANSWERS ON QUESTIONS

Main part

A 24-year-old woman consulted a local GP with complaints of

weakness, fever up to 39.2 ° C, pulling pain in the lumbar region,

frequent, painful urination in small quantities.

From the anamnesis it is known that she considers herself a patient from the age of 14, when she first noted

the appearance of the above complaints, acute pyelonephritis was diagnosed, conducted

treatment.

In the next 2 years, repeated hospitalizations with similar complaints,

diagnosed with chronic pyelonephritis. At 16, the patient was asked

spa treatment, which gave positive results.

Deterioration about 2 weeks ago when, after hypothermia

chills appeared, fever up to 39 ° C, severe paroxysmal pain

in the lumbar region, which radiated down the abdomen, accompanied by frequent

painful urination.

On examination: the condition is relatively satisfactory. Height - 175 cm. Weight - 64

kg The skin is clean, normal color. There are no fathers. In the lungs breathing

vesicular, no wheezing. Heart sounds are muffled, rhythmic. Heart rate - 70 beats per

minute, blood pressure - 120/80 mm RT. Art. The abdomen is soft, painless on palpation in all

departments. The liver and spleen are not enlarged. Symptom of lumbar effusion

areas are positive on the right. Frequent, painful urination.

In the analyzes: leukocytes - 8.9 × 10 9 / l, ESR - 36 mm / h, urea - 4.3 mmol / l,

creatinine - 72.6 μmol / l, total protein - 46 g / l. GFR - 92 ml / min / 1.73m 2

.

Urinalysis: specific gravity - 1009, protein - 0.5, white blood cells - outside the field

vision, mucus, squamous cells.

Survey and excretory urography - the kidneys are usually located, shadows

stones were not revealed. There is a mushroom-like deformation of the cups, the necks are elongated,

the pelvis is atonic. The contours of the kidneys are uneven, the accumulation of contrast on the right is reduced.

Urodynamics is not broken.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. Make a differential diagnosis.

5. Suggest and justify the tactics of further treatment.

Situational task 166 [K002013]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient B. 26 years old, a housewife, was admitted to the department in the direction of a doctor

the local therapist in a planned manner with complaints of a headache in the morning,

nightmares, “brokenness” in the morning.

From the anamnesis it is known that he suffers from type 1 diabetes for 3 years. On

regularly administers insulin preparations throughout the years: Protafan (extended

insulin) 12 units at 8.00 and 14 units. s / c at 20.00 and Novo-Rapid (short-acting insulin) 8

units - 6 units - 4 units PC. НbA1c 3 months ago - 6.0%. Over the past week has become

mark the above complaints. Registered glucose in the morning on an empty stomach - 9.8-8.2

mmol / l. Independently increased the evening dose of Protafan to 16-18 units, improvement

not noted, woke up at night from nightmares and severe sweating.

On examination: condition is relatively satisfactory Active. Skin

integuments and mucous membranes of normal humidity and turgor. There are no fathers, no striae. Body mass

- 70 kg, height - 175 cm. Vesicular breathing, no wheezing, BH - 16 in 1 minute. Cordial

tones are clear, rhythmic, heart rate - 80 per minute, blood pressure - 120/70 mm RT. Art. Pulse in all arteries

satisfactory quality. The language is clean. The abdomen is soft, painless. The liver is not

increased. The kidneys are not palpable, the striking symptom is negative. Tactile

pain, temperature sensitivity saved. The thyroid gland is not enlarged,

painless. No lactorrhea.

In the analyzes: at 12.00, capillary blood glucose (express method) - 4.7 mmol / l.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. Make and justify a treatment plan.

5. Assess the prognosis for the patient. Tactics for further observation.

Situational task 167 [K002014]