patient 60 years hospitalized in the surgical ward after 6 days after the onset of

pain in the right iliac region. The patient's condition is satisfactory. Temperature -
37,2 °. There was no chill. Palpation of the abdomen - pain in the right iliac region
where the seal is determined by the dimensions of 7 × 8 cm with indistinct borders,
painful. Symptom Shchetkina-Blumberg weak positive. Symptoms Rovzinga,
Sitkovskiy positive. According to the patient, in the past 6 months it marks a
strengthening of constipation. Leukocytosis - 10.2 × 10/9 / l.
1) What is your presumptive diagnosis. 2) What disease should be excluded? 3)
whether the emergency operation is shown? 4) Your medical tactics and surveys.
1) Acute appendicitis, appendiceal infiltrate.
2) Cancer of the cecum. 3) No. 4) Conduct a conservative anti-inflammatory
therapy. When resorption of infiltration is necessary to survey - barium enema or
colonoscopy. Next, the operation in a planned manner for chronic appendicitis
(appendectomy) after 3 months. When the abscess shows the emergency surgery
clinic - opening and drainage of an abscess.

ZadachaNo2
Man 20 years. Ill for about 6 hours ago, when there were severe epigastric pain,
which soon were located in the right part of the abdomen, more in the right iliac
region. Temperature - 37,6 °. Tongue dry. Abdomen not distended, palpation
soreness in the right iliac region, which is determined by muscle tension and sharply
positive symptom Shchetkina-Blumberg. Leucocytes - 14.5 × 10/9 / l.
1) What is your preliminary diagnosis. 2) What disease should be excluded? 3)
What is necessary to conduct a survey for its elimination? 4) What decision should
be taken?
Task No3
Woman 32 years. Second pregnancy - 34 weeks. The history of chronic calculous
cholecystitis. About 8 hours ago there were small pain in the epigastric region. It
was single vomiting. After 1.5 hours, the pain shifted to the right hypochondrium.
The pains are of a permanent nature, with no irradiation. The body temperature -
32,7 ° C. Leucocytes - 11,6 × 10/9 / l. Language
4
somewhat dry. Abdomen increased in size due to the uterus. On palpation - tense
and painful in the right hypochondrium. Symptom Schetkina- Blumberg is not terms,
Rovzinga negative Sitkovskiy - positive.
1) What is your preliminary diagnosis. 2) What disease should be removed, and
how? 3) Your tactics of treatment.
Task No4 Patient 22 years, operated 16 hours ago for acute appendicitis, there
were weakness, dizziness. Normal temperature. Skin pale, pulse 110 per minute.
The abdomen was soft, painful in the postoperative wound. In sloping areas of the
abdomen percussion determined by the shortening of the percussion sound, the
border of which is shifted by turning the patient on his side. Leukocytosis 11,2 ×
10/9 / l.
1) What is the complication you suspect a patient? 2) How to confirm your guess?
3) What should be done?
Task No5 The patient of 50 years, was admitted to the surgical ward on the 4th day
of the onset of the disease, the diagnosis of acute appendicitis is beyond doubt.
Neither palpation or with vaginal and rectal examination revealed no clear
evidence about the infiltration. The patient decided to operate. Opening the
abdomen and found tight appendicular infiltrate.
1) What are your actions on the operating table? 2) What is the further treatment of
the patient?
Objective responses No1 1) Acute
appendicitis, appendiceal infiltrate. 2) Cancer of the cecum. 3) No. 4) Conduct a
conservative anti-inflammatory therapy. When resorption of infiltration is
necessary to survey - barium enema or colonoscopy. Next, the operation in a
planned manner for chronic appendicitis (appendectomy) after 3 months. When the
abscess shows the emergency surgery clinic - opening and drainage of an abscess.
5
No2Problem 1) Acute appendicitis. 2) Differential diagnosis of perforated gastric
ulcer and
duodenal ulcer. 3) abdominal plain radiography for free gas.
After exclusion of the perforation of the stomach or duodenal ulcers
emergency operation - appendectomy.
Task No3 1) Acute appendicitis. 2) Given the history, the localization of pain is
necessary to exclude acute
cholecystitis. It is necessary to perform an ultrasound. 3) The emergency
surgical intervention, if we can not exclude acute appendicitis.
Problem 1 No4) intraperitoneal bleeding. 2) Complete blood count (erythrocytes,
Hb), ultrasound of the abdomen
on the free liquid. 3) Emergency operation - relaparotomy, stop bleeding.
Problem 1 No5) infiltration drainage area (for introduction antiseptics).
 Wound Closure. 2) Conducting the conservative anti-inflammatory therapy.
Elective
surgery - appendectomy in 2-3 months.
2. abdominal hernia Task No1
The patient of 54 years with right inguinal hernia during the rearrangement
of furniture there is a sharp pain in the right groin area, continuing after the
termination of the efforts that led the patient to seek help in a medical institution.
On examination: revealed the presence of a right groin of tumor formation oval
dimensions 6h4h3 cm tugoelasticheskoy consistency, tenderness and not reduce a
into the abdominal cavity. Cough impulse is not conducted. 1) What is your
diagnosis?
June
2)Which disease should make a differential diagnosis? 3) Therapeutic tactics.
Task No2
patient 30 years operated on for strangulated inguinal hernia. When opening
the hernia sac was found infringement of the two loops of the small intestine,
which in appearance viable species. 1) Character infringement of the small
intestine. 2) What should be checked during the operation? 3) Maintain the
postoperative period.
Task No3
During surgery on the right-oblique pahovo- scrotal hernia at the opening of
the hernia sac in the latter was a loop of the small intestine, which imbedding into
the abdominal cavity. When audit hernial sac appeared that one of its walls
thickened and provided with a wall of the caecum vermiform appendix that is
located in the hernial sac. 1) Ask the diagnosis given anatomical features, revealed
during surgery. 2) What is the further sequence of operation? 3) Do you produce
appendectomy?
Task No4
For you to receive a patient appealed 40 years, who complained of the
presence of acute pain in the left groin, occurred about 3 hours ago. When viewed
in this region is determined ovoidal formation density elastic size 5x6 cm, painful.
Education is located below the crural arch. Normal temperature. 1) What is your
diagnosis? 2) What kind of disease it is necessary to make a differential diagnosis?
3) What is the treatment strategy?
Task No5
 A patient 46 years old, was admitted to the hospital within 6 hours from the
moment of strangulated inguinal hernia, it was spontaneous reduction. The surgeon
decided to perform a hernia repair with the plastic of the inguinal canal. In this case,
during the operation failed toin detail the
7
examineabdominal organs, but adjacent to the neck of the hernia sac intestinal
loops are not changed, effusion in the abdominal cavity do not. The operation took
place without complications. The next day, the patient complained of bloating and
abdominal pain, the temperature rose to 38 ° C, but these effects were seen as a
reaction and post-operative palsy. However, by the end of the day it became clear
that the patient developed peritonitis. 1) What is the cause of peritonitis? 2) What
is the tactical error was made by the surgeon? 3) The further treatment tactics.
Objective responses No1
1) Strangulated right inguinal hernia. 2) coprostasia and false infringement. 3) The
emergency surgery.
Task No2
1) Retrograde pinching small bowel loops. 2) Detect the third loop of the small
intestine, which is usually exposed to infringement. Assess its viability and define
the scope of surgical intervention.
3) The first day of bed rest and the use of analgesics. In the second or third day,
you can sit and walk.
Task No3
1) Right oblique sliding inguinal-hernia scrotal 2) Overlay purse-string suture on
the neck of the hernial sac 1.5-2 cm above the transition places the peritoneum in
the cecum. Plastic rear wall of the inguinal canal, or by Lichtenstein
Postempskomu indicated.
3) No.
ProblemNo4)
1 Strangulated a left femoral hernia. 2) in the inguinal lymph node metastasis,
syphilis. 3) The emergency surgery.
8
No5 Problem
1) entrapment of the small intestine loop. 2) It was necessary to perform an audit of
the abdominal cavity. 3) The emergency surgery - laparotomy, the abdominal
cavity revision.
 3. Complications of peptic ulcer ZadachaNo1
patient 26 years. Within 2.5 weeks is hospitalized for an ulcer 12 duodenal ulcer
size up to 1.8 cm. In the treatment of pain gone completely, but in recent days has
become a bother heaviness in the epigastric region by the end of the day. At control
endoscopic and radiological studies have shown that ulcer healed, but barium slurry
is retained in the stomach for 14 hours.
1) Formulate a detailed diagnosis. 2) whether the patient is shown surgical
treatment? 3) If shown, what operation would you choose, if not, what kind
of treatment you assign?
ZadachaNo2 patient 51 years. I dealt with complaints of feeling of heaviness in the
epigastric region, early satiety, belching rotten, dramatic weight loss. Three weeks
before admission appeared periodic profuse vomiting with the remnants of food
eaten the day before. Over 7 years suffers from gastric ulcer and annual
exacerbations. OBJECTIVE: exhausted, dry skin, flabby, going to fold. The
abdomen was soft, "splashing". BP - 90/75 mm Hg. Art. Positive symptom
chvostek.
1) What kind of complications can think of? 2) What is expected during
fluoroscopy of the stomach? 3) Assess the water - electrolyte metabolism. 4) What
are the expected changes in hematocrit, nitrogen metabolism,
the relative density of urine? 5) treatment tactics.
ZadachaNo3
The clinic delivered a patient 44 years old in serious condition. For many years,
suffering from gastric ulcer. Last 2:00 bothers vomiting like "coffee grounds". Over
the past 2 months I lost 12 kg. The patient is exhausted.
1) What is the complication of peptic ulcer occurred in a patient? 2) What should
be done?
9
ZadachaNo4
patient 32 years suffers a stomach ulcer 12 duodenal ulcer for 6 years. The
last week of intense hunger pains and night. Suddenly developed severe weakness,
cold sweat, pain relief. BP - 90/60 mm Hg. Art. Blood Analysis: Erythrocytes 4.0 ×
10/12 / l, Hb - 140 g / l. At manual study of the feces of normal color.
1) What is the complication developed in a patient? 2) What is the reason the
disappearance of pain? 3) How do you explain the normal blood test performance?
4) What will the feces 1-2 days? 5) How to confirm the diagnosis?
ZadachaNo5
 taken to the patient complained of pains in epigastrium, gases and stool delay.
Acutely ill, about 8 hours ago, when there were sharp epigastric pain was the single
vomiting. For 10 years, suffering from duodenal ulcer. Last worsening - a month
ago. It was treated as an outpatient. At an extract according EGDS - ulcer in step
rumen. The patient's condition serious. Pale skin. Pulse 124 per minute. BP - 95/60
mm Hg. Art. Tongue dry, coated with white bloom. The abdomen is not involved in
the act of breathing, tense, sharply painful in all departments, symptoms Shchetkina
- Blumberg, Resurrection positive. Bowel sounds dramatically weakened.
1) What is your presumptive diagnosis. 2) What research should be performed to
confirm? 3) What kind of treatment you offer the patient?
Answers ZadachaNo1 1) Duodenal ulcer.
Subcompensated
stenosis outlet of the stomach. 2) Yes. 3) 2/3 gastric resection.
ZadachaNo2 1) About decompensated cicatricial pyloric stenosis. 2) Increased
gastric tone reduction, delay barium evacuation to 48
hours. 3) Dehydration: dry skin, reduced turgor, copious vomiting,
lower blood pressure.
April
10)Increase of all indexes: hematocrit - due to blood clots, relative density of urine
- due to oliguria and increased reabsorption, increasing rates of nitrogen
metabolism. 5) Preparations for operation. Intravenous belkisoderzhaschih and salt
solutions according to the data analysis of blood electrolytes, gastric lavage
evenings.
ZadachaNo3 1) Malignization stomach ulcers. 2) EGD with biopsy for the
diagnosis of morphological verification. Ro- scopy stomach. Ultrasound of the
abdomen (for metastases), if possible - CT. The question of choosing a method of
surgical treatment.
ZadachaNo4 1) bleeding from the ulcer 12 duodenal ulcer. 2) Due to the fact that
hydrochloric acid binds with blood. 3) Not occurred hemodilution phase. 4)
melena. 5) Emergency EGD.
ZadachaNo5 1) of perforated duodenal ulcer, diffuse peritonitis. 2) survey
radiography of the abdominal cavity. 3) Surgical treatment: laparotomy, inspection
of the abdominal cavity, suturing perforated ulcer, readjustment of the abdominal
cavity, the abdominal cavity drainage.
4. Acute cholecystitis Task No 1 Patient 52 years
complains of pain periodically appears paroxysmal character in the right upper
quadrant radiating to the right shoulder and shoulder blade with an increase in
body temperature to 39 to 39.5 0 C, pouring sweat in the last year. Over the last
month such attacks more frequent and began to appear every 2-3 days. Sometimes
the attacks were accompanied by jaundice, which quickly disappeared, and then
reappeared. The general condition was satisfactory. He noted some weakness.
Belly of the usual form, soft. The liver is not enlarged. The gallbladder is not
palpable. Tenderness to palpation in
11.
epigastrium White blood cell count of 9.2 x 103 in 1 mm, ESR 38 mm / hr.
Ultrasound gallbladder of normal size, contains concretions, there is dilatation of the
intrahepatic ducts, choledoch 1.2 cm.
1) What is the diagnosis you put? 2) What is the strategy of additional examination
and treatment?
Task No 2 The patient was 69 years old, fat woman suffering cholelithiasis,
chronic calculous cholecystitis, severe diabetes, kardiosklerosis with circulatory
insufficiency II A degree. Bouts of cholecystitis in a patient come in 3-4 times a
year. Two days ago, after the errors in the diet, another painful attack began with
an irradiation of pain in the right shoulder and shoulder blade, nausea, repeated
vomiting that did not bring relief. At admission, the state of moderate severity, is
determined by soreness in the right hypochondrium, positive symptoms of Ortner,
Kera, and frenicus-symptom. Ultrasound at admission - a gallbladder 146x72 mm,
the wall of the gallbladder - 8 mm, in the region of the neck of the gallbladder
fixed concrement 41x32 mm, holedoch 6 mm. Conservative therapy was started.
With dynamic ultrasound, after a day, the ultrasound semiotics is the same.
1) What is the diagnosis of the patient, which confirms the diagnosis? 2) Principles
of conservative therapy? 3) Therapeutic tactics, the possibility of using minimally
invasive methods
surgical treatment (specify, which)?
Task No 3 A patient 65 years old, suffering from attacks of cholelithiasis, another
attack was completely stopped. Within 2 months, the patient continued to observe
dull aching pains in the right hypochondrium, which disturbed her constantly.
When palpation in the right hypochondrium, considerable dimensions were
determined for a densely elastic painless formation with a smooth surface.
Symptoms of irritation of the peritoneum were not determined. Body temperature
all this time remained normal, leukocytosis was absent, there was no shift of the
leukocyte formula. With ultrasound - gall bladder 123x63, wall 4 mm, in the neck
area fixed concrement 23x18 mm, holedoch 6 mm.
1) Your diagnosis and treatment tactics?
12
Task No 4 A patient 46 years after receiving fatty foods first appeared severe pain
in the right upper quadrant with irradiation in the right shoulder and right shoulder
blade. The body temperature rose to 37.80 C, there was repeated vomiting. When
palpation of the right hypochondrium, the bottom of the painful gallbladder was
determined, positive symptoms of Ortner, Kera, the symptom of Shchetkin-
Blumberg was negative. At admission an ultrasound is performed - a gallbladder
115x63 mm, a wall of 3 mm, concrements are defined in the lumen of the
gallbladder. After the appointment of conservative therapy, the condition
improved, the temperature decreased to normal, the pain decreased, the day after
the injection the gallbladder ceased to palpate, there was a slight soreness at the
point of the gallbladder. With dynamic ultrasound - gall bladder 82h59 mm, wall
3mm, holedoch 8 mm. However, after the relief of a painful attack, the patient had
an icteric skin, the bilirubin levels began to increase.
1) Your diagnosis. 2) What should be the diagnostic algorithm and therapeutic
tactics?
Task No 5 A 42-year-old patient is delivered for the third time in the last year to
the clinic with an attack of acute cholecystitis. The last time pain in the right
hypochondrium appeared two days ago, did not seek medical help, and was
engaged in self-medication. 3 hours before the arrival of pain in the abdomen
began to have a spilled character, more on the right flank, notes hyperthermia up to
390C. Has acted with the phenomena of a boring of a peritoneum which gradually
grow, the expressed leukocytosis with shift of the neutrophilic formula to the left.
1) What is the complication of acute cholecystitis in a patient? 2) What additional
methods of instrumental diagnostics
Is it necessary to apply for verification of the diagnosis? 3) What is the treatment
tactic?
Answers Problem No1
1) There is a complication of cholelithiasis - cholangitis. 2) The performance of ERCPG and
EPST to eliminate the causes of cholangitis - choledocholithiasis and / and stenosis of BSD, then
it is necessary to perform cholecystectomy.
Task No2
1) Acute obstructive calculous cholecystitis, which is confirmed by the clinical picture and
ultrasound data.
13
2) Within 24-48 hours after admission, conservative therapy is provided (antibiotic therapy,
antispasmodics, infusion therapy). 3) The ineffectiveness of conservative therapy within 24-48
hours is an indication for urgent surgery, considering concomitant pathology, it is necessary to
perform minimally invasive operations (cholecystostomy under ultrasound control, open
cholecystostomy under local anesthesia).
Task No3
1) There is a complication - edema of the gallbladder, shown
surgery - cholecystectomy.
Task No4
1) Acute calculous cholecystitis, mechanical jaundice. 2) Given that the attack of acute
cholecystitis was stopped (the clinical picture and the data of dynamic ultrasound), but the
patient had mechanical jaundice (dilution of the bile ducts, according to ultrasound), it is
necessary to perform ERCPH, ESTT, then cholecystectomy.
Problem No5
1) There is a complication of acute calculous cholecystitis - bile peritonitis.
2) To verify the diagnosis, you can apply ultrasound, laparoscopy. 3) An emergency operation is
shown.
5. Postcholecystectomy syndrome Task No 1 Patient N. 62 years old was operated on 30 days
ago for acute phlegmonous calculous cholecystitis, in history there was jaundice. A
cholecystectomy "from the bottom" was performed. In the gallbladder, a large number of small
calculi are found. Due to the presence of a pronounced infiltrate in the hepatoduodenal ligament,
a detailed audit of the choledochus was not performed. Cholangiography on the operating table
was not performed. The abdominal cavity is sewn with the insertion of a safety drainage into the
subhepatic space, which was removed on the 6th day after the operation. The patient's condition
was satisfactory, but on the 12th day after the operation she had an external biliary fistula.
Symptoms of irritation of peritoneum
14
no. The day was separated up to 600-700 ml of bile. Over time, the patient had a weakness,
began to disturb diarrhea, there was an achiolic chair. Blood bilirubin 120,3 microns / liter.
1) What intraoperative research is not performed in the patient? 2) What could have caused the
formation of an external biliary fistula?
3) What is the treatment tactic?
Task No. 2 Patient C. 79 years later, laparoscopic cholecystectomy was performed for acute
calculous phlegmonous cholecystitis. The diagnosis before the operation was verified by
ultrasound. The next day after the operation for the safety drainage, 200 ml of bile was allocated,
there appeared peritoneal signs in the right lateral region of the abdomen. With repeated
laparoscopy, the incompetence of the stump of the cystic duct was revealed. Conversion
completed. When the audit was found: holedoh - 1.3 cm, does not contain palpable calculi.
According to the intraoperative cholangiography, the stenosis of the BSDK of 1.2 cm in length
was detected.
1) The cause of the incompetence of the stump of the cystic duct.
2) Further tactics.
Task No 3 Patient S. 52 years old, obese woman was operated for acute gangrenous calculous
cholecystitis. Due to the expressed adhesive process and infiltration in the neck of the bladder,
the operation was accompanied by considerable technical difficulties. Cholecystectomy "from
the cervix" was performed. When palpation and probe revision of choledochus pathology is not
revealed. During the operation there was a leakage of bile in the subhepatic space, the source was
not installed. The operation is completed by draining the subhepatic space. Drainage in the
postoperative period was marked by a slight serous discharge with an admixture of bile.
Drainage is removed for 7 days. The patient is in a satisfactory condition discharged from the
hospital on the 14th day. After 9 months, she returned with a clinical picture of cholangitis
accompanied by mechanical jaundice. Ultrasound revealed that hepatitis choledochitis was
enlarged to 10 mm, there was dilatation of intrahepatic bile ducts, concrements were not
revealed.
1) The cause of development of cholangitis and dilatation of intra- and extrahepatic bile ducts.
2) What tactical mistake was made during the operation?
15
Task No 4 Patient B. 47 years old she entered the department for laparoscopic cholecystectomy.
Due to the presence of jaundice in the anamnesis before the operation, ERCPH was produced - a
"valve" stone of choledocha was identified. A typical ESTT of 2.5 cm was performed. In the
evening of the same day, the patient developed pronounced shingles in the epigastric region of
the abdomen, nausea, vomiting, which did not bring relief, bloating. Symptom Kerte positive.
The amylase of blood and urine is increased.
1) What complication developed in a patient?
Task No 5 Patient G. 60 years about the STSD stenosis the typical EPTS was performed. The
next morning the patient complained of weakness, dizziness, a single liquid black stool,
moderate pain in the right upper quadrant. Upon examination: the stomach is slightly inflated,
with palpation soft, moderately painful in the right hypochondrium and in the epigastric region.
Symptom Shchetkin-Blumberg negative. Blood pressure - 100/60 mm Hg Ps - 90 per minute,
weak filling and tension, Hb - 105 g / l, er. - 2,32 · 10 12 / l, blood amylase - 128 units.
1) What complication developed? 2) Therapeutic tactics.
Answers Task No1 1) Intraoperative choleography. 2) Biliary hypertension associated with the
presence of residual choledocha stone or stenosis of DXH or BSDK.
3) Execution of ERCPH with subsequent EPTS.
Task No2 1) Biliary hypertension caused by stenosis of BSDK. 2) Intraoperative EPTS;
transduodenal papillosfinkterotomy; external draining of choledocha followed by ERCPH and
EPST.
Task No3 1) Post-traumatic stricture of choledochus. 2) Intraoperative cholangiography has not
been performed to clarify the source of bile flow.
16
Task No4 1) Acute pancreatitis.
Task No5 1) Intestinal bleeding. 2) Hemostatic therapy with repeated duodenoscopy and
endoscopic hemostasis, with ineffectiveness - laparotomy.
6. Acute pancreatitis Task No1
In patients with fatty pancreatic necrosis, on the 5th day of the onset of the disease, a dense,
moderately painful infiltrate was determined in the epigastric region, without clear boundaries.
Against the background of conservative therapy, it decreased somewhat in size, but by the third
week of the disease pains increased, hectic temperature appeared, and tachycardia increased. On
examination: the patient's condition is severe, the skin is pale. Pulse 96 per minute, blood
pressure - 120/80 mm Hg. The tongue is dry. The abdomen is swollen, soft, in the epigastrium a
painful tumor-like formation up to 10 cm in diameter is detected; peritoneal symptoms are
negative, the peristalsis is tapped. Blood test: Hb - 105 g / l, leukocytes - 18 × 10/9 / l, eos.- 3, p /
y - 29, s / i - 52, mon-8, lymph-8, ESR 48 mm / h .
1) Your presumptive diagnosis. 2) What additional studies can clarify the diagnosis? 3) Your
treatment tactics.
Task No2
In patients with hemorrhagic pancreatic necrosis, on the 14th day of the onset of the disease,
pains in the abdomen and lumbar region on the left increased, the hectic temperature increased to
39.5 ° C. On examination: the patient's condition is severe, the skin is pale. Pulse 108 per minute.
The tongue is dry. The abdomen is slightly inflated, with palpation painful in epigastrium and in
the left hypochondrium, peritoneal symptoms are negative, peristaltic sounds are listened to.
There is a skin hyperthermia and puffiness of the lumbar region to the left. The Mayo-Robson
symptom is dramatically positive. White blood cells 20 × 10/9 / l.
1) Your presumptive diagnosis. 2) What special methods can clarify the diagnosis? 3) Your
treatment tactics.
17th
Task No3 A patient of 50 years old entered the clinic of acute pancreatitis. With emergency
laparoscopy in the abdominal cavity, hemorrhagic exudate and "stearin spots" on the visceral
peritoneum of the mesentery root of the transverse colon were revealed.
1) Your diagnosis. 2) Your plan for surgical treatment.
Task No4
A 37-year-old patient is delivered 12 hours after the onset of repeated vomiting with bile and
abdominal pain in the upper abdomen. The disease is associated with the intake of alcohol and
fatty foods. On examination: the condition is heavy, the pallor of the skin, acrocyanosis, the
stomach is swollen, is limited to the act of breathing, sharply painful in the epigastric region.
Percutorno - shortening of sound in the sloping places of the abdomen. Positive symptoms of
Schetkina - Blumberg and Mayo - Robson. Pulse - 96 per minute, weak filling. The temperature
is 37.2 ° C. Blood pressure is 95/60 mm Hg. Art. Leukocytes are 17 × 10/9 / L.
1) Your presumptive diagnosis. 2) What research needs to be done to clarify the diagnosis? 3)
Your treatment activities and their rationale.
Problem No5
At the patient of 49 years after reception of plentiful meat, fat and spicy food there were pains of
a surrounding character in the top departments of a stomach, a multiple vomiting. The patient
suffers from gastric ulcer for 6 years. On examination: the abdomen is not swollen, participates
in the act of breathing by all departments, moderately tense and painful in the epigastric region.
The pulse is 96 per minute. The temperature is 37.2 °. Blood pressure is 125/90 mm Hg. Art.
Leukocytes are 17 × 10/9 / L.
1) Your presumptive diagnosis. 2) What research needs to be done to clarify the diagnosis?
Answers Task No1
1) Abscess of stuffing bag. 2) ultrasound of the pancreas, depending on the pathology found -
puncture. If possible, a CT scan. 3) When the diagnosis is confirmed, puncture and draining
US-control.
18
TaskNo2
1) Phlegmon of retroperitoneal tissue. 2) ultrasound, diagnostic puncture. 3) Puncture followed
by draining or indications - autopsy
phlegmon.
Problem No3
1) Mixed pancreatic necrosis. 2) Inspection of the stuffing box, sanation of the abdominal cavity,
drainage
abdominal cavity and stuffing bag, cholecystostomy.
Problem No 4
1) Acute pancreatitis. Pancreatic necrosis, fermentative shock. 2) ultrasound of the pancreas.
Amylase of blood and urine. 3) Complex conservative treatment, after which the question of
the need for diagnostic laparoscopy.
Problem No5
1) Penetration of a stomach ulcer into the body of the pancreas,
complications - acute pancreatitis. 2) Scopy of the stomach. Ultrasound
pancreas. Amylase of blood and urine. FGDs.
7. Intestinal obstruction Task No1
The 42-year-old patient, operated 2 years ago about the rupture of the spleen, went to the clinic
with complaints of acute abdominal pain that arose 2 hours ago, frequent urge to vomit. The pain
is cramping. There is no chair, the gases do not depart. Worried, loudly screaming. The abdomen
is bulged more in the upper half, peritoneal symptoms are doubtful, the tension of the muscles of
the anterior abdominal wall is expressed. X-ray reveals numerous levels and cups of Klauber. 1)
Your diagnosis. 2) Is there a need for additional studies of the patient? 3) Therapeutic tactics.
19
Task No2
The patient was admitted to the clinic for 25 years with complaints of cramping, severe pain in
the lower abdomen. The patient is restless, tends to change the position of the body, reduced
nutrition. The tongue is wet. Pulse - 68 per minute. The abdomen is swollen, soft. In the right
half of the mesohastrium, palpation is determined by a densely-elastic formation of 6x8 cm. The
diagnosis of ileocecal intussusception is diagnosed by the surgeon of the admission department.
The patient is urgently operated. During the operation in the terminal ileum, an elongated
formation 5 cm in diameter was found with an uneven fragmented densely elastic surface that
was not connected to the intestinal wall. The leading department is greatly expanded. The colon
is asleep. 1) Your diagnosis. 2) The circle of the differential diagnosis. 3) Additional research
methods. 4) Tactics of treatment.
Task No3
The patient was admitted to the surgical department for 2 years from the moment of the disease.
Complaints of moderate pain in the lower abdominal cramped abdomen, bloating, stool and gas
retention. The disease began gradually. He suffers from constipation, notes that such conditions
were observed several times and were resolved at home after a cleansing enema. General
condition of moderate severity. P - 78 in 1 min. The abdomen is asymmetric - the right half is
sharply swollen. When palpation soft, evenly painful. The right half of the abdomen occupies a
large formation of a soft - elastic consistency. The peristalsis is not listened to, it is determined
by the "noise of splashing". Percutally over the formation of high tympanitis. Rectal: the ampulla
of the rectum is empty, the sphincter gaping. When you try to perform enema fluid pours back
after the introduction of 300.0 ml.
1) Your diagnosis. 2) With what diseases it is necessary to differentiate the given
pathology? 3) What should be the medical tactics?
Task No4
A 56-year-old patient is operated on in an emergency procedure for acute intestinal obstruction.
Compensated, serious concomitant pathology in the pre-operative period is not revealed. Prior to
surgery, an acute adhesive commissural obstruction was suspected, but during the revision of the
abdominal organs it was found that the obstruction was caused by a tumor
20
sigmoid colon. A tumor with dimensions 5,0х4,0х4,0 cm circularly narrows the lumen of the
intestine, sprouts the serous membrane, is mobile, is not connected with surrounding organs.
Below her gut slept. Thin and colon gums before the tumor are full of gas and contents.
1) Your diagnosis. 2) What you need to pay attention to the surgeon in carrying out
revision of the abdominal cavity in this case? 3) What operational benefit is shown?
Problem No5
Patient N. 32 years old is on treatment in the traumatology department about a compression
fracture of the spine without neurological disorders. From an anamnesis: three days ago fell from
a height of 3 floors. Complaints about absence of stool and gas withdrawal during three days,
bloating, moderate abdominal pain. State of moderate severity. Рs - 72 in 1 min. The abdomen is
moderately swollen, there is no asymmetry, it participates in the act of breathing. At palpation
soft, evenly painful in all departments. There are no peritoneal signs and muscle tension.
1) The diagnosis. 2) With what diseases it is necessary to conduct differential
diagnosis? 3) What research needs to be done? 4) Therapeutic tactics.
Answers Problem No1
1) Acute small intestinal obstruction. 2) Not needed. 3) Emergency laparotomy, elimination of
obstruction, determination of viability of the intestine, resection of the intestine with doubt in
viability.
Task No2
1) Helminthiasis. Acute obstructive intestinal obstruction. 2) Foreign body (phyto -, tricho -,
lithobesoires). 3) There is no need. 4) Mechanical division of the conglomerate without opening
the intestine. If this is not possible - displacement of the conglomerate in the distal direction,
enterotomy, removal of the foreign body, suturing the enterotomy wound.
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Task No3
1) Savor of the sigmoid colon. 2) Cancer of the sigmoid colon. 3) Surgical treatment.
Task No4
1) Cancer of the sigmoid colon. Acute colonic obturation
obstruction. 2) It is necessary to audit the abdominal organs for
metastases. 3) Obstructive resection of the sigmoid colon.
Problem No5
1) Dynamic paralytic intestinal obstruction. 2) Acute mechanical intestinal obstruction.
Coprostasis. Closed
trauma of the abdominal cavity organs. 3) Rectal examination, ultrasound of the abdominal
cavity, ectal examination, ultrasound of the abdominal cavity organs, radiography of the thoracic
and abdominal cavities, passage of the passage of the barium passage through the intestine, and
diagnosis of laparoscopy. 4) In the case of dynamic intestinal obstruction, Pu is assigned
conservative therapy, with its inefficiency - surgical treatment.
8. Diseases of the colon Task No. 1
In a 64-year-old patient with hypertensive disease of the 1st degree, multiple polyps (about 30)
of the left half of the colon, 0.3x0.3 to 0.8x1.0 cm in size, were found in fibrocolonoscopy.
Bleeding from one polyp is observed.
1) How is it better to stop bleeding?
2) What kind of disease should this patient think? 3) In what treatment does the patient need?
Task No2
The patient was admitted to the clinic for 75 years with obstructive intestinal obstruction caused
by cancer of the sigmoid colon of the 3rd degree.
1) What is the emergency operation shown to her?
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Task No3
The patient, who entered the clinic, complains of severe pain in the left side of the abdomen,
repeated vomiting, nausea, weight loss of 13 kilograms over the past 2 months. Upon
examination, the surgeon revealed a tumor-like formation up to 5 cm in the left mesogastric
region, dense, inactive.
1) What diagnosis should I put? 2) What instrumental survey methods should be performed?
3) What is the tactic of treatment?
Task No4
A woman underwent surgery for a giant ventral hernia. During the operation, necrosis of the
fatty intestine of the colon was detected.
1) What should the surgeon do in this situation?
Problem No5
The patient is 63 years old, suffers from constipation, worried about bloating, weight loss.
1) What methods of colon research should be prescribed?
Answers Problem No1
1) Carry out electrocoagulation of the bleeding polyp. 2) On the polyposis of the left half of the
large intestine. 3) In the left-sided hemicolectomy.
Task No2
1) Operation - laparotomy, revision of the abdominal cavity organs, elimination of intestinal
obstruction, transversostomy.
Task No3
1) Colon cancer. 2) Irrigoscopy, a colonoscopy with biopsy. 3) Surgical treatment - left-sided
hemicolectomy.
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Task No4
1) Removal of necrotic fat suspension, drainage
abdominal cavity, continue hernioplasty.
Problem No5
1) Finger rectal examination, irrigoscopy, colonoscopy.
9. Diseases of the rectum Problem No1

The 36-year-old patient, suffering from persistent constipation, turned to the doctor with complaints
about severe pain in the anus, which appear after the act of defecation and last about 1.5 hours.
Periodically marks veins of scarlet blood on feces. At the age of 28 she suffered from dysentery. 1) What
disease is characterized by these complaints? 2) What additional research methods should this

sick? 3) With what diseases should the differential

diagnosis? 4) What is the significance of the transferred disease for this disease?

dysentery?
Task No2

The patient is 61 years old. Appealed to the doctor with complaints of pain in the anus, itching in the
perineum, loss of the nodes from the anus during the act of defecation, which then gradually enter the
rectum. 1) What kind of disease should you first think about? 2) Indicate the stage of the disease. 3)
Does the patient show conservative or surgical treatment? 4) List the main types of operational benefits
for this disease.

Task No3

A patient of 60 years is diagnosed with rectal cancer at a distance of 14 cm from the anus, obturating
the lumen, and metastases in the right lobe of the liver.

24

1) Indicate the stage of the disease according to the TNM classification 2) What is the complication? 3)
What palliative surgical treatment can be performed?

Task No4

The 54-year-old patient complained of dull pains in the depth of the perineum, intensifying with walking
and physical activity, elevated body temperature to 39-400С during the week. On examination,
attention is drawn to the asymmetry of the gluteal regions. 1) What kind of disease should I think of? 2)
The most valuable method of diagnosis. 3) Method of treatment.

Problem No5

The 63-year-old patient complained of a prolapse of the rectum in the act of defecation and physical
exertion, he did not independently adjust himself, only with his hand. 1) Indicate the stage of the
disease. 2) Method of treatment.

Answers Problem No1

1) For a chronic anal fissure. 2) Finger research, examination with an anascope, rectal mirror,
sigmoidoscopy. 3) With hemorrhoids, a tumor of the rectum. 4) None.

Task No2

1) About chronic hemorrhoids. 2) II stage of the disease. 3) Surgical. 4) Operation Milligan-Morgan,

ligation of nodes with latex rings.

Task No3

1) T3NxM1. 2) Acute intestinal obstruction. 3) Sigmostomy.

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Task No4

1) Acute ischiorectal paraproctitis. 2) Finger examination of the rectum. 3) Dissection of the abscess with
a semilunar incision.

Problem No5
1) II stage. 2) Zerenin-Kymmell operation - fixation of the rectum wall to the anterior longitudinal
ligament of the spine.

10. Peritonitis Task No1 Patient L. turned 54 years in the admissions department of a surgical hospital
after 14 days from the moment of the disease. The disease developed against the background of
complete well-being with the appearance of pain in the epigastric region, then the pains moved to the
right iliac region, accompanied by nausea, dry mouth, with a single vomiting. She did not apply for
medical help, she was engaged in self-medication. After 10 days from the moment of the disease,
diarrhea joined up to 3-4 times a day, hyperthermia - 38.20C. Hospitalized in an infectious hospital
where a diagnosis of acute intestinal infection is suspected, therapy is started. Improvements in the
condition did not occur. It is directed to a surgeon's consultation. State of moderate severity. Рs - 88 in 1
min., АД - 130/80 mm Hg. Art. In the right iliac region, a morbid tumor-like formation with dimensions
of 8.0x8.0x6.0 cm of a densely elastic consistency is determined. Symptoms of irritation of the
peritoneum are negative. Leukocytes of blood - 12,0х109 / l, shift of the leukocyte formula to the left.
The patient is hospitalized in the surgical department, prescribed analgesics, antibacterial therapy. At
night, intense pains all over the stomach arose. When examined - the abdomen is sharply painful and
tense in all departments, the symptom of Shtutkin-Blumberg is positive.

1) Your diagnosis. 2) What mistakes are made by an infectious disease doctor? 3) What are the
diagnostic errors made by the surgeon? 4) What tactical errors are admitted by the surgeon? 5) What
treatment tactics should be chosen?

Task No2

Patient A., 43, suffering from duodenal ulcer, felt intense pain in the upper abdomen. He asked for
medical help. Surveyed by a surgeon, a survey was conducted.

26th

Performed: radiography of the abdominal cavity for free gas, ultrasound of the abdominal cavity, blood
and urine analysis. Pathology is not revealed. The diagnosis is an exacerbation of duodenal ulcer. It is
directed to treatment to the gastroenterologist. Antiulcer therapy is prescribed. Short-term
improvement of the condition. The remaining pain syndrome, fever to 38.20C, nausea and vomiting
made the patient again, on the 3rd day after the onset of the disease, go to the surgeon. The condition
is heavy. Skin and visible mucous pale color. P - 124 in 1 min. AD - 90/60 mm Hg. The tongue is dry. The
abdomen is upset. In the act of breathing does not take part. At palpation painful and strained in all
departments. Positive symptomThe abdomen is upset. In the act of breathing does not take part. At
palpation painful and strained in all departments. Positive symptom Shtutkin - Blumberg throughout the
abdomen. Percutaneous liver stupidity is absent, tympanitis is determined, dullness in gentle places.
When auscultation, pathological intestinal noises are heard - "the noise of a falling drop".

1) Your diagnosis. 2) What examination was necessary for the patient to be carried out at the primary

address to the surgeon? 3) What other research methods could be used for

the establishment of the correct diagnosis during primary treatment? 4) What is the treatment tactic?

Task No3
On the operation of the patient, M. 53 years, operated in an emergency, the following changes were
identified. The parietal and visceral peritoneum is hyperemic, otchnaya, the loops of the small intestine
are considerably overfilled with gas and liquid contents, covered with fibrin overlays, in the abdominal
cavity in all sections of about 500.0 ml. purulent - fibrinous effusion. The appendix is altered
gangrenosum, at the apex there is a perforation up to 0.5 cm in diameter, between the loops of the
small intestine three interintestinal abscesses of 50.0 ml of pus were found.

1) Your intraoperative diagnosis. 2) What tactics should a surgeon choose? 3) What should be used for
decompression of the intestine? 4) In what way is it necessary to complete the operation?

Task No4

The patient was taken to the department with complaints of hernial protrusion and pain in the right
inguinal region, delay of gases and stool. He got sick acutely, about 8 hours ago, when acute pains
appeared in the epigastrium, there was a single vomiting. Within 6 years suffering a right-sided inguinal
and scrotal hernia. From the earlier surgical treatment refused. For 10 years peptic ulcer of the
duodenum. The last aggravation is a month ago. It was treated out-patient. At an extract, according to
EGDS, - an ulcer in a stage

27th

scarring. The patient's condition is difficult. The skin is pale. Pulse - 124 per minute. Blood pressure -
95/60 mm Hg The tongue is coated with a white bloom. The abdomen does not participate in breathing,
is tense, sharply painful in all departments, the symptom of Shchetkin-Blumberg is positive. Intestinal
noises are greatly weakened. In the right ileal region there is a hernial protrusion 8x7x6 cm, strained,
sharply painful on palpation, not directed into the abdominal cavity. 1) Is your presumptive diagnosis? 2)
What research should be done to confirm it? 3) What kind of treatment will you offer the patient? 4)
Does the clinical picture correspond to the nature of the pathology you are suggesting?

Task No5 A 36-year-old patient was taken to a surgical hospital complaining of constant, gradually
increasing pains in the lower abdomen, which arose among a patient in full health 8 hours ago.
Objectively: a moderate abdominal distension is defined, a spoiled soreness in the lower parts, a
moderate tension of the muscles of the anterior abdominal wall. Doubtful symptom of Shtutkin -
Blumberg. Pulse - 100 per minute. Leukocytosis - 15,0х109 / l. 1) Your diagnosis. 2) Survey plan to
confirm the diagnosis. 3) Treatment plan.

Answers Problem No1

1) Acute destructive appendicitis, appendicular abscess with

breakthrough into the free abdominal cavity. 2) Poorly collected anamnesis of the disease, no
consultation

the surgeon. 3) Upon admission, an ultrasound of the abdominal cavity is not performed, not performed

CT scan. 4) In the case of the diagnosis of an appendicular abscess, the patient is shown prompt surgery
in an emergency order - opening and draining the abscess extraperitoneously. 5) Surgical treatment.

Task No2
1) Covered perforated ulcer of duodenum. Peritonitis. 2) Perform EGDS followed by a repeated X-ray

abdominal cavity to free gas. 3) Diagnostic laparoscopy.

28

4) Given the presence of three-day peritonitis and a violation of hemodynamic indicators, it is necessary
to conduct preoperative preparation and urgently operate the patient.

Task No3

1) Acute gangrenous - perforated appendicitis. Distributed purulent - fibrinous peritonitis. Multiple

abscesses of the abdominal cavity. 2) Appendectomy, sanation and drainage of the abdominal cavity. 3)
Nasointestinal intubation. 4) Laparostomy, program laparosanation.

Task No4

1) Perforated ulcer of duodenum, diffuse peritonitis. 2) Review of the radiography of the abdominal
cavity. 3) Surgical treatment: laparotomy, revision of abdominal organs, suturing perforative ulcers,
sanation of the abdominal cavity, drainage. 4) The clinical picture corresponds to a perforated ulcer.

The cause of the error in diagnosis can serve as a "hernia of Broca", i.e. a false infringement of the
inguinal and scrotal hernia, which is present in the patient.

Problem No5

1) Peritonitis. 2) A general analysis of blood and urine, an overview radiograph of the abdominal
organs, a consultation with a gynecologist, ultrasound of the abdominal cavity organs, and if
necessary, laparoscopy. 3) When confirming the diagnosis - surgery - laparotomy.

11. Diseases of the breast

A patient of 35 years complains of reddening and tightening of the nipple. Upon examination, the
nipple and part of the halo is covered with damp crusts and scabbards, during which the wet, grainy
surface is detected. The nipple is thickened and dense to the touch. Regional lymph nodes without
pathology.

1) What disease did you suspect of the patient? 2) How to clarify the diagnosis? 3) How to treat a
patient?

29

Task No2 A woman of 28 years complains about the presence of education in the left axillary region,
which becomes denser and slightly painful during the menstrual cycle. The formation of a rounded
shape with a diameter of 4 cm, soft-elastic consistency, is lobed.

1) What can be diagnosed? 2) What should I do?

Task No3

In a nursing woman, 4 weeks after birth, stitching pains appeared in the mammary gland. The gland
increased in volume. The next day the temperature rose to 39 ° C, there was a headache, a sense of
weakness, lost appetite, feeding with the left breast became painful. On examination, it was found
that the left gland is enlarged in volume, there is lymphangitis. With palpation, the whole gland is
painful, dense, but neither local infiltrates, nor areas of fluctuations are determined.

1) Your diagnosis. 2) What is the tactic of treating the patient?

Task No4 A woman of 30 years is diagnosed: "Right breast cancer IIb stage."

1) How to treat a patient?

Task No5 A woman of 30 years, never pregnant, had a painful sensation in the mammary glands,
intensified before menstruation. The glands began to swell, and from the nipples there appeared a
discharge of gray-green color. The mammary glands had a roughly lobed structure, and in the upper-
outer quadrant of the gland a fine granularity was found. After the monthly pain, the sensations
decreased noticeably, and then appeared again before the menstrual period.

1) What can be diagnosed? 2) How to treat a patient?

thirty

Answers Task No1 1) Paget's Cancer. 2) Imprint from a wet surface on a cytological examination.

Mammography. 3) Upon confirmation of the diagnosis - radical mastectomy followed by

radiation therapy.

TaskNo2 1) Additional mammary gland. 2) The operation is shown - removal of the given formation
with the subsequent

histological examination.

TaskNo3 1) Lactostasis. Lactogenic panmastitis in the infiltration stage. 2) Expressing the milk with
the help of a breast pump, application of heparin, troxyvasin ointment, UHF or EHF. According to the
indications - antibacterial therapy simultaneously with antifungal drugs.

Task No 4 1) Conduct preoperative radiotherapy with subsequent surgical treatment (radical

mastectomy). After a study with the definition of the hormonal profile to decide the question of
hormone therapy. Preventive courses of chemotherapy.

TaskNo5 1) Diffuse fibrocystic mastopathy. 2) Treatment conservative (microdoses of iodine,

vitamins A, B, E, histogens

with hyperestrogenemia).

12. Diseases of the thyroid gland Task No1

The patient, operated six months ago about thyrotoxic goiter, came to the hospital with complaints
about weakness, drowsiness, loss of strength, progressive weight gain (30 kg). During the
examination, attention was drawn to pastoznost, puffiness of the face, dryness and roughness of the
skin. Thyroid gland is not enlarged. Postoperative scar in good condition. TTG - 30mE.

31
1) What happened to the patient? 2) How should it be treated?

Task No2

At the patient 51 years 15 years ago the nodal euthyroid struma in the size of 3 × 3 cm was
diagnosed. All the years the education did not cause her any anxiety. Over the past 3 months,
education has doubled. When palpation, the surface of the formation is uneven, the consistence is
dense. Education is limited in mobility. The lymph nodes along the left nerve muscle are enlarged
and dense.

1) What is your diagnosis? 2) How can I confirm it? 3) How will you treat the patient?

Task No3

The patient, operated for a diffuse goiter with symptoms of thyrotoxicosis of moderate severity, the
next day after the operation, paresthesia appeared in the area of the fingertips, a feeling of
crawling. Then there was a symptom of "midwifery hand", pain in the muscles of the forearm.

1) What state should I think about? 2) How can I clarify your assumption? 3) How can a patient be
helped?

Task No4

AboutThe 36-year-old patient found a tumor-like formation on the front surface of the neck. He
does not make any complaints. Education appeared 5 years ago, when the patient lived in the North
Caucasus, and it gradually increases slowly. On ultrasound - a solid education in the left lobe - 8 × 7
cm. When examined, the patient has good nutrition. Pulse 78 per minute. Heart tones are clear. In
the left lobe of the thyroid gland is determined by eye and palpation of the oval shape, dense
consistency formation with a smooth surface, size 10 × 8 cm, painless, mobile when swallowed. Eye
symptoms are not expressed. T4 - 1.0; T3 - 1.5; TTG - 2.0.

1) Your diagnosis. 2) Tactics of treatment.

Task No5 At the evening round, your attention was drawn to the patient, who in the morning was
made thyroidectomy about thyrotoxic goiter. The patient

32

complained of weakness, bursting pain in the left side of the neck, difficulty swallowing. When
removing the dressing, a significant asymmetry of the neck was determined due to the pronounced
swelling of its left half, a soft consistency. When pressing on it in the area of the graduate appeared
a small bloody discharge.

1) What complication arose in the patient and why? 2) What kind of help should the patient
provide?

Answers Task No1 1) The patient developed late severe postoperative hypothyroidism. 2)
Replacement hormone therapy (L - thyroxine or eutiroksom), starting with small doses, gradually
increasing under the control of TSH to a normal level of hormones.
Task No2 1) Thyroid cancer with metastases to the regional lymph nodes on the left. 2) Execution of
fine needle aspiration puncture under control

Ultrasound followed by cytological examination. 3) Operation - thyroidectomy in the extrafascial

version in combination with

Krail's operation on the left.

Task No3 1) Early postoperative hypoparathyroidism 2) Determine the level of parathyroid hormone
and calcium in the blood. 3) During the period of muscle spasms, enter into / in the calcium solution,
AT-10, starting from 5 drops, 2 times per os and increasing the dose until stabilization. Calcium D3
nikomed per os in the afternoon - 2 tablets.

Task No4 1) Nodal euthyroid goiter IIIst (confirm the diagnosis with cytological

study of the TAB biopsy). 2) Operation - hemithyroidectomy in the subfascial version.

Task No5 1) Postoperative bleeding. 2) In the operating room under endotracheal anesthesia,
dissolve the seams, inspect the wound and stop the bleeding.

33

13. Diseases of the veins Problem No1

The patient of 48 years has addressed to the doctor with complaints to sensation of gravity,
completeness in legs, fast their fatigability at long standing or walking. These phenomena quickly
pass after the patient assumes a horizontal position. Sick for 11 years. The examination revealed a
sharp widening of the superficial veins of the left shin and thigh with pronounced pigmentation and
trophic disorders of the skin in the distal parts of the limb. In the same place, there is pastility and
small swelling. 1) Your presumptive diagnosis. 2) What functional tests should be performed? 3)
What special methods of research can clarify the diagnosis? 4) Treatment.

Task No2

The 42-year-old patient complained of pain along the course of varicose veins along the medial
surface of the upper third of the right tibia, the lower and middle thirds of the thigh, general
malaise, an increase in temperature to 37.6 ° C. The second day is sick. The process began after a
bruised abdomen and quickly spreads upward. Varicose veins are 18 years old. On examination:
pronounced varicose veins of the system of a large saphenous vein without signs of trophic
disorders, hyperemia and swelling along the veins, palpation - increase in skin temperature and
painful compaction all over. 1) Formulate a detailed diagnosis. 2) What is the danger of complication
and does it represent a threat to the patient's life? 3) What should be the tactics of a polyclinic
surgeon and on-duty surgeon of a hospital upon receipt of such a patient?

Task No3

A 62-year-old patient who has suffered a thrombosis of the femoral vein on the right has a strong
persistent edema and an enlargement of the suprapubic veins. Trophic disorders of the soft tissues
of the limbs are not noted. In antegrade phlebography, postthrombotic occlusion of the iliac and
femoral veins was found above the saphenous-femoral anastomosis and below it. 1) Your
presumptive diagnosis. 2) Tactics of treatment.

34

Task No4

A young woman turned to a vascular surgeon, who developed varicose veins on her right leg against
an uncomplicated pregnancy. The surgeon found that the deep veins of the right shin are passable,
there is a lack of perforating veins in its lower third. At a palpation veins soft, painless, the skin over
them is not changed. Based on the clinical situation, what should the patient recommend?

Problem No5

A patient of 48 years old with acute thrombophlebitis of the left lower limb, who is on treatment in
the hospital and who does not observe strict bed rest, suddenly on a background of complete well-
being there appeared sharp pains behind the sternum, shortness of breath, lack of air, dizziness. 1)
What diagnosis can I put a patient? 2) What is the tactic of treatment?

Answers Task No1 1) Varicose disease of the left lower limb in the stage of trophic disorders. 2)
Trials of Brody-Troyanov-Trendelenburg, Pratt and Sheinis. 3) Phlebography, duplex scanning of
vessels of the lower extremities. 4) Radical operation. Combined phlebectomy.

Task No2 1) Varicose disease. Acute thrombophlebitis of superficial veins. 2) In the rapid growth of
thrombosis in the proximal direction and the threat of pulmonary embolism.

3) The surgeon of the clinic should immediately hospitalize the patient, and the on-duty surgeon of
the hospital - execute the Troyanov-Trendelenburg operation in an emergency.

Task No3 1) Post-thrombotic disease. Varicose form, stage I. 2) Surgical treatment - cross bypass
large hidden vein of the other side above the bosom (Operation Palma).

35

Task No4 1) Wearing elastic bandages; operation phlebectomy in the postpartum period.

Task No5 1) Thromboembolism of the pulmonary artery. 2) Emergency therapy of pulmonary

thromboembolism in conditions of resuscitation, thrombolytic therapy.

14. Diseases of arteries Problem No1

A patient of 60 years turned to the doctor with complaints of intense pain in the right lower leg at
rest and worse with walking. These phenomena appeared suddenly 2 months ago and gradually
progressed. When examined, it was found that the skin of the right foot is ivory, it feels colder than
the left. The symptom of "plantar ischemia" is positive. The pulse on the popliteal artery and below
is not determined. 1) Your presumptive diagnosis. 2) Tactics of management of the patient. 3)
Options for possible treatment tactics in the hospital.

Task No2
A day after the onset of the disease, a 53-year-old patient was taken to the waiting room. At
admission I complained of severe pain in the left leg of a constant nature, which suddenly appeared
against the background of relative well-being. State of moderate severity. Skin integuments of the
left foot and lower leg to the level of the upper third are pale, cold to the touch, with a "marble
pattern." There is no swelling, active movements in the joints of the fingers are preserved, pulsation
on the popliteal and arteries of the foot is absent. From the anamnesis of life it is known that the
patient had a myocardial infarction about a year ago, there is atrial fibrillation. 1) Your presumptive
diagnosis. 2) What, in your opinion, could be the cause of this disease? 3) How will you treat the
patient?

Task No3

A 26-year-old patient complained of intermittent claudication after 150 meters, cold extremities,
paresthesia of feet, baldness of the shins.

36

He is sick for 6 months, before he suffered a nervous shock, smokes a lot. At the examination, the
pulse on the femoral and popliteal arteries is somewhat weakened, the noise is not listened. The
Oppel test is 30 seconds. The test of Lenennedo - Lavastin - 18 seconds. Reoindex - 0.5. On
thermograms - thermal "amputation" of toes. On the angiogram - stenosis of the distal parts of the
arteries of the lower leg. 1) Your presumptive diagnosis. 2) Plan for additional research. 3) Tactics of
treatment.

Task No4

In a 67-year-old patient with hypertensive disease, a tumor-shaped formation in the mesogastrium

was found on the left with dimensions of 12x10x7 cm, dense to the touch, immobile, pulsating. 1)
The presence of what disease can be assumed in the patient? 2) What additional methods of
research can the patient do? 3) Your medical tactics.

Problem No5

A patient arrives with atherosclerotic gangrene of the foot with spreading of the edema to the lower
leg, up to the knee joint. Gangrene is wet and accompanied by pronounced endotoxicosis. The
patient has several serious concomitant diseases of the cardiovascular and respiratory system, in the
anamnesis of two myocardial infarctions. Diabetes mellitus moderate.

1) Your tactics?

Answers Task No1 1) Atherosclerotic thrombosis at the femoral artery level. 2) Urgent
hospitalization is necessary in the department of vascular surgery. 3) After examination using
Doppler and angiography, surgical treatment: thrombectomy or shunting.

Task No2 1) The patient has a clinical picture of thromboembolism of the femoral artery, stage II
ischemia. 2) Postinfarction cardiosclerosis, atrial fibrillation. 3) An emergency operation is indicated
- thrombectomy.

37
Task No3

1) Obliterating endarteritis, one hundred

About Google TranslateCommunityMobileTask No3

1) Obliterating endarteritis of stage II. 2) Dopplerography, radionuclide study of microcirculation. 3)

Treatment conservative: regimen, spasmolytic mixtures, quantum therapy to improve
microcirculatory processes, cessation of smoking.

Task No4

1) Aneurysm of the abdominal aorta. 2) To confirm the diagnosis, it is advisable to perform

ultrasound, and then - aortography. 3) When confirming the diagnosis, surgical treatment is shown -
resection of an aneurysm with prosthetics.

Problem No5

1) An urgent amputation of the middle or lower third of the thigh is shown after minimal
therapeutic preparation.

II. Urology 1. Methods of research. Task No1.

A 52-year-old patient went to see a urologist with complaints about the discharge of brown semen
during sexual intercourse. In a laboratory study, hemospermia was detected. -the reason for
hemospermia is the doctor's tactics in this case

Task No2. In the urological department, a woman of 35 years with complaints of paroxysmal pain in
the right lumbar region, accompanied by nausea, vomiting and frequent urge to urinate. In the
survey image of the urinary tract, at the level of the transverse process of the 4th lumbar vertebrae,
the shadow is suspicious on the stone, oval in size 0.5 * 0.5 cm-which additional radiographic
examinations must be performed to establish the nature of the detected shadow.

38

Task No3. The patient has 60 years of painless macrogematuria with vermicular clots of blood. With
cystoscopy, the mucosa of the bladder is normal, and blood is isolated from the mouth of the left
ureter. In the overview radiograph of the urinary tract, the contours of the kidneys are not
determined, there are no shadows of suspicious stones on the projection of the urinary tract.
Excretory urograms of pathological changes in the projection of the cup-and-pelvic system were not
revealed. Passage of contrast medium in the ureters is not violated. -What disease first of all it is
necessary to think, and what X-ray examinations should be performed to establish the diagnosis.

Task No4. A 32-year-old patient has a typical picture of right-sided renal colic. On the radiograph of
the urinary system in the projection of the lower third of the right ureter, a shadow of a stone
measuring 0.8 * 0.4 cm is determined. After the injection of 5 mg of baralgina IV and a warm bath,
the pain subsided, but after 30 minutes they resumed again. The blockade of the round ligament of
the uterus was made according to Lorin-Einstein. The pain subsided for a short time, and then
resumed again. The patient is restless, assumes various positions, groans, asks for help. -What
should be done to stop renal colic.
Task No5.

A patient of 44 years suffering from a stone of the lower third of the left ureter, 6 hours ago there
was an attack of left-sided renal colic, the body temperature increased to 38.4 C, and there was a
tremendous chill. The abdomen is painful in the left hypochondrium, the painful lower pole of the
left kidney is palpable. On the survey X-ray of the urinary system in the projection of the juxtavezic
section of the left ureter, the shadow of the stone is determined by the dimensions 0.5 * 0.4cm. -
which conservative method of treatment will allow us to hope for relief of acute pyelonephritis.

Answers Task No1. Hemospermia can be a consequence of inflammatory or neoplastic processes in

the prostatic urethra. Required

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finger prostate examination and instrumental examination - urethroscopy.

Task No2. The patient needs to produce excretory urography, with the help of which it is possible to
find out the expansion of the cup-and-pelvis system to the right.

Task No3. In the first place, one should think about the tumor of the left kidney. To establish the
diagnosis, ultrasound should be performed as a "screening test," and then a computer, magnetic
resonance, or multispiral tomography to determine the prevalence of the processes.

Task No4. Renal colic in the patient is due to a violation of the outflow of urine from the right kidney
and an increase in intra-local pressure. The reason for this is the stone in the lower third of the
ureter. Taking into account the low efficiency of earlier performed measures, the right ureter is
catheterized with the catheter beak being proximal to the calculus.

Task No 5. The patient is shown a catheterization of the left kidney pelvis with the subsequent
administration of antibiotics and the conduct of detoxification therapy.

2. Trauma of the urogenital system. Task No1.

The 34-year-old was taken to the clinic for pain of the left lumbar region, which arose after the fall
and contusion of the left lumbar region. From the anamnesis it is known that after the injury there
was twice a macrohematuria. The patient's condition is satisfactory. Pulse and blood pressure are
normal. From the side of the chest and abdominal organs there are no pathological changes. There
is a slight swelling in the left lumbar region. - Your preliminary diagnosis.

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Task No2. A 25-year-old patient was taken to the clinic for pain in the right lumbar region, a
hematuria with clots. From anamnesis it is known that an hour ago he was struck in the right lumbar
region. The position of the patient is compulsory: there is a pronounced left-sided scoliosis, a
swelling in the right lumbar region is determined. Pulse 105 beats per minute. Arterial pressure
85/50 mm / Hg. There are no signs of irritation of the peritoneum. Free fluid in the abdominal cavity
is not determined. On excretory urograms, the left kidney is of the usual size, the cup-and-pelvic
system is not changed. Passage of radiopaque substance on the ureter is not violated. On the right,
the contrast substance in the projection of the kidney and urinary tract is not determined -your
diagnosis is a medical tactic
Task No3. A 35-year-old patient entered the clinic for pain in the suprapubic region, ishuria. From
the anamnesis it is known that 3 hours ago, being in a state of intoxication, received a blow to the
suprapubic region. The attempt to perform an independent urination was unsuccessful. The
situation of the patient is compulsory. Sits, bending, holding his hands in the lower abdomen. There
is a symptom of "vanka-vstanka". When rectal examination, there is an overhanging of the anterior
wall of the rectum. A free liquid is detected in the abdomen. -your preliminary diagnosis-diagnostic
and therapeutic tactics.

Task No4. The patient is diagnosed with an extraperitoneal rupture of the bladder. -cure tactics

Task No5. A 42-year-old patient entered the clinic for urethrorrhagia. From the anamnesis it is
known that an hour ago he fell on the construction site, hit the crotch on the board. -your
preliminary diagnosis

Task No6. The 42-year-old is in the trauma department, where he was hospitalized 2 hours ago for
fractures of the pelvic bones. Derived from

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state of shock. The enlarged bladder is palpable, it is not wet on its own, there is urethrorrhagia. -
Your diagnostic tactics.

Answers Task No1. From the anamnesis it is known that the patient had a trauma to the left lumbar
region, after which there appeared a repeated macrogematuria. In addition, there is swelling in the
left lumbar region. These circumstances give the doctor an opportunity to suspect a kidney damage.
To address the nature of changes in the kidney, it is necessary to perform excretory urography,
which will allow to establish the conditions of the contralateral kidney and, possibly, will reveal the
flow of contrast medium beyond the cup-and-pelvis system.

Task No2. The anamnesis, the objective data allow to suspect damage of the right kidney. There are
signs of bleeding from the kidney, which led to lower blood pressure and increased heart rate. Only
the nature of the damage is unclear. The patient is shown surgery - lumbootomy on the right,
revision of the kidney, stopping bleeding. The operation is performed according to vital indications -
bleeding. The nature of the operational benefit on the kidney will be resolved during surgery /
organ-preserving or organ-carrying operation.

Task No3. The pain above the bosom that has arisen after the injury, the patient's forced position,
the presence of the "vanka-vstanka" symptom, the hanging of the anterior wall of the rectum, the
free fluid in the abdominal cavity, make it possible to suspect an intraperitoneal rupture of the
bladder. Cystography is shown, which will reveal the leakage of radiocontrast beyond the bladder,
which is an indisputable sign of its damage. An urgent operation is shown: laparotomy, suturing of
the bladder rupture, epicystostomy.

Task No4. Extraperitoneal rupture of the bladder is an indication for the operation of cystostomy,
revision of the bladder, closure of the rupture, drainage of the pelvic fat by Buyalsky-McWarther.

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Task No5. The fall on the perineum with subsequent urethrorrhagia allows one to suspect a rupture
of the bulbous urethra. It is necessary to produce urethrography.

Task No6. Urethrorrhagia, absence of independent urination allow one to suspect damage to the
urethra in a patient with a fracture of the pelvic bones. Need urethrography.

3. Urolithiasis. Task No1. A patient of 65 years complains of urge to urinate when walking and jolting
riding. Sometimes there is an interruption of the urine stream during urination. -your presumptive
diagnosis-what kind of studies do you propose to conduct to clarify the diagnosis-what kind of
therapy do you offer

Task No2. A 37-year-old patient suddenly had acute pain in the right lumbar region, radiating to the
thigh: restless behavior, rapid urination. In the anamnesis of urine, fresh red blood cells. your37
years suddenly there was a sharp pain in the right lumbar region, radiating to the thigh: behavior
restless, urination rapid. In the anamnesis of urine, fresh red blood cells. -your presumptive
diagnosis-what kind of studies do you propose to conduct to clarify the diagnosis-what kind of
therapy do you offer.

Task No3.

In a patient 40 years old, within 3 days, pain in the lower back on the left, accompanied by an
increase in body temperature to 39-40 degrees. With chills, pyuria. From the anamnesis it is known
that a stone was found a year ago in the upper third of the left ureter, measuring 3.0 by 1.0 cm.
They offered surgical treatment, which the patient refused. -your presumptive diagnosis-what kind
of studies do you propose to conduct to clarify the diagnosis-what kind of therapy do you offer.

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Task No4. In a patient of 48 years with excretory urography, there is a defect in filling in the pelvis of
the left kidney-what additional methods of investigation should be performed to clarify the
diagnosis.

Task No5. A 28-year-old patient has a shade in the projection of the middle part of the right ureter,
suspicious of the calculus. A few days ago he suffered an attack of acute pain in the lower back to
the right-your presumptive diagnosis-what kind of research is needed to determine the nature of
the shadow.

Answers Task No1. You can assume the stone of the bladder. To clarify the diagnosis, ultrasound,
cystoscopy and pelvic x-ray are advisable. They will allow to reveal the X-ray negative concrement
and establish the presence of prostatic hyperplasia or another obstacle to the outflow of urine.
When a stone of the bladder is found, cystolithotripsy is indicated, when combined with prostate
hyperplasia or sclerosis of the wall of the bladder - cystolithotomy with adenomectomy or wedge-
shaped resection of the bladder neck, as these diseases, causing difficulty urinating, promote stone
formation

Task No2. Renal colic on the right. To clarify the diagnosis, it is advisable to perform an ultrasound
examination and a survey image of the urinary tract. With ultrasound, a stone in the kidney, a
dilatation of the pelvic-locomotor system when it is located in the pelvis, a dilatation of the
overlying urinary tracts with a ureteral stone: a panoramic image of the urinary system in the
projection of the kidney or ureter to the right can be detected X-ray positive calculus. When
confirming the diagnosis, a hot bath, intravenous and intramuscular injection of 5ml of baralgina is
indicated.

Task No3. Acute left-sided calculous pyelonephritis. To clarify the diagnosis it is necessary:
ultrasound of the kidneys, a survey of the urinary system, excretory

44

Urography. When the diagnosis is confirmed, urgent surgery is indicated - ureterolithotomy,

nephrostomy on the left, followed by anti-inflammatory therapy.

Task No4. For the purpose of differential diagnosis of an X-ray negative calculus, a tumor of the left
kidney and a blood clot in it, it is necessary to perform ultrasound of the left kidney.

Task No5. MKB, the stone of the middle third of the right ureter, excretory urography is necessary.

4. Prostate adenoma. Oncourology. Task No1.

A 65-year-old patient complained of strong urge to urinate, the inability to self-urinate, and the pain
in the lower abdomen. These symptoms increase within 14 hours. - presumptive diagnosis -
diagnostic and treatment recommendations.

Task No2. A patient of 70 years complains of weakness, headache, nausea, vomiting, involuntary
discharge of urine from the urethra drop by drop. The skin is pale, the tongue is dry, covered with a
brown coating. The abdomen is soft, the kidneys are not palpable, the symptom of Pasternatsky is
negative on both sides. The percussion of the bladder is determined at 6 cm above the bosom. The
prostate gland is uniformly enlarged, of a densely-elastic consistency, its surface is smooth, the
interlobar groove is smoothed. Urea of blood serum 18 mg / l -pre-positive diagnosis-treatment Task
No3. The on-duty urologist who had just completed an emergency operation, 2 hours and 30
minutes from the reception room, was informed that a patient with painless total hematuria had
acted.

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-what should be the tactics of the urologist, the urgency of the diagnostic and treatment
procedures.

Task No4. In a 52-year-old patient in the right hypochondrium, a balloting formation measuring 10 *
8 cm with a dense, tubercular surface is palpable. When percussion over education tympanitis. The
data of excretory urography do not allow to exclude with certainty the disease of the right kidney. -
which methods of examination will confirm or exclude urological diseases.

Answers Task No1. Given the patient's advanced age, one can think of an acute urinary retention
caused by hyperplasia / adenoma / prostate. It is advisable to take blood for the study of a prostatic
specific antigen. Perform a transabdominal ultrasound. After digital examination of the prostate, a
catheterization of the bladder is indicated. In the absence of renal failure, excretory urography with
descending cystography is necessary. Further - preparation of the patient for adenomectomy.
Task No2. Involuntary excretion of urine in a crowded bladder, and enlargement of the prostate
gland are a manifestation of paradoxical ishuria, characteristic of prostate adenoma of stage 3. This
stage is accompanied by the phenomena of renal failure: anemia, electrolyte disorders, intoxication,
which manifests itself in this patient with weakness, nausea, headache. The patient is shown
cystostomy with subsequent detoxification therapy, correction of electrolyte disorders and
preparation for a possible subsequent stage of treatment - adenomectomy.

Task No3. Total hematuria is observed in diseases of the kidneys and bladder. The most common
cause of total hematuria is the tumor of the urinary system. Hematuria once emerged, may not
subsequently recur. Therefore, at the time of hematuria, it is important to find out the source of
bleeding, so that in the subsequent examination,

46

attention to the affected organ. To identify the source of bleeding at the time of hematuria,
absolute cystoscopy is indicated.

Task No4. The presence of a bumpy tumor, a positive symptom of balloting and tympanitis over the
formation indicate the localization of the process in the retroperitoneal space. Tympanitis with
percussion is due to the presence of intestinal gases in the ascending section and the hepatic angle
of the large intestine. If percussion over education was blunted, one should think about localization
of the process in the abdominal cavity. It is necessary to exclude kidney tumor. To establish the
diagnosis and determine the tactics of treatment are shown: ultrasound scanning, computer or MR-
tomography, spiral computed tomography with 3D reconstruction, vascular examination of the
kidneys, echodopplerography.

5. Pyelonephritis. Nephrogenic arterial hypertension. Task No1. A patient of 35 years entered the
clinic with complaints of pain in the lumbar region, an increase in body temperature to 39 degrees C,
a chill. The second day is sick. Correct physique. Body temperature 39 deg. Pulse 100 beats per
minute, rhythmic, satisfactory filling. In the lungs, vesicular breathing. The tongue is dry, not coated.
The abdomen is soft. Pasternatsky's symptom is positive on the left. There is no dysuria.
Microhematuria, leukocyturia. When ultrasound is observed, the dilation of the pelvic-locomotor
system is left. The mobility of the left kidney is limited. The ultrasound picture of the right kidney is
not changed. In the survey image of the urinary system, at the level of the transverse process 3 on
the left - a shadow suspicious on the calculus, measuring 9 * 4 mm. Excretory urograms of
pathological formations in the cup-and-pelvic system of the right kidney are absent. Passage of the
contrast medium on the ureter is not violated. Left moderate pyeloectasia. Expansion of the ureter
is proximal to the above described shadow of the calculus. In the case of polypositional urography,
the shadow of the calculus coincides with the ureteral shadow performed by the contrast medium. -
Your diagnosis? -What are the therapeutic measures shown?

Task No2. A patient of 40 years old entered the clinic complaining of dull pain in the lumbar region
to the right, sometimes a rise in body temperature to 37.4; the release of turbid urine, increased
blood pressure to

47
180/115 mm RT Art. Repeatedly she was on examination and treatment in urological hospitals about
chronic pyelonephritis. Correct physique. Pulse 96 beats / min rhythmic, intense blood pressure
180/110 mm RT st. Heart sounds are deaf, the accent of the second tone on the aorta. The abdomen
is soft. Pasternatsky's symptom is positive on the right. At times, dysuria, leukocyturia. With
ultrasound, attention is drawn to the decrease in the size of the right kidney /8.0 * 4.0 cm /, its
outlines are uneven. The left kidney is 11.0 * 5.0 cm in size with an even contour. In a survey of the
urinary system in the projection of the urinary tract, shadows of concrements have not been
revealed. Contours of the kidneys

are not clearly defined. Excretory urograms of pathological changes in the cup-pelvis system and
ureter were not revealed on the left. On the right the kidney is 8 * 4 cm bean-shaped with an
uneven contour. The cups are deformed in places, of a kolboid shape. On the aortograms, the
arterial vessels of the right kidney are narrowed, in places the avascular areas, a positive symptom
of the charred tree: -your diagnosis? - What is the treatment tactic?

Task No3. A patient of 30 years was taken to a hospital with a diagnosis of acute pyelonephritis. It is
sick for 2 days. He noted pain in the lumbar region to the right, an increase in body temperature to
38.7 degrees, was a chill. To the doctor did not address. When examined, the condition is of
moderate severity, the skin is hyperemic. Pulse is 108 beats per minute. The tongue is dry, coated
with a whitish coating. The abdomen is soft. The kidneys are not palpable. Pasternatsky's symptom
is positive on the right. Leukocytosis. Leukocyturia. On a survey photograph of the urinary system of
shadows, concrements have not been revealed. The contour of the lumbar muscle on the right and
the shadow of the right kidney are not determined. -What diagnostic measures will allow to confirm
the diagnosis of acute pyelonephritis?

Task No4. The patient was admitted to the clinic for 30 years complaining of an increase in arterial
pressure to 190/120 mm RT of the body, is sick after a contusion of the lumbar region. Within a year
I was unsuccessfully treated in a therapeutic hospital. Pulse 80 beats per minute rhythmic, intense.
Heart sounds are deaf. Accent of the second tone on the aorta. The kidneys are not palpable.
Pasternatsky's symptom is negative on both sides. When auscultation of the projection of the renal
vessels on the anterior wall of the abdomen - a rough systolic noise. There is no dysuria. - Your
preliminary diagnosis?

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-What research needs to be done to clarify the diagnosis?

Task No5. A patient of 32 years complains of pain in the lumbar region, an increase in blood
pressure to 180/120 mm RT Art. The patient is 3 years old. Pulse 80 in min. rhythmic, satisfactory
filling. The abdomen is soft, the kidneys are not palpable. Pasternatsky's symptom is weakly positive
on the right. In the vertical position of the body, the lower segment of the right kidney is palpable.
There is no dysuria. Occasionally, the hematuria. - Your preliminary diagnosis? -plan survey.

Answers Task No1. Stone of the left ureter. Acute obstructive left-sided pyelonephritis.
Catheterization of the left ureter. In the case of an insurmountable obstacle / stone of the ureter /
operation of puncture nephrostomy is indicated. After restoration of the outflow of urine from the
left kidney, the appointment of antibacterial anti-inflammatory treatment.
Task No2. Chronic pyelonephritis, wrinkled right kidney, nephrogenic hypertension. -Guides,
anamnesis and examination data indicate the terminal stage of chronic pyelonephritis on the right,
which shows the nephrectomy on the right.

Task No3. Ultrasonography of the kidneys - dilatation of the pelvic-locomotor system on the right,
limiting the mobility of the right kidney. Excretory urography - due to the absence of contrast agent
isolation from the patient side, the presence of a dumb kidney, the presence of Lichtenberg's
symptom and the immobility of the diseased kidney during respiratory movements / urography on
inhalation and exhalation. Computer tomography of the kidneys will reveal the cause of the absence
of kidney function.

49

Task No4. The patient's young age, high blood pressure, a small difference between systolic and
diastolic pressures, a disease associated with a lumbar injury, possibly perirenal hematoma,
followed by the organization and sclerotherapy of paranephric fiber, and the failure of
antihypertensive therapy suggest nephrogenic arterial hypertension. To clarify the diagnosis, it is
necessary investigate blood pressure in the horizontal, vertical positions of the patient's body, after
physical exertion ki, as well as to conduct a survey urorentgenovskoe / urography, renal vascular
studies /.

Task No5. Nephroptosis on the right, nephrogenic hypertension. To clarify the diagnosis shows
excretory urography, aortography in the horizontal and vertical position of the patient's body

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