A 4-year-old girl named Jessica began wetting the bed again after 3 months of being dry. She cried when urinating and seemed crabby and tired. Her mother recognized these as signs of a urinary tract infection. The nurse practitioner diagnosed cystitis based on a urine sample and prescribed antibiotics. The nurse also referred Jessica to a urologist who discovered she has vesicoureteral reflux.

1. Case 6 CLASS 1
Jessica Peyton, age 4, began wetting her bed again after being dry at night for the past 3
months. She cried when she urinated and was crabby and lethargic. Jessica’s mother had seen
these signs before, and recognized them as manifestations of yet another urinary tract
infection. She took Jessica to a pediatric nurse practitioner who had just opened an office
nearby. After taking a thorough health history, the nurse practitioner obtained a urine sample,
diagnosed cystitis, and prescribed an antibiotic. She also referred Jessica to a urologist, who
discovered that Jessica has vesicoureteral reflux.
1. What findings in the urine sample would be characteristic of cystitis?
2. Why would a urinary tract infection cause Jessica to develop nocturnal enuresis?
3. Why did the nurse practitioner suspect that Jessica had vesicoureteral reflux?
4. Explain what vesicoureteral reflux is.
5. Why does vesicoureteral reflux predispose to urinary tract infection?
Case 7 CLASS 2
A 58-year-old obese woman with hypertension, type 2 diabetes, and chronic kidney disease is
admitted to hospital after a right femoral neck fracture sustained in a fall. Recently, she has
been complaining of fatigue and was started on epoetin alfa subcutaneous injections. Her
other medications include an angiotensin-converting enzyme inhibitor, a β-blocker, a diuretic,
calcium supplementation, and insulin. On review of systems, she reports mild tingling in her
lower extremities. On examination, her blood pressure is 148/60 mm Hg. She is oriented and
able to answer questions appropriately. There is no evidence of jugular venous distention or
pericardial friction rub. Her lungs are clear, and her right lower extremity is in Buck traction
in preparation for surgery. Asterixis is absent.
Questions
A. Describe the pathogenesis of bone disease in chronic kidney disease. How could this
explain her increased likelihood of sustaining a fracture after a fall?
B. Why was erythropoietin therapy initiated?
C. What is the significance of a pericardial friction rub in the setting of chronic kidney
disease?
Case # 1 IWST
A 52-year-old patient M. who has suffered from chronic glomerulonephritis for 12 years
visits his physician with complaints of recently appeared symptoms of drowsiness in the day
time and difficulty falling asleep at night, fatigability, apathy, sensation of fullness in the
retrosternal and epigastric regions, nausea, diarrhea, and itching of the skin. On examination:
blood pressure is 165/95 mm Hg, the area of the cardiac dullness is increased to the left,
pericardial friction rub over the whole area of the heart during auscultation. 24-h Diuresis is
450 ml
Laboratory data:

2. Questions:
1. Find abnormalities in laboratory data
2. Explain pathogenesis of the abnormalities in laboratory data
3. Define the pathology, stage of the pathology
4. Explain pathogenesis of pericardial friction rub
CASE# 1. IWS. A 19-year-old young man complains of decreased libido and potency, poor
facial hair growth, increase in the mammary glands. Objectively: height= 185 cm, BMI=23
kg/m2, eunuchoid body proportions, bilateral gynecomastia. Poor hair growth on the face,
body pubes hair growth on the female type. The penis is without pathology, turgor of the
scrotum is reduced, pigmentation is absent, testicular hypoplasia. Preliminary diagnosis:
Congenital hypogonadotropic hypogonadism. Kleinfelter Syndrome
Questions
1.What investigations are needed to confirm the diagnosis?
2. Offer the methods of treatment.