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4. Ultrasound of the kidneys: the kidneys are sharply enlarged
in size up to 14 by 7.5 cm, the parenchyma is edematous, of reduced
echogenicity, 25 mm thick, the cup-pelvis complex is compressed by
edematous parenchyma.
5. Chest X-ray: there are no focal and inltrative changes, the
pulmonary pattern is enhanced due to the vascular component.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 5
Patient N, 58 years old, a nutritionist, was admitted to the poly-
clinic for an appointment with a family doctor with complaints of
swelling of the legs, fear of death, discomfort in the legs, general
weakness, sweating.
It is known from her medical history that she has been suering
from rheumatoid arthritis for 25 years. Prednisone, gold preparations,
NSAIDs were treated. A year ago, proteinuria was rst detected –
1.3 g / l, consulted a nephrologist, but did not receive treatment.
On objective examination: The general condition is satisfactory.
Consciousness is clear. The position is active. Satisfactory nutrition.
The skin is of normal color, clean, normal humidity. Subcutaneous fat
has a homogeneous consistency. Swelling of the shins, feet. Hair and
nails are not changed. The thyroid gland is not visually determined,
with palpation of a soft-elastic consistency, painless. Peripheral lymph
nodes are not enlarged. The muscular system is developed satisfacto-
rily. The joints are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inside of the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness is are within
t.me/medicina_free
252
normal limits. During auscultation, the heart tones are muted, rhythm
is regular, no murmurs. Blood pressure 100/70 mm Hg, heart rate 92
per minute.
Respiratory system. On examination, the chest is of the correct
shape, symmetrical. With comparative percussion over the entire sur-
face of the lungs, a clear pulmonary sound is determined, the boundar-
ies of the lungs are within normal limits. During auscultation over the
lungs, vesicular respiration is determined on both sides, no wheezings.
BR 15 per minute
On palpation, the abdomen is soft and painless during palpation.
The liver protrudes 3 cm from under the edge of the costal arch, dense.
Liquid stool, 2 times a day, diuresis: marks the urge to urinate at night
1-2 times.
Complete Blood Count: RBC – 4,6х10
12
/L, Нb –130 g/L, MCH –
27 pg/cell, WBC – 6,0х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 483,0х10
9
/L, ESR – 64 mm/h.
Total protein - 42 g/l, albumins - 19 g/l, creatinine - 120 mmol/l,
daily proteinuria - 8.2 g. Daily diuresis: 800ml.
Nephrobiopsy: the preparation contains a fragment of the renal
parenchyma, cortical and cerebral layer with up to 6 glomeruli, 2 of
which are sclerosed, the remaining glomeruli of normal size, with the
deposition of homogeneous amorphous masses in capillary loops (+
congo-mouth coloration). Conclusion: amyloidosis of the kidneys.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
t.me/medicina_free
253
Clinical case No. 6
Patient N, 38 years old, hairdresser, was admitted to the poly-
clinic for an appointment with a family doctor with complaints of pain
in the lumbar region on the left, an increase in body temperature to
39°C, chills.
It is known from the anamnesis that there are no chronic diseases.
Heredity is burdened on the mother’s side: stomach ulcer. She was
ill with tuberculosis at the age of 7, was registered for 4 years, then
the phthisiologist was removed from the register. SARS gets sick
1-2 times a year.
On objective examination: the right physique. Pulse is 100 beats
per 1 minute, rhythmic, satisfactory lling. BH 17 per minute. BMI
= 22. Blood pressure is 120/80 mm Hg. Vesicular respiration in the
lungs, the abdomen is soft. The heart tones are clear, rhythmic, a soft
systolic noise is heard at the top. Pasternatsky’s symptom is positive
on the left. The kidneys are not palpable. Palpation of the left kidney
(its area) is sharply painful. There is no dysuria. Macrohematuria, leu-
kocyturia.
In the overview image of the urinary system on the left, at the
level of the transverse process of the III lumbar vertebra, there is
a shadow suspicious of a concretion measuring 4 x 4 mm.
There are no pathological changes in the cup-pelvic system of
the right kidney on excretory urograms. The passage of contrast agent
through the ureter is not disturbed. Moderate pyeloectasia on the left.
Enlargement of the ureter above the concretion shadow. With polypo-
sitional urography, the shadow of the concretion coincides with the
shadow of the ureter made with a contrast agent.
According to ultrasound data, the left kidney is enlarged in size,
the cavity system is expanded, the parenchyma is diusely thickened
(up to 25 mm), of uniform density.
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254
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 7
Patient N, 42 years old, a builder, was admitted to the polyclinic
for an appointment with a family doctor with complaints of lower back
pain on the right, accompanied by an increase in body temperature to
39-40 ° C, chills.
It is known from the anamnesis that a year ago a stone was found
in the upper third of the right ureter measuring 1x1.5 cm. At the same
time, an operation was oered, which the patient refused. The above
complaints are bothered for 3 days. He denies chronic diseases. He-
redity is burdened: the father has a single kidney from birth. There
were no contacts with tuberculosis patients. ARVI gets sick 2-3 times
a year. He does not take medications.
On objective examination: The general condition is severe, slug-
gish, adynamic. Consciousness is clear. Satisfactory nutrition. The
skin is of normal color, clean, normal humidity. Subcutaneous fat
has a homogeneous consistency. BMI = 24. Hair and nails are not
changed. The thyroid gland is not visually determined, with palpation
of a soft-elastic consistency, painless. Peripheral lymph nodes are not
enlarged. The muscular system is developed satisfactorily. The joints
are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation, the heart tones are muted, rhythm is
regular, the splitting of 2 tones is heard. Blood pressure 110/80 mm
Hg, heart rate 92 per minute.
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255
Respiratory system. On examination, normal shape of the chest,
symmetrical. With comparative percussion over the entire surface of
the lungs, a clear pulmonary sound is determined, the boundaries of
the lungs are within normal limits. During auscultation over the lungs,
vesicular respiration is determined on both sides, no wheezings. BR
18 per minute
On palpation, the abdomen is soft, painful in the right hypochon-
drium. Pasternatsky’s symptom is positive on the right.
Complete Blood Count: RBC – 4,6х10
12
/L, Нb –136 g/L, MCH –
27 pg/cell, WBC – 13,0х10
9
/L, neutrophils bands – 16%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 20 mm/h.
In the analysis of urine, leukocytes cover all elds of vision with
a thick layer.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 8
Patient N, 55 years old, assessor, was admitted to the polyclinic
for an appointment with a family doctor with complaints of headaches,
dry mouth, thirst (drinks up to 3 liters of uid per day), general weak-
ness, fatigue, nausea, vomiting, frequent urination, sometimes itchy
skin, shortness of breath during exercise, heart failure.
From anamnesis: he has been ill for 12 years, when edema of the
face, shins and feet, headaches rst appeared. In subsequent years,
arterial hypertension (BP 160/100-190/110 mmHg) joined. Protein,
leukocytes and erythrocytes were periodically detected in the urine.
Despite the doctors’ recommendations, he did not carry out planned
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256
treatment. He was treated inpatient, received prednisone, ascorutin,
diuretics, after discharge, the condition improved, the swelling went
down, the protein in the urine decreased to 0.33%. Recently, head-
aches have become persistent, nausea, vomiting, dry mouth, thirst,
itching, decreased appetite, the patient lost weight.
On objective examination: the condition of moderate severity.
Somewhat inhibited, apathetic, sleepy. Low nutrition, BMI 19 kg/m2.
The skin is dry, pale, traces of scratching. The face is puy, soft swell-
ing of the legs (when pressed, a fossa remains). Hair and nails are not
changed. The thyroid gland is not visually determined, with palpation
of a soft-elastic consistency, painless. Peripheral lymph nodes are not
enlarged. The muscular system is developed satisfactorily. The joints
are not externally changed.
In the lungs, breathing is vesicular, weakened in the lower parts
on both sides, there are no wheezing. The heart is expanded to the left
by 2 cm. Heart tones are muted, frequent extrasystoles. Heart rate 88
beats/min. BP 210/120 mm Hg. The liver and spleen are not enlarged.
The symptom of pounding is positive on both sides. Urination 8-10
times a day, including 1-2 times at night, urine is dark in color.
Complete Blood Count: RBC – 2,8х10
12
/L, Нb –69 g/L,
WBC – 9,8х10
9
/L, neutrophils bands – 2%, neutrophils segments –
67%, lymphocytes – 20%, monocytes – 8%, eosinophil – 1%, PLT –
126,0х10
9
/L, ESR – 75 mm/h.
GUT: specic gravity 1003, protein - 0.8 g / l, WBC - 3-8 in n /a,
RBC – 35 in f/v, hyaline cylinders – 1-2, granular 1-2.
Daily albuminuria 800 mg / day. Creatinine 370 mmol / L. GFR
according to the formula SKD / EPI 15 ml / min.
ECG - hypertrophy of the left ventricle, decrease in voltage, elon-
gation of PQ, smoothness and two-phase T wave, frequent ventricu-
lar extrasystoles.
With ultrasound of the kidneys, the right 8.1x3.7 cm, the left
9.4 x 4.1 cm. The contours are uneven, the thickness of the parenchy-
ma is 14-15 mm, the kidney tissue is diusely hyperechogenic, blood
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257
ow is depleted, cortical-medullary dierentiation is impaired. There
are single small cysts in both kidneys.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 9
Patient N, 25 years old, a robotics specialist, was admitted to the
polyclinic for an appointment with a family doctor with complaints
of swelling of the legs, face, lower back pain, bloody urine and a de-
crease in its daily discharge, weakness, malaise, headaches, some vi-
sual impairment.
From anamnesis: ill for 3 weeks. The disease began with sore
throat when swallowing and nasal congestion with copious purulent
discharge, headaches, temperature up to 39-40 ° C. After 3 days, the
temperature dropped, and my health improved. A week ago, swelling
of the face and shins appeared, the urine turned red. Again he noticed
periodic temperature rises to subfebrile gures. In the past, he have
noted repeated sore throats and exacerbations of sinusitis.
On objective examination: the skin is clean, pale. There is swell-
ing of the face, especially in the eyelid area, soft warm swelling of the
shins and feet. Hair and nails are not changed. The thyroid gland is not
visually determined, with palpation of a soft-elastic consistency, pain-
less. The muscular system is developed satisfactorily. The joints are
not externally changed. Palpated slightly enlarged lymph nodes of the
pharyngeal ring, painful on palpation. The pharynx is hyperemic, the
tonsils are hypertrophied, with a purulent plaque. On the back wall of
the pharynx – purulent discharge from the nose. The tones of the heart
are pure, sonorous. BR 15 per minute. Heart rate - 80 beats per min-
ute, blood pressure - 170/100 mmHg. The abdomen is soft, sensitive
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258
to palpation in the epigastrium. The liver and spleen are not enlarged.
The kidneys are not palpable. The symptom of pounding is positive on
both sides. There is no dysuria.
Complete Blood Count: RBC – 4,6х10
12
/L, Нb –129 g/L, MCH –
27 pg/cell, WBC – 5,3х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 27 mm/h.
In the general urine analysis, the specic gravity is 1018-1020,
protein is 0.99 g /l; RBC – 40-50 in n/a, WBC – 2-3 in n/a. A smear
from the throat gave the growth of beta-hemolytic streptococcus.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 10
Patient N, 28 years old, a neonatologist, was admitted to the
polyclinic for an appointment with a family doctor with complaints
of malaise and subfebrile body temperature, weight loss, weakness.
The disease began with a sore throat when swallowing, the tempera-
ture is up to 39-40 ° C. After 3 days, the temperature dropped, and
state of health got better. She received treatment with folk remedies.
Within two weeks, the symptoms of ARVI disappeared. A week ago,
she again noticed periodic temperature rises to subfebrile gures.
It is known from the anamnesis that the patient had contact with
a tuberculosis patient three weeks ago.
On objective examination: the skin is pale. BMI = 17. There is
swelling of the face, especially in the eyelid area. Palpated slightly
enlarged lymph nodes of the pharyngeal ring, painful on palpation.
Hair and nails are not changed. The thyroid gland is not visually
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259
determined, with palpation of a soft-elastic consistency, painless. The
muscular system is developed satisfactorily. The joints are not exter-
nally changed. The pharynx is hyperemic, the tonsils are hypertro-
phied, without plaque. The tones of the heart are pure, sonorous. Heart
rate - 84 beats per minute, blood pressure - 120/80 mmHg. The abdo-
men is soft, painless. The liver and spleen are not enlarged. The kid-
neys are not palpable. The symptom of pounding is positive on both
sides. There is no dysuria.
Complete Blood Count: RBC – 3,4х10
12
/L, Нb –105 g/L, MCH –
27 pg/cell, WBC – 12,0х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 220,0х10
9
/L, ESR – 25 mm/h.
GUT: specic gravity 1003, protein - 0.4 g / l, leuc. - 11 in f/v, er.
5 in f/v, cylinders hyal 1, reaction pH - 4.4.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
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260
Chapter 10. STANDARD OF ANSWERS
FOR THE NEPHROLOGY SECTION
Clinical case No. 1
1. What is the preliminary diagnosis?
Preliminary diagnosis: chronic glomerulonephritis, latent, com-
plication: CKD, stage 3, renal arterial hypertension, anemia.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory and instrumental studies. Blood: leukocytosis, in-
creased ESR, hyperbrinogenemia, hypoproteinemia, dysprotein-
emia, hypergammaglobulinemia. Increased creatinine levels. Urine:
low specic gravity, proteinuria, leukocyturia, hematuria, cylindruria.
Rehberg-Tareev test: reduction of glomerular ltration and tubular re-
absorption. Nechiporenko’s test: hematuria, cylindruria (Casts). Zim-
nitsky’s test: hypostenuria, isostenuria, nocturia. Radioisotope renog-
raphy is a symmetrical decrease in ltration and excretory functions
of the kidneys. Excretory urography is a symmetrical decrease in the
ltration function of the kidneys. Kidney biopsy: morphological vari-
ants of kidney damage.
3. What is the patient’s management?
Treatment is carried out over a long period and can take from
several months to several years, and sometimes throughout the pa-
tient’s life. Treatment tasks: 1) achieve the reverse development
of kidney lesions with the restoration of their function; 2) stop the
progression of nephritis; 3) slow down the rate of increase in CKD.
Mode: avoid hypothermia, excessive physical exertion, psychoemo-
tional stress. It is forbidden to work at night, in hot and cold rooms,
business trips, overheating, sunburn are not recommended. Diet: is
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