1. Autoimmune thyroiditis. Hypothyroidism, moderate (manifest), decompensated.

2. The diagnosis of “primary hypothyroidism” was established on the basis of the patient’s complaints: fatigue, memory loss, drowsiness, chilliness, constipation, weight gain, hearing loss, hoarseness. The severity of hypothyroidism based on the detailed

clinical picture of the disease. An increase in the thyroid gland, an increase in the level of anti-TPO, indicating an autoimmune process – autoimmune thyroiditis.

3. The patient is recommended to undergo an ultrasound of the thyroid gland to clarify the size, echogenicity of the tissue and its vascularization, scintigraphy of the thyroid gland.

4. Replacement therapy with thyroid hormones (L-thyroxine). In patients younger than 55 years old who do not have cardiovascular diseases, L-thyroxine is prescribed at a dose of 1.6-1.8 mcg / kg of body weight. Treatment begins with a full dose of drugs. The approximate initial dose for men is 100 mcg / day.

5. It is necessary to increase the dose of L-thyroxine by 25 mcg.

Case study 191 [K000429]


Main part

A 52-year-old woman consulted a general practitioner with complaints of persistent dry mouth, thirst, frequent urination, general weakness, and skin itching.

He considers himself ill for six months, when dry mouth and thirst appeared. A week ago, a skin itch appeared, which made me see a doctor.

Works as a cook in a children’s institution. In history – 5 years of chronic pancreatitis. Mom suffered from diabetes.

On examination: the condition is satisfactory. BMI – 36 kg / m2. Waist circumference – 106 cm, hip circumference – 109 cm. The skin is clean, there are scratch marks on the hands. Vesicular breathing in the lungs, no wheezing.

Heart sounds are rhythmic. Heart rate – 70 beats per minute. BP – 120/70 mm Hg. Art. The abdomen is soft, painless on palpation in all departments. The liver and spleen are not enlarged. no dysuria

In the analyzes: fasting blood glucose – 5.8 mmol / l, total cholesterol – 6.1 mmol / l, TG – 2.7 mmol / l, HDL-C – 1.0 mmol / l.


1. Suggest the most likely diagnosis.

2. Make a plan for additional examination of the patient.

3. As a result of the study, it was found that the patient’s fasting blood glucose was 6.1 mmol/l, 2 hours after taking 75 g of glucose – 11.1 mmol/l; HbA1c – 7.1%. Prescribe treatment. Justify your choice.

4. Give the patient nutritional advice.

5. After 6 months, the patient again came to see the doctor. As a result of the therapy, the patient’s weight decreased by 6 kg. HbA1c decreased by 0.5% and the individual goal was achieved. What is your next treatment strategy? Justify your choice.


1. Diabetes mellitus type 2, HbA1c target < 7.0%. Obesity 2 degrees. Hyperlipidemia (metabolic syndrome).

2. Repeated determination of glycemia in the following days, oral glucose tolerance test, determination of HbA1c.

3. The patient has grade 2 obesity and baseline HbA1c = 7.1%. Recommended lifestyle changes: diet, physical activity. Monotherapy: Metformin, and DPP-4 or GLP-1 aGLP.

4. Restriction of caloric content of the diet is recommended for the purpose of moderate weight loss. This will also provide a positive effect on glycemic

control, lipids. The maximum restriction of fats (primarily of animal origin) and sugars is necessary; moderate consumption of complex carbohydrates (starch) and proteins is recommended. Recommend the use of carbohydrates in the composition of vegetables, whole grains, dairy products. It is important to include mono-rich foods in your diet.

– and polyunsaturated fatty acids (fish, vegetable oil).

5. Leave ongoing therapy unchanged, as there is a decrease in body weight and the target level of HbA1c is reached. Continue dynamic monitoring. HbA1c control 1 time in 3 months. Self-monitoring of glycemia with a glucometer.

Case study 192 [K000430]


Main part

A 51-year-old man consulted a district general practitioner complaining of dryness, thirst, polyuria, and blurred vision.

Sick for 2 years. Didn’t follow the diet. Self-monitoring of glycemia was not carried out. At night I took Metformin 500 mg.

On examination: satisfactory condition, BMI – 26 kg/m2. Skin of normal color. Vesicular breathing in the lungs, no wheezing, respiratory rate – 16. Heart sounds are rhythmic, muffled, accent II tone over the projection of the aorta. Heart rate – 70 beats per minute, blood pressure – 160/100 mm Hg. Art. The abdomen is soft, painless on palpation in all departments. The liver and spleen are not enlarged. The symptom of tapping in the lumbar region is negative.

An oculist examination revealed non-proliferative retinopathy in the right eye. In the analyzes: fasting glycemia – 9.0 mmol / l, postprandial – 12 mmol / l. Total cholesterol – 6.9 mmol/l, TG – 2.7 mmol/l, HDL-C – 1.0 mmol/l; creatinine – 101 ┬Ámol/l, GFR (according to the CKD-EPI formula) – 70.8 ml/min; albuminuria – 100 mg / day.


1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

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

4. Which group of drugs would you recommend for a patient to correct hyperglycemia? Justify your choice.

5. What group of antihypertensive drugs would you recommend to a patient as part of combination therapy? Justify your choice.

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