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I. Passport data

1. FULL NAME:
2. Age:
3. Married
4. Address:
5. pensioner
6. Receipt date:

II.  Anamnesis

1) Complaints of the patient upon admission to the clinic

A) Main complaints about:

 Pain during urination of a cutting nature, passing after urination;

 aching pains in the bladder, arising from the urge to urinate;
 frequent daytime urination up to 20 times;
 frequent nighttime urination up to 6 times.

B) Minor complaints about:

 general weakness;
 irritability.

2) Complaints of the patient at the time of supervision (December 2, 2010).

 aching pains in the bladder, arising from the urge to urinate;

 frequent daytime urination up to 8 times;
 frequent nighttime urination up to 4 times.

    III.  History of the present disease

    Considers herself ill since 2003, when she became very cold at work. There
were pains during urination of a cutting nature, frequent urination during the day
and at night. She turned to a therapist, underwent a course of antibiotic treatment,
the names of which she does not remember. Since 2003, she underwent treatment
once a year in the autumn or winter months with a therapist regarding the
appearance of the same complaints. In November 2007, after hypothermia, pain
reappeared during urination of a cutting nature, frequent urination during the day
and at night. Was sent for inpatient treatment at the urological clinic. Discharged
with recovery.

    In November 2010, while walking on the street, she underwent general
hypothermia. From November 20, pains appeared during urination of a cutting
nature, frequent daytime urination up to 20 times and nighttime up to 10 times,
then pains appeared in the suprapubic region with the urge to urinate. She was
treated with herbal tea with lemon and honey, and did not notice any improvement
in her condition after these procedures.

    On November 22, she turned to the  local therapist with these complaints. The
doctor referred the patient to  laboratory research. After the obtained test results, on
November 29, the patient again came to the appointment, the doctor, based on the
results of laboratory tests and clinical data, sent for inpatient treatment at the
urological clinic.

    1. Past diseases.

    As a child, she often suffered from sore throats up to 4 times a year.

    In 1980 she underwent an appendectomy operation.

    Now he has colds every 2 years.

    She did not suffer from sexually transmitted diseases. I was not in contact with
infectious patients. Tuberculosis, viral hepatitis denies. Hemotransfusions were not
performed, she was not a donor.

    2. Heredity.

    Heredity is not burdened.

    3. Allergic history. 

    The patient has no intolerance to drugs or food.

    IV.  Life story

    She was born in 1946. At the age of 7 she went to school, she did not lag behind
her peers in mental and physical development. Graduated from 10 classes. Since
1963 she has been working as a controller for 25 years at the factory, has no
occupational hazards. From 1993 to 2005 she worked at the Gorpechat kiosk.
    Menstruation from 13 years old, regular, not abundant, painless. Climax at 47
years old. Pregnancy - 2, childbirth - 2.

    She is married, has two children (healthy).

    Currently he lives in a  comfortable apartment with all the necessary

amenities. The food is good, complete and regular.

    Bad habits: does not smoke, does not use alcohol and drugs.

    V. The present state of the patient.

    1) General examination of the patient.

    The general condition is satisfactory. The patient's position is active.

    Consciousness is clear. The facial expression does not represent any painful

processes.

    The physique is correct. Normosthenic type of constitution. Height 165 cm,

weight 68 kg. BMI = 25. Subcutaneous adipose tissue is moderately developed (the
thickness of the skin fold on the abdomen at the level of the navel is 3 cm), evenly
distributed.

    The skin is pink in color, moderate moisture and elasticity. Turgor of soft tissues
is normal. Hair, nails are in good condition.

    Visible mucous membranes of normal moisture, pink color.

    Peripheral lymph nodes (submandibular, cervical, supraclavicular, subclavian,

axillary, inguinal) are not visible on examination. On palpation, submandibular
lymph nodes of the size of a pea, elastic consistency, painless, not welded to the
surrounding tissues are determined. Other groups of lymph nodes are not palpable.

    The development of the muscular system is satisfactory, the tone is normal, there
is no pain on palpation of the muscles. Muscle strength is satisfactory, there are no
contractures, asymmetry of individual muscle groups.

    The joints are of the correct configuration, painless. Active and passive

movements in full.

    VI. Respiratory organs.

    The shape of the nose is not changed.

    Nasal breathing is free.

    The rib cage is of the correct configuration, without deformation,
symmetrical. The breathing type is mixed. Breathing is rhythmic. Respiratory rate
18 in 1 minute. Respiratory movements of both sides of the chest are medium in
depth, uniform and symmetrical. The auxiliary muscles are not involved in the act
of breathing.

    The chest is painless. The elasticity of the chest is normal. The voice shake is the
same on both sides.

    Lung percussion:

    With comparative percussion of the lungs, a clear sound comes to light.

    Topographic percussion data:

    Standing height of the tops:

    Front: on the right - 2 cm above the level of the clavicle,

                      on the left - 2 cm above the level of the clavicle

    Behind: at the level of the spinous process of the VII cervical vertebra

    Kroenig's margin width: 4.5 cm on the right, 5 cm on the left.

    Lower boundaries of the lungs:

Topographic lines On right Left

Okologosdinnaya VI intercostal space -

Midclavicular VI rib -

Anterior axillary VII rib VII rib

Medium axillary VIII rib VIII rib

Posterior axillary IX rib IX rib

Scapular X edge X edge

Paravertebral Spinous process of the XI thoracic vertebra Spinous process of the XI thoracic vertebra

Mobility of the lower edges of the lungs (in cm):

Topographic line On right Left

Scapular 3 3 6 3 3 6
 

    Lung auscultation:

    On auscultation over the lungs, vesicular respiration is

determined. Bronchophonia is not changed, the same on both sides.

    Vii.  The cardiovascular system

    The region of the heart is not changed. The apical impulse is not visualized or
palpable.

    Cardiac impulse and epigastric pulsation are not detected. The pulsation of the
jugular veins and carotid arteries is not detected.

    Heart percussion:

    The boundaries of the relative dullness of the heart:

    right - 1 cm outward from the right edge of the sternum in the IV intercostal
space

    upper - at the level of the lower edge of the III rib along the left peristernal line

    left - 1 cm medially from the midclavicular line in the V intercostal space

    The diameter of the relative dullness of the heart: 12 (cm). The configuration of

the heart has not been changed.

    The boundaries of the absolute dullness of the heart:

    right-left edge of the sternum in the IV intercostal space;

    upper - at the level of the IV rib along the peristernal line

    left - 2 cm medially from the midclavicular line in the V intercostal space

    The diameter of the absolute dullness of the heart: 6 cm.

    The width of the vascular bundle is 5 cm.

    On auscultation, heart sounds are rhythmic, muffled. Heart rate 70 beats per
minute. The rhythm of the heartbeats is correct.

    The pulse on the radial arteries is 70 beats per minute, synchronous, rhythmic,
satisfactory filling and tension, normal value, even, the same on both arms.

    Blood pressure on the left hand 110/70 mm Hg. Art.

    BP on the right hand 110/70 mm Hg. Art.

    VIII.  The gastrointestinal tract.

    There is no smell from the mouth. The mucous membrane of the oral cavity is
pink in color, the tonsils are not enlarged. Gums pale pink. Tongue pink, moist,
clean, well-defined papillae.

    The abdomen is not enlarged. Dilated saphenous veins, striae and hernial

formations are absent. The muscles of the abdominal wall are evenly involved in
the act of breathing. With percussion of the abdomen, a tympanic sound is
determined.

    On superficial palpation, the abdomen is soft, painless. The symptom of

peritoneal irritation is negative.

    The sigmoid colon is palpable in the left iliac region, cylindrical in shape, dense
elastic consistency, smooth, mobile, painful.

    The rest of the colon is not palpable. By the method of ascult-affriction,

the  lower border of the stomach is determined 3 cm above the navel.

    The lesser curvature of the stomach and the pylorus are not palpable.

    The pancreas is not palpable.

    Protrusions, deformities in the liver are not detected.

    Sizes of hepatic dullness according to Kurlov:

    along the midclavicular line - 10 cm,

    along the midline of the body - 8 cm,

    along the left costal arch-7 cm.

    The liver is palpated 1 cm below the edge of the right costal arch on a deep
breath, the edge of the liver is soft, even, rounded, painless.
    The gallbladder is not palpable.

    The spleen is not palpable.

IX.  The urinary system.

    When examining the kidney area, pathological changes are not detected. The
kidneys are not palpable. Pasternatsky's symptom is negative on both sides.

    Local pain is observed on palpation of the bladder. The ureteral points are

painless. With percussion, dullness is determined 2 cm above the pubis above the
overflowing bladder.

    Reproductive system: no features.

    X. Neuropsychic environment.

    Consciousness is clear. Mood is good. Dermographism is pink. No

paralysis. Visual acuity and hearing are reduced.

    XI.  Preliminary diagnosis: Chronic cystitis.

    XII.  Laboratory and additional research methods

General blood analysis:

Index Meaning Norm

Hb 122 g / l 120-140 g / l

ESR 14 mm / h 2-15 mm / h

Leu 4.2 × 10 9 / l 4 × 10 9 - 7.5 × 10 9 / l

stab neutrophils 1% 16 %

segmented neutrophils 56% 45 - 70%

eosinophils 1% 2 - 5%

monocytes 7% 4 - 9%

lymphocytes 33% 20 - 40%

    UAC indicators correspond to the norm

    General urine analysis:

Index Meaning Norm
Colour Straw yellow from straw yellow to amber yellow

transparency Transparent urine urine is clear

protein 0,066 ‰ 0,033 ‰

erythrocytes 2-3 in sight 0-1 in sight

leukocytes 7-14-25 in sight 0-1 in sight

    According to OAM: proteinuria, hematuria, leukocyturia.

Urine analysis according to Nechiporenko:

leukocytes 4000 in 1 ml Up to 4000 in 1 ml

erythrocytes 0 in 1 ml Up to 1000 in 1 ml

According to the analysis of urine according to Nechiporenko: all indicators are

normal.

    Wasserman reaction: negative

    Ultrasound conclusion:

    Kidneys. On the left, single small cystic formations, one of them 15 mm.

    XIII.  The final diagnosis and its rationale: Chronic cystitis.

    The diagnosis of Chronic cystitis is based on:

 complaints: intense pain during urination of a cutting nature, passing after

urination; aching pains in the bladder, arising from the urge to
urinate; frequent daytime urination up to 20 times; frequent nighttime
urination up to 6 times.
 anamnestic data: connection of the onset of the disease with hypothermia,
since 2003 the diagnosis of chronic cystitis has been made for the first
time;
 objective research data: pain on palpation of the bladder;
 laboratory test results: presence of protein in urine, leukocyturia,
hematuria.

XIV.  Differential diagnosis:

Symptoms of the Cystitis Bladder tuberculosis Bladder cancer
disease

Pain Intense in the area of the Pain in the bladder and lumbar Persistent, not
bladder, aggravated by region associated with
urination and passing after it urination

Violation of Day and night pollakiuria Dysuria difficult to respond to Dysuria

urination (dysuria) antibiotic therapy

Urine changes Leukocyturia, hematuria Hematuria Hematuria

OAM data Leukocyturia, hematuria, Acid reaction, presence of Tumor cells are
protein and urine sediment tuberculous  mycobacteria present in urine
sediment

Chromocystoscopy Not performed (extremely Tuberculous tubercles, ulcers, Tumor

painful) scars

    XV.  Etiology and pathogenesis.

    Cystitis refers to a  polyetiological disease, to which numerous factors

predispose. The causative agents of cystitis are usually Escherichia coli,
Staphylococcus aureus, Proteus, Streptococcus, viruses, fungi. Anatomical and
topographic features of the genitourinary tract play an important role in the
development of cystitis in women.

    In this patient, microorganisms most likely entered the bladder along the
ascending pathway along the urethra. The transfer of infection into the bladder
occurs due to the turbulent flow of urine during urination. Chronic cystitis can
cause the development of an inflammatory process in the kidneys (due to reflux).

    For the occurrence of cystitis, in addition to pathogenic microflora, additional

predisposing factors are required. The most significant of them are: impaired blood
circulation in the wall of the bladder and small pelvis, impaired emptying of the
bladder, and a decrease in the body's resistance to infection.

    XVI.  Treatment

Mode: general
o
o Meals: ATS table. Eliminates spicy, irritating dishes, spices. Milk -
sour diet, cranberry juice, jelly are recommended.
o Drug treatment:
 Cefogram 1.0 g 2 times a day.
 Furagin 0.1 g 3 times a day.
o Nomycin 400 mg 2 times a day.
o Furadonin 100 mg 3 times a day.
 o Urotol
o Fetolysin
o Spazmolin 2.5 g once a day.
o Diclofenac suppositories for the night.
o Instillation into the bladder:

0.25% silver nitrate solution 40 ml alternating with sea buckthorn oil every other
day.

    XVII.  Patient observation diary.

    2.12.10. The condition is satisfactory. Consciousness is clear. Body temperature:

◦ 
morning-36.5  C. Daytime diuresis - 8 times, nighttime - 4 times The patient
complains of slight pain in the suprapubic region. Palpation of this area reveals
soreness. The patient notes that the pain during urination persisted, but became less
intense. Prescribed: KLA, biochemical blood test, OAM, urine analysis according
to Nechiporenko. He receives treatment according to the scheme.

    3.12.10 . The condition is satisfactory. Body temperature: morning-36.7  ◦ C.

Daytime diuresis - 8 times, nighttime - 3 times The patient complains of slight pain
in the suprapubic region. Palpation of this area reveals soreness.

    6.12.10 . The condition is satisfactory. Consciousness is clear. Body

◦ 
temperature: morning -36.1  C. HELL 130/90 mm Hg. Daytime diuresis - 6
times, night - 3 times. The patient complains of mild pain in the suprapubic
region. Palpation of this area reveals soreness. Prescribed: KLA, biochemical
blood test, OAM, urine analysis according to Nechiporenko.

    XVIII.  Epicrisis

    Patient Maksimova N.F., born in 1946, was admitted to the urological

department on November 29, 2010 in a planned manner with complaints of pain in
the lower abdomen, increased frequency and pain during urination. Was diagnosed
with chronic cystitis. In the course of treatment, there is a positive trend:
normalization of the frequency of urination, a decrease in the intensity of
pain. Currently, the patient's condition is satisfactory. The observation of the
patient was discontinued due to the end of the supervision.

    The prognosis for the life and working capacity of the patient is favorable