Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course
DEPARTMENT OF FACULTY THERAPY
Head department professor x
Lecturer Associate Professor x
Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.
Start of supervision: 02.21.2003.
End of supervision: 26.02. 2003.
Date of receipt : 02/18/03
The diagnosis with which he was sent to the clinic: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, stage II activity.
Preliminary diagnosis: Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.
Clinical diagnosis : Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.
At the time of supervision: complaints of mild pain in the metacarpophalangeal, wrist, knee and shoulder joints, painful limitation of mobility and a slight increase in skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness.
Upon admission: aching pain in the metacarpophalangeal, wrist, knee and shoulder joints, which occurs not only during movement, but also at rest; severe painful limitation of mobility and increased skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness; loss of appetite, dizziness.
History of present illness:
He considers himself sick since 1999, when he first experienced sharp pain in the left wrist and metacarpophalangeal joints of both hands, short-term stiffness in these joints, and noted general malaise. The occurrence of pain is associated with working conditions - constant hypothermia and dampness. He was hospitalized at the Central District Hospital of Asekeyevsky District, where he was diagnosed with rheumatoid arthritis. After 2 weeks of treatment (diclofenac, cannot indicate the dosage), the pain subsided. After being discharged from the clinic, I began to notice that the joints began to react to changes in the weather, and pain occurred in spring and autumn. In the spring of 2000, swelling and pain appeared in the shoulder and knee joints. The regional clinic sent him to the Regional Clinical Hospital, where he was prescribed prednisolone tablet. within one month, physiotherapeutic treatment. Joint pain disappeared and mobility increased. Spring 2001 was sent for spa treatment to a sanatorium in Pyatigorsk. 02/18/03 readmitted to the rheumatology department of the Regional Clinical Hospital due to an exacerbation of the disease: aching pain in the metacarpophalangeal, wrist, knee and shoulder joints, which occurs not only during movement, but also at rest; severe painful limitation of mobility and increased skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness; loss of appetite, dizziness.
Born in ***, the third child in the family, he grew up and developed according to his age. He did not lag behind his peers in physical and mental development. I went to school at the age of 7, studied satisfactorily, and was involved in physical education in the main group. After graduating from school, he was drafted into the army and the navy. Married, has one child (daughter). Denies childhood diseases (measles, rubella, scarlet fever, diphtheria). Notes a hereditary predisposition to joint diseases: the mother had joint pain. There is a reaction to the administration of nicotinic acid - skin rash, ulcers on the mucous membranes. Denies tuberculosis, hepatitis, malaria, and sexually transmitted diseases. There were no blood transfusions. I have not traveled outside the region for the last 6 months. Bad habits: does not smoke, drinks alcohol in limited quantities. Living conditions are satisfactory, meals are regular.
The patient's condition is satisfactory, consciousness is clear, the position in bed is active, the patient is accessible to contact. The physique is normosthenic. The patient's appearance corresponds to age and gender. Height 164 cm, weight 64 kg. The skin is dry, clean, the color of the skin is pale, the elasticity of the skin is preserved, the visible mucous membranes are pink and moist. Limitation of movement in the wrist, metacarpophalangeal, shoulder, knee joints. Synovitis of the wrist, metacarpophalangeal joints of both hands: swelling, increased skin temperature over the joint area, pain on palpation. There are no rashes, scratches, petechiae, or scars. Male pattern hair growth. Hair splits. The nail plates are of the correct shape, the nails are brittle, the nail plates do not peel off. Subcutaneous fatty tissue is moderately expressed and evenly distributed. There is no edema or acrocyanosis.
Examination by organ systems:
Respiratory system
The nose is not deformed, breathing through the nose is free. The chest is cylindrical in shape, the collarbones are at the same level, the ribs run obliquely downwards, the intercostal spaces do not bulge or sink. Both halves of the chest evenly participate in the act of breathing and produce vocal tremor. Respiratory rate 16 per minute. Percussion above the pulmonary fields is a clear pulmonary sound. There are no local sound changes. Topographic percussion data: standing height of the apexes of the lungs - in front - 3 cm on both sides, in the back - at the level of the spinous process of the 7th cervical vertebra. The width of the Kernig margins is 5 cm on both sides. Mobility of the lower edge of the lungs along the midclavicular line is 5 cm on both sides. Vesicular breathing, no wheezing, no pleural friction noise.
The lower borders of the lungs.
Right Landmarks Left
6th intercostal space parasternal line
6th intercostal space midclavicular line
7th intercostal space anterior axillary line 7th intercostal space
8th intercostal space mid-axillary line 8th -\-\-\-\\-\-\\\-\
9th intercostal space posterior axillary line 9th -\-\-\-\-\-\-\-\
10th intercostal space scapular line 10th -\-\-\-\-\\-\-\-
11th intercostal space paravertebral line 11th -\-\-\-\\-\-\-\
The heart area is not changed. There is no pathological pulsation of blood vessels. There is no cyanosis, peripheral edema, or shortness of breath.
The pulse is rhythmic, blood pressure in the right arm is 110/70 mm. Hg Art., on the left 110/70 mm. Hg Art. The pulsation of the vessels of the lower extremities is symmetrical and good. Apical impulse in the 5th intercostal space on the left, medially from l. medioclavicularis sinistra by 1 cm, width 1.5 cm, moderate strength and height.
Limits of relative cardiac dullness:
2nd intercostal space - along the edge of the sternum
2nd intercostal space – edge of the sternum
3rd intercostal space - 1 cm outward from the right edge of the sternum
3rd intercostal space - 1 cm from the edge of the sternum to the left
4th intercostal space - 1.5 cm outward from the right edge of the sternum
4th intercostal space –1.5 cm from the edge
right sternum left
5th intercostal space –2 cm from the edge of the sternum to the left
Limits of absolute cardiac dullness
Right – 4th intercostal space 1 cm from the sternum on the left.
Left - 5th intercostal space 2.5 cm from the sternum on the left.
Upper – along the upper edge of the 4th rib along the parasternal line
Digestive system
Pink lips. The oral mucosa is clean, moist, pink. The tongue is moist, slightly coated with a white coating at the root. The abdomen is of normal shape and size, evenly participates in the act of breathing, is soft, painless, and accessible to deep palpation. There is no ascites or visceroptosis. The sigmoid colon is palpated in the form of a dense cylinder, 2 cm wide, painless. The cecum is palpated in the form of a soft cylinder, 3 cm wide, painless. The transverse colon is palpated 2 cm below the navel in the form of a soft cylinder, 3 cm wide, painless. The edge of the liver is smooth, elastic in consistency, painless. The dimensions of the liver according to Kurlov are 10 x 8 x 7 cm. Palpation of the points of the gallbladder is painless. The stool, according to the patient, is filled once a day.
The kidneys are not palpable. The points of the kidneys and urinary tract are painless. There is no pain when tapping the lumbar region. Urine is light yellow in color and transparent. Urination is free, painless, 5-6 times a day. Daily diuresis is about 1200 ml. Doesn't urinate at night.
Hematopoietic organ system
There are no hemorrhages or hemorrhagic rash on the skin. The mucous membranes are pale pink. Lymph nodes are not enlarged. The spleen is not palpable; percussion is determined from the IX to the XI rib along l. axillaris media sinistra. Tapping the flat bones is painless.
Dimensions of the spleen according to Kurlov: diameter 4 cm, length 6 cm.
Height 164 cm, weight 64 kg. Hairline corresponds to gender. General development is appropriate for age. The face is round, pale. Subcutaneous tissue is moderately developed and evenly distributed. Upon examination, the contours of the neck are smooth. The thyroid gland is not enlarged. There is no tremor of the hands, tongue, or eyelids.
Musculoskeletal system Restriction of movement in the wrist, metacarpophalangeal, shoulder, and knee joints. There is a crunch in these joints when moving; morning stiffness until lunchtime. Synovitis of the wrist, metacarpophalangeal joints of both hands: swelling, increased skin temperature over the joint area, pain on palpation.
central nervous system
The patient is sociable and emotionally labile. Speech is clear, attention is maintained. Pain sensitivity is not reduced. There are no paresis or paralysis. Intelligence is average. Insomnia due to severe joint pain. The patient treats the disease adequately and easily comes into contact. Pulse 62 per minute. Muscle strength is age appropriate. Sweating during physical activity. There are no pathological symptoms.
Rheumatoid arthritis is mainly common among the female population
Russian scientists have conducted a lot of research to study rheumatoid arthritis in order to better understand where the pathology came from and what is the reason for its progression among the elderly and young population of the country.
Rheumatoid arthritis is a degenerative process of connective tissue of joints, ranking second among similar pathologies. This disease is a problem for humanity because it prevents the musculoskeletal system from performing proper functions. The disease prevents a person from living fully and enjoying life. Rheumatoid arthritis can last for years, attacking the immune system. Having studied the statistical data, you can see that rheumatoid arthritis is more common among the female population. The essence is the body’s destruction of its own cells, organs and tissues, for no reason. The only indicator is the high production of autoantibodies and lymphocytes.
The etiology of rheumatoid arthritis remains unclear to this day. Key research in search of the root cause of this pathology is carried out in the following directions: probable diseases of an infectious nature, disorders of the endocrine system, increased susceptibility to various environmental influences are studied, genetic factors and biochemical disorders are studied. A group of Russian and foreign scientists argue that the acutely infectious moment has significant weight in the etiology of the disease. There are several points of view regarding the etiology of this disease. The first group of researchers claims the origin of the disease is due to staphylococcal infection. The second group argues that a polyetiological process is involved here. Recently, there has been news confirming the role of streptococcal infection in the development of pathology. Domestic researchers claim that rheumatoid arthritis develops for the following reasons:
Risk factors that make you more susceptible to rheumatoid arthritis:
To study the course of rheumatoid arthritis in more detail, it is necessary to consider its pathogenesis.
Bacteria enter the human body through the respiratory tract, where the center of a chronic disease is formed. This center is the cause of continuous intoxication and increased sensitivity of the body to the penetration of bacteria. To date, the pathogenesis of the disease has not been fully studied.
There are three components involved in the development of the disease.
The pathogenesis of the disease involves antibodies that are not produced in a healthy person. The production of such antibodies indicates the body’s response to changes in cartilage tissue. Microbial intoxication, hypersensitivity and autosensitization have a huge impact on cellular nutrition, which ensures the preservation of the structure and function of cartilage tissue.
Changes in the adrenal cortex play an important role in the origin of the disease, this confirms that in its treatment it is necessary to use drugs containing hormones. The pathogenesis of the disease is associated with genetic predisposition. It is based on genetically determined autoimmune processes. As you can see, the pathogenesis is very complex. It includes the interconnection of cellular and molecular mechanisms, which ultimately influence degenerative changes in joints and the inflammatory process.
Rheumatoid arthritis begins with inflammation of the synovium, which becomes irreversible. This prolonged inflammation of the synovium contributes to the formation of pannus. Pannus is a synovial membrane that becomes thickened, on which outgrowths form during its degeneration. This stage of inflammation characterizes the initial manifestations of the disease.
As the disease progresses, tissue cartilage becomes deformed. The cartilage tissue is covered by granulation tissue, ranging from the processes of bone tissue resorption to the complete destruction of the cartilage.
Through granulation of cartilaginous tissue, joints begin to deform and joint dislocations occur. The ongoing degeneration of articular bones does not allow a person to live fully; small bone defects develop, characterizing the onset of the second stage of development of the disease.
Due to degenerative and inflammatory processes in the joints, ankylosis develops. That is, the joints become less mobile or become completely immobile. Due to the immobility of the joint, the tissue shell of the cartilage begins to degenerate, and in parallel with it, the connective bone and fibrous tissues grow.
The site of tissue scarring at any time may be subject to fibroid necrosis, as a result of which rheumatoid arthritis becomes chronic. A characteristic morphological manifestation of arthritis is rheumatoid nodes. They can form in both the central and outer parts of the cartilage. Rheumatoid nodes have different sizes, dense, large or small, which can only be recognized under a microscope.
There are classifications and diagnostic criteria that have been adopted in all countries. After making a diagnosis, the doctor must provide the patient with the nature of the disease, its characteristics, the stage of development of the disease and decide on treatment. It is quite difficult to determine rheumatoid arthritis, since many pathologies can occur simultaneously with rheumatoid arthritis and be confusing or have the same symptoms. The variety of clinical manifestations creates a serious obstacle in recognizing the disease. Therefore, research was carried out and the classifications, forms and types of rheumatoid arthritis were studied to make it easier for the doctor to determine the diagnosis and treatment.
Neutrophils play a special role in the development of the disease; they support the inflammatory process in the joints by reducing their content in the blood. When the course of the disease weakens, neutrophils are eliminated from the body, opening a new corridor for the development of Felty syndrome. It usually manifests itself 1–40 years after the onset of rheumatoid arthritis, with the average period of disease manifestation being 10–15 years.
Felty syndrome is a rare disease. It's also not that easy to detect. To diagnose the syndrome, it is necessary that the patient has symptoms of leukopenia and splenomegaly, both symptoms must be present, otherwise it will be impossible to identify it.
The second special clinical form is Still's disease. The etiology is still unknown. Still's disease is thought to develop due to viral and bacterial infections. An important sign of rheumatoid arthritis is joint damage, accompanied by fever and redness of the skin. Redness appears as a purple color in areas of greatest irritation.
The third form of arthritis is probable rheumatoid arthritis. This type of arthritis is diagnosed after testing for seronegativity and seropositivity.
Researchers identify four stages of disease development. Classification of stages:
Classification of degrees of activity of rheumatoid arthritis:
When rheumatoid arthritis is in remission, the patient is not bothered by joint pain and there is no morning stiffness.
A low degree of activity manifests itself in minor joint pain, short-term stiffness, ranging from half an hour to an hour. Stiffness appears after staying in one position, as well as after prolonged sleep. Patients claim that on a ten-point rating scale, pain with a low level of activity is 3 points.
The average degree of activity is characterized by longer-lasting stiffness. In some cases it can be up to 12 hours. Pain syndrome is present almost constantly, even in a state of complete rest. The joints swell and swell. A rise in body temperature is possible, but is rare at this stage.
A high degree of activity is accompanied by severe pain, pronounced exudative phenomena (swelling, edema, bursitis). The inflammatory process occurring in the internal organs reveals itself through fever and limited mobility. The joints begin to deform and change in appearance. Rheumatoid nodules appear.
Ministry of Health of the Russian Federation
Altai State Medical University
Department of Clinical Immunology and Allergology
Head department: prof. MD...
Curator: student of group 531 of the pediatric faculty...
Clinical history
Clinical diagnosis: Rheumatoid arthritis, articular form, degree I; seropositive; X-ray stage IIb, N.F.S. 2 tbsp.
Address: Barnaul
Place of work: pensioner
Supervision period: 3.12.08-5.12.08
Clinical diagnosis: Rheumatoid arthritis, articular form
The patient's complaints at the time of admission
1. pain that gets worse in the morning, limited mobility in small joints of the hands, feet (interphalangeal, metacarpophalangeal, radiocarpal, metatarsophalangeal, ankle), periodically in the shoulder, knee joints.
2. swelling in the area of small joints of the hands and feet.
3. morning stiffness in the joints until lunch.
4. severe general weakness, lethargy.
5. low-grade fever. At the time of supervision there are no complaints.
Considers himself sick since 2003, he became acutely ill. The first symptoms, swelling, pain, stiffness in the joints of both hands (interphalangeal, metacarpophalangeal), appeared in the morning. I consulted a therapist. He was referred for consultation to a rheumatologist. A diagnosis of polyarthritis was made. I received GCS according to the regimen (I don’t remember which ones exactly), methotrixate first intramuscularly, then per os. A good clinical effect was observed. Some time after the discontinuation of GCS, an exacerbation of the articular syndrome occurred, and the use of GCS was resumed. This treatment was carried out until January 2007, then he independently discontinued methotrixate and took GCS. In September 2007, my health worsened; pain, swelling, and stiffness appeared in the small joints of my feet. Consulted with a rheumatologist, it was recommended: Nise, delagil, prednisolone 15 mg per day, followed by a reduction in the maintenance dose. There was an improvement in health. After 4 months, he stopped delagil on his own (according to the patient, his vision deteriorated). In March 2008, his health worsened again. Consulted with a rheumatologist, recommended: sulfasalazine, corticosteroids, NSAIDs. I took sulfasalazine for 2 months, noted improvement, and then discontinued it on my own. In November 2008, the condition worsened again (pain suddenly appeared, first in the right hand, then in the left, and later the pain spread to the shoulder and elbow joints;) - he was hospitalized in the regional hospital.
Born in Magadan. The only child in the family. He grew and developed normally. Graduated from high school and college. Start of work at 24 years old. He worked as a teacher at the institute. Currently retired. Material and living conditions are satisfactory.
Denies tuberculosis and hepatitis. Suffers from chronic gastritis, sinusitis. There were no injuries or blood transfusions. Operations - tonsillectomy, maxillary sinusotomy in 1960. No allergies. Chronic intoxication: does not smoke, does not drink alcohol. Heredity is not burdened.
General condition of the patient: At the time of examination, satisfactory, position in bed is active, consciousness is clear, facial expression is concerned, there are no ocular symptoms. The behavior is normal, the physique is correct.
Skin and mucous membranes: Pale pink color. No cyanosis or icterus is observed. The skin is dry, tissue turgor and elasticity are reduced. The mucous membranes are clean, there is no icteric staining of the frenulum of the tongue and sclera. There is no swelling on the limbs or face.
Subcutaneous fatty tissue: moderately expressed.
Peripheral lymph nodes: not palpable.
Muscles: average degree of development, atrophic, painless, without compaction.
Osteoarticular apparatus: There is a slight curvature of the spine in the lumbar region. Joints without visible pathology. They are slightly painful on palpation. The range of active and passive movements is not limited in all planes.
Respiratory organs: respiratory rate - 20 per minute, regular rhythm, mixed type. Nasal breathing is not difficult. No pain is observed independently or with pressure and tapping at the tip of the nose, in the areas of the frontal sinuses and maxillary cavities. The larynx is of normal shape, palpation is painless. There is no pain when talking or swallowing. The right and left halves of the chest are symmetrical. Movement of both halves of the chest, synchronously, without lag. Palpation of the chest is painless. On palpation of the chest: vocal tremor is weakened, resistance is moderate. With comparative percussion of the lungs on symmetrical areas of the chest, the sound has a boxy tint.
Topographic percussion of the lungs: Lower border of the lungs:
Parasternal: 6 m/r.
Midclavicular: 7 m/r.
Before. axillary: 8 m/r. 8 m/r.
Avg. axillary: 9 m/r. 9 m/r.
Posterior axillary: 10 m/r. 10 m/r.
Scapular: 11 m/r. 11 m/r.
Paravertebral: 12 m/r. 12 m/r.
Mobility of the pulmonary edge: 3 cm.
On auscultation in symmetrical areas of the chest, breathing is weakened and vesicular.
Circulatory organs. Heart examination: When examining the heart area, no pathological pulsations were found. The apical impulse is localized in the 5th intercostal space 1.5 cm medially from the midclavicular line, S=2.0*1.5 cm, high, strong, resistant.
The limits of relative and absolute dullness of the heart are within normal limits.
Width of the vascular bundle: right - in the 2nd intercostal space along the right edge of the sternum, left - in the 2nd intercostal space along the left edge of the sternum.
The transverse size of the relative dullness of the heart is 3 + 8.5 = 11.5 cm, Botkin’s angle is obtuse.
Auscultation of the heart tones: clear, arrhythmic, no pathological noises were detected.
Vascular examination: Upon examination, no pathological pulsations were found. The walls of the arteries are smooth and elastic. Pulse: frequency 60 beats/min, irregular rhythm, high filling, hard, synchronous on both hands. There is no pulse deficiency, no pulsation is noted on the nail phalanges. Blood pressure is 130/70 in both arms. Auscultation of peripheral vessels did not reveal any pathological noises. The veins of the legs are unchanged.
Digestive organs: Lips pale pink, moist. The tongue is pink, of normal shape and size, the papillae are well defined. The mucous membrane of the tongue is moist, without visible defects. The gums are pink, there are no bleeding or defects. The pharynx is clean, not swollen, slightly reddish, the tonsils are not enlarged and do not protrude from behind the palatine arches. The teeth are permanent, the condition is satisfactory. The oral cavity has been sanitized. The salivary glands are not enlarged and painless. Appetite is good, no regurgitation or vomiting.
Inspection. The belly is of normal shape and symmetrical. Collaterals on the anterior surface of the abdomen and its lateral surfaces are not pronounced. There are no scars or other changes in the skin. The muscles of the abdominal wall are not involved in the act of breathing. No hernial protrusions were detected in the standing position.
Superficial indicative palpation. On superficial palpation there are no zones of skin hyperalgesia. There is no diastasis of the rectus abdominis muscles. The stomach is not tense. The Shchetkin-Blumberg symptom is negative.
Deep methodical sliding palpation according to Obraztsov-Strazhesko-Vasilenko revealed no pathology.
Percussion reveals intestinal tympanitis of varying severity, pain and no free fluid.
Auscultation. Intestinal motility is preserved, there are no pathological sounds.
Pancreas: not palpable.
Examination of the liver and gallbladder:
The gallbladder is not palpable, there is no pain on palpation at the point of the gallbladder, and it is not determined by percussion. Ortner's, Carvoisier's, and phrenicus symptoms are negative.
Liver. Palpated at the level of the edge of the costal arch. The edge is soft, sharp, painless. Dimensions according to Kurlov: 10*9*7 cm.
Spleen: Not palpable.
Stool once a day, shaped, brown.
Urinary organs: No complaints. The development of sexual characteristics I and II corresponds to age.
Kidney research. When examining the kidney area, no pathological changes were revealed. The kidneys are not palpable (in 3 positions), the palpated area is painless. The symptom of effleurage is negative. There is no pain on palpation along the ureters. Diuresis 3-4 times a day.
Nervous and endocrine system. The condition is satisfactory. No complaints. The patient is fully conscious. Intelligence corresponds to the level of development. Memory impairment and attention were not noted. The patient is in an even mood, reacts adequately to everything that surrounds him, is sociable, sociable, and has correct and developed speech. No pathological manifestations of the endocrine system were identified. The thyroid gland is not palpable. Percussion and auscultation revealed no pathological changes in the thyroid gland.
Preliminary diagnosis and its rationale
Based on the patient's complaints about:
- severe pain, aching in the joints (interphalangeal, wrist, elbow, shoulder, ankle, knee).
- swelling in the joint area.
- morning stiffness, we say that the osteoarticular system is involved in the pathological process.
Based on the medical history:
There were complaints of swelling and redness of the joints of the right hand. Then limited mobility appeared in these joints. A month later, pain and aching appeared in the joints of the other hand, elbow and shoulder joints. Then, within a month, similar symptoms appeared in the ankle and knee joints.
In the mornings, the patient felt stiffness in the joints and limited function. All this time the patient had a low-grade fever.
And also based on the diagnostic criteria for rheumatoid arthritis (American Rheumatological Association, 1987).
The diagnosis of rheumatoid arthritis is made when at least four of the following criteria are present:
- Morning stiffness for 1 hour or more, persisting for at least 6 weeks
- Increase in volume of three or more joints for at least 6 weeks
— Increased volume of the wrist, metacarpophalangeal and proximal interphalangeal joints for at least 6 weeks
- Symmetry of joint damage
— Typical changes revealed by x-rays of the hands: erosion of the articular surfaces and osteoporosis
— The presence of rheumatoid factor in the serum, a preliminary diagnosis can be made:
Rheumatoid arthritis with predominant damage to the distal interphalangeal joints of the hand. N.F.S. 2 tbsp.
1) General blood test + formula
2) General urine test
3) BAC (urea, bilirubin with fractions, formol test, AST/ALAT, serum creatinine)
4) Analysis of protein fractions by electrophoresis.
5) Latex test for rheumatoid factor.
6) Ultrasound of the abdominal organs.
8) X-ray of the lungs, fluorogram.
9) Consultation: pulmonologist, allergist, cardiologist.
Teacher: Ph.D. assistant professor
Concomitant: urolithiasis, right kidney stone. Chronic cholecystitis, latent course, remission stage. Chronic pyelonephritis, latent course, remission stage. Stage 0 chronic renal failure. Gastric ulcer in the scar stage. Erosive gastritis, remission stage. Chronic hepatitis B (“+” HBS a/g).
Curator: student of group 610
Profession, position: pensioner
Marital status: Married
Place of residence: Primorsky Territory, Mikhailovsky District, Novoshakhtinsky, Grushevaya St. 5-2
Date of receipt: 09.28.2010
The main ones: for constant, diffuse, burning pain in the knees, ankles mainly on the left, shoulders mainly on the right, elbows, I-IV metacarpophalangeal, I-IV proximal interphalangeal joints of both legs and arms. Pain of maximum intensity in the morning and at night. For morning stiffness (massage and slight physical activity brings relief) for more than an hour. To limit movements in the above joints. For swelling, without changes in the skin, a local increase in temperature over the ankle, mainly on the left, joints, I-IV metacarpophalangeal, I-IV proximal interphalangeal joints of both legs and arms. For pain in the cervical spine, constant, aching, aggravated by movement.
Additional : For weakness, lethargy, malaise, poor sleep (lasting 4-5 hours, superficial, often waking up at night).
He considers himself sick since 2004, when his knee joints first became ill and swollen (the pain is diffuse, burning; maximum in the morning, decreases within 30 minutes after physical activity, lying on the bed), the pain went away on its own after a few days. Then pain periodically appeared in the ankle and shoulder joints.
In 2006 the same symptoms appeared in the metacarpophalangeal, proximal interphalangeal joints of the hands and feet. In the same year, the patient was registered with a general practitioner at his place of residence with a diagnosis of rheumatoid arthritis and sent for treatment to Clinical Clinical Hospital No. 1. Treatment was carried out: tab.Prednisolon 0.001, tab.Metotrexati 0.0075, tab.Acidi folicis, with positive dynamics.
Since February 2008 Methotrexate was discontinued, and the patient also stopped taking prednisolone on his own.
He was hospitalized as planned in September 2009. in Clinical Clinical Hospital No. 1, treatment was prescribed: tab.Prednisolon 0.015 mg, tab.Sulfasalasin 2.
Deterioration (constant pain, treatment does not help) since November 2009, and therefore the dose of prednisolone was increased to 0.003 per day. According to the patient, prednisolone became ineffective, the latter was replaced by tab.Dexamethasone.
In March 2010 I discontinued sulfasalazine on my own. Dexamethasone, due to its ineffectiveness (according to the patient), was replaced with tab.Methilprednisolon 0.012.
09/28/2010 The patient was hospitalized at Clinical Clinical Hospital No. 1 as planned in order to adjust the doses of medications.
Physically and mentally developed in accordance with gender and age.
Household history: living conditions at different periods of life were satisfactory.
Nutritional history: satisfactory nutrition, high quality, balanced, in sufficient quantity. Weight 82 kg, height 174 cm, BMI=27.3 (within the age norm).
Bad habits: does not smoke, does not drink alcohol, does not use drugs.
Past diseases: notes periodic colds - acute respiratory infections, acute respiratory viral infections, sore throat (2-3 times a year).
Epidemiological history: denies tuberculosis, malaria, venereal diseases. There has been no travel outside the permanent place of residence and no contact with infectious patients over the past six months. Hepatitis B since 2004
Allergological history : not burdened
Hereditary history : not burdened
Transfusion history: there was no transfusion of blood or its components.
Current condition of the patient:
Consciousness – clear, condition – moderate severity, position – active, physique – normosthenic, nutrition – satisfactory, skin – normal color, humidity – moderate, rashes – absent, peripheral lymph nodes are not palpable.
Chest examination:
Static examination: the shape is normosthenic, the epigastric angle is 90 degrees, there are no pathological curvatures of the spine or asymmetry; tight fit of the shoulder blades.
Dynamic examination: there is no lag of one of the halves of the chest during breathing, the type of breathing is mixed with a predominance of abdominal breathing, rhythmic breathing, no shortness of breath. The number of breaths per minute is 16.
Palpation of the chest : palpation of the chest is not painful. The width of the intercostal spaces is not changed, the resistance of the chest is preserved. Voice tremor is carried out evenly on symmetrical areas of the chest.
Comparative percussion of the lungs: over the entire surface of the lungs there is a clear pulmonary sound.
Topographic percussion of the lungs:
The standing height of the apex in front is 4 cm above the collarbone.
The standing height at the top of the back is at the level of the 7th cervical vertebra.
The width of the Krening fields is 7 cm.
The lower border of the lung: along the parasternal line – 5th intercostal space.
Midclavicular – 6th intercostal space.
Anterior axillary – 7th intercostal space.
Scapular – 10th intercostal space.
Paravertebral – spinous process of the 11th thoracic vertebra.
Excursion of the lower edge – 6 cm.
The standing height of the top at the front is 3cm.
The standing height at the back is at the level of the 7th cervical vertebra.
The width of the Krening fields is 5 cm.
Lower border of the lung:
Along the parasternal line – 3rd intercostal space, corresponds to the upper limit of the relative dullness of the heart.
Midclavicular – 3rd intercostal space, corresponds to the upper limit of the relative dullness of the heart.
Mid-axillary – 8th intercostal space.
Posterior axillary – 9th intercostal space.
Paravertebral – spinous process of the 11th thoracic vertebra
Excursion of the lower edge – 7 cm.
All data correspond to normal values.
Vesicular breathing is heard over the entire surface of the lungs. No wheezing.
Examination of the heart area: cardiac hump, cardiac impulse, and other pathological pulsations were not detected.
Palpation: apical impulse: localization - 5th intercostal space 1.5 cm medially from the left midclavicular line. Area 2cm square, low in height, moderate strength, not resistant. The heartbeat is not detected. There is no “cat purring” symptom.
Percussion of the heart: boundaries of relative dullness of the heart: right in the 4th intercostal space along the right edge of the sternum. Upper - in the 3rd intercostal space, along the line running from the left sternoclavicular joint. Left - in the 5th intercostal space 1.5 cm medially from the left midclavicular line. The data is normal.
Borders of absolute dullness of the heart: the right border runs along the left edge of the sternum; upper along the lower edge of the 4th ribs, from the upper border of the relative dullness of the heart; left 1 cm medially from the left border of relative dullness of the heart. The data obtained are normal.
Contours of the cardiovascular bundle: right contour: in the 1st, 2nd, 3rd intercostal space, 2.5 cm away from the anterior midline to the right. In the 4th intercostal space by 3.5 cm.
Left contour: passes to the left of the sternum and is spaced from the anterior midline at the 1.2 intercostal space by 3 cm, in the 3 intercostal space by 4 cm, in the 4 intercostal space by 7 cm, in the 5 intercostal space by 9 cm.
The contours of the cardiovascular bundle correspond to the norm.
Dimensions of the heart and vascular bundle: heart diameter – 12 cm. The length of the heart is 13.5 cm. The height of the heart is 9.5 cm. The width of the heart is 10 cm. The width of the vascular bundle is 5.5 cm.
Normal heart sizes: heart diameter – 11-13 cm. The length of the heart is 13-15 cm. The height of the heart is 9.5 cm. The width of the heart is 10-10.5 cm. The width of the vascular bundle is 5-6 cm.
The heart configuration is normal.
Auscultation of the heart: heart sounds are loud, rhythmic, no murmurs are heard.
Examination of the great vessels of large and medium caliber: examination and palpation of the aorta in the jugular notch, as well as examination of the anterolateral surface of the neck without any features. Pulsation of the carotid arteries, swelling and visible pulsation of the neck veins were not detected. Venous pulse is negative.
Examination of the arterial pulse: the pulse is the same in both arms. Heart rate 78. Pulse of medium filling, medium tension, medium in size, resistant, regular rhythm. The nature of the vascular wall is elastic and uniform. Capillary pulse is negative. Blood pressure 140/85 (without the use of antihypertensive drugs).
Examination of the oral cavity: the red border of the lips is pink, without cracks or rashes. The mucous membrane of the oral cavity is pale pink, moist, without hemorrhages. The gums are pink, do not bleed, without inflammation. The tongue is moist, not coated. The tonsils do not act as palatal buds. The mucous membrane of the pharynx is moist, pink, clean.
Examination of the abdomen: The abdomen is involved in the act of breathing. Dilation of the saphenous veins, hernias, and divergence of the rectus muscles are absent.
Superficial indicative palpation of the abdomen according to Obraztsov-Strazhesko: pain is not determined. Pathological formations are not determined.
Deep sliding methodical topographic palpation of the intestines and stomach according to Obraztsov-Strazhesko and Vasilenko: the sigmoid colon is palpated in the left iliac region in the form of a cord, 2.5 cm in diameter, dense consistency, not rumbling, painless. The cecum is palpated in the right iliac region in the form of an elastic cord, not rumbling, painless. The transverse colon is palpated on the right in the form of a painless, elastic, slightly rumbling cord. The ascending colon in the right flank is not palpable. The descending section of the colon is palpated in the left flank in the form of a painless, elastic, slightly rumbling cord.
Examination of the liver: upon examination of the right hypochondrium, epigastric region, no bulges, dilated skin veins, anastomoses, hemorrhages, or spider veins were found.
Percussion of the liver: the upper border of the liver is at the level of the 5th rib, along the right parasternal, midclavicular and anterior axillary lines. The lower border of the liver is located along the right midclavicular line at the level of the lower edge of the costal arch. Along the anterior midline - at the border of the upper and middle third of the distance between the xiphoid process and the navel. Along the left costal arch - at the level of 7-8 ribs.
Liver dimensions according to Kurlov:
the first size is the distance between the upper and lower borders of the liver along the right midclavicular line, it is equal to 10 cm.
the second size is the distance between the upper and lower borders of the liver along the anterior midline, it is 9 cm.
The oblique size of the liver corresponds to the lower border of the liver along the left costal arch, it is 8 cm.
Examination of the gallbladder: examination of the area of projection of the gallbladder on the right hypochondrium revealed no changes. The gallbladder is not palpable.
Examination of the spleen: when examining the hypochondrium in the area of the projection of the spleen onto the left lateral surface of the chest and the left hypochondrium, bulging due to enlargement of the organ is not observed.
Percussion of the spleen: the length along the 10th rib is 7 cm. Diameter – 5 cm.
Palpation of the spleen: the organ is not palpable.
Palpation of the pancreas according to Groth: the organ is not palpable.
Urinary organs: Examination of the lumbar region - no changes. When palpating the kidneys in a horizontal and vertical position of the patient, the organs are not palpable. Pain when tapping the lumbar region on the right and left is not detected. There is no pain on palpation in the area of the upper and lower ureteral points. The bladder is not detected by percussion and palpation. Auscultation of the renal arteries does not reveal any murmurs.
Nervous and endocrine system:
Consciousness is clear. Intelligence is normal. Age-related memory decline, speech is not impaired. Superficial sleep, lasting 4-5 hours. Coordination of movements and gait are not changed. There are no convulsions or paralysis. Reflexes: reaction of the pupils to light (friendly, fast); corneal, pharyngeal – preserved.
Secondary sexual characteristics correspond to age and gender. Skin pigmentation was not detected. When palpating the thyroid gland, the isthmus is palpated in the form of a thin elastic plate.
The patient does not complain about changes in smell, touch, vision, or taste. Age-related hearing loss.
Rheumatoid nodes, tophi, depigmentation, pigmentation, induration, ulcerative defects, point necrosis are absent.
Spine : scoliosis, pelvic tilt, contracture of paravertebral and gluteal muscles – absent. Tamajer's and Kushelevsky's symptoms are negative.
Hip joint : lameness, “duck gait” - absent. Thomas test, Faber's sign is negative.
Knee joint: Painful on palpation. Defiguration due to exudative-proliferative changes. There is no atrophy of the quadriceps muscle.
Ankle joint and foot area: Achilles bursitis on the left, spreading to the lower third of the leg. Morton's finger - no. Hammertoes, cockerel deformity, extensor deformity, and heel telalgia are absent on both sides.
Tarsal joints: Painful when palpating the joints of both legs.
Metatarsophalangeal joints: Painful on palpation of all toes.
Interphalangeal joints: Painful when palpated at the proximal toe joints. Hallus valgus type foot deformity.
Shoulder joint: Moderately painful on palpation. Limitation of movements. Atrophy of the supraspinatus, infraspinatus muscles, bicipital synovitis of the intertubercular groove is absent. The subacromial bursa is painless. Yargeson's sign is negative.
Elbow joint: Slight pain on palpation. There is no elbow bursitis. Thomsen's sign is negative.
Wrist and carpal joints: Carpal flexion test positive on the right and left. Small cyst of the dorsum of the wrist, ankylosis of the wrist in flexion and extension, Dupuytren's contracture, atrophy of the muscles of the first finger with displacement of the end of the left bone to the rear, dorsal displacement of the ulna - absent on both sides. Finkelstein's sign is negative on both sides.
Metacarpophalangeal and interphalangeal joints: Defiguration due to exudative-proliferative changes in the metacarpophalangeal and interphalangeal joints of the hands. Atrophy of the interspinous muscles of the hands. Inability to clench hands into fists. Ulnar deviation, “swan neck”, “button loop”, “lorgnette hand” deformities are absent on both sides. Giberden's and Bouchard's nodes are absent. Flexion contracture of the distal joints is absent. Fake hands, clawed paw - no.
Main diagnosis: Rheumatoid arthritis, polyarthritis. Impaired joint function of the second degree. II FC. Secondary osteoarthrosis, polyosteoarthrosis, primary gonarthrosis. Achilles bursitis on the left. Osteochondrosis of the spine, with a predominant lesion of the cervical spine.
Clinical blood test
General urine analysis
Urine analysis according to Nichiporenko
Blood chemistry
Cryoglobulins on CEC
Feces on I/worms
Blood test for HIV, EDS, HBS a/g
Determination of blood group and Rh factor
A/t to the Russian Federation (Ig M) 12.calculation of the index Das 28
Echocardiography and Dopplerography
X-ray of hands and feet
X-ray of the knee joints
Ultrasound of internal organs
Electrolytes (Na, K)
1. Clinical analysis for research:
• red blood cells – 4.57 * 10 12 in 1 l (4-5.6 * 10 12 )
• hemoglobin – 144 g/l (120-140 g/l)
• platelets –309*10 9 /l (180-350*10 9 /l)
• leukocytes –9.75*10 9 /l (4.3-11.3 *10 9 /l)
Conclusion: Accelerated ESR syndrome
2. General urine test
specific gravity – 1020 (1010-1030)
reaction – acidic (neutral or slightly acidic)
transparency is incomplete (transparent)
epithelium – 2-3 in the field of view (0-3 in the visual field)
leukocytes – 0-1 in the field of view (up to 3 in the visual field)
Leukocytes 5300 (<4000)
Red blood cells 1200 in 1 ml (<1000 in 1 ml)
Cylinders 400 (0-1 for 4 counting chambers)
Conclusion: increased content of all cells
4. Biochemical blood test
— Total protein – 66.5 g/l ((66-88 g/l)
Urea – 6.54 mmol/l (2.5-8.33 mmol/l)
Creatinine – 102 mmol/l (61-115 mmol/l)
ALT – 16.0 U/l (0-41 U/l)
AST – 21.2 U/l (0-38 U/l)
— Blood glucose – 3.7 mmol/l (3.3-6.4 mmol/l)
— Total bilirubin – 15.4 µmol/l (8.6-21.0 µmol/l)
— Cholesterol 5.19 mmol/l (5.2-6.2 mmol/l)
— Triglycerides 1.3 mmol/l (0.45-0.81 mmol/l)
— Alkaline fostotaza 175 U/l (1-270 U/l)
— LDH 422 U/l (0-451U/l)
— GGT 15.7 U/l (0-66 U/l)
— Uric acid 312 µmol/l (202-417 µmol/l)
— Creatine kinase 54 U/l (0-190 U/l)
— Phosphorus 1.34 mmol/l (0.84-1.45 mmol/l)
Visibility is good, the background is pink, the contours are expanded chaotically, there are 3-4 of them in a position, they are significantly shortened, and in places they look like dots.
Conclusion: spastic state of capillaries.
— Fibrinogen 4.6 g/l (2-4 g/l)
— TV 16.6 sec (13-17 sec)
— APTT 37.5 sec (28-40 sec)
— RFSHK 5 mg/100 ml (up to 4 mg/100 ml)
— Ethanol test “—” (neg.)
Conclusion: increased fibrinogen content
7. Cryoglobulins on CEC 0,003
8. Feces for helminth eggs : no helminth eggs were found in the feces.
9. Blood test for EDS, HIV infection - negative HBS a/g positive
10. Determination of blood group and Rh factor – blood group II, Rh factor “+”
11. A/t to the Russian Federation, DAS Index 28
— RF 40 mg/ml (up to 20 mg/ml)
— DAS index 28 (painful joints – 45, swollen joints – 21, ESR 22mm/h, VAS score 6) = 3.3
Conclusion: The increase in RF corresponds to stage II, the DAS index corresponds to a moderate degree of activity.
— Total protein 67.6 g/l (66-8 8 g/l)
— Albumin 47.33% (46.9-61.4%)
— Globulins: alpha 1 3.19% (2.2-4.2%)
alpha 2 11.96% (7.9-10.9%)
beta 15.73% (10.2-18.3%)
gama 21.79% (17.6-25.4%)
Conclusion: increased levels of alpha2 and beta globulins
13.Rheovasography of the extremities
Conclusion: The volume of pulse blood flow in the upper and lower extremities is reduced; significantly in the area of the left forearm and hand. The elasticity of the vascular wall in the area of the upper and lower extremities is not changed. Venous outflow is not obstructed.
14. Seromucoid 0.285 units. (0.12-0.22 units)
15. CRP 12 mg/dl (up to 5 mg/dl)
Conclusion: the increase corresponds to Art. II.
16. Thymol test 3.0 units (4.0 units)
17.CEC 0.048 units (0.036-0.044 units)
Conclusion: the increase corresponds to class I.
— Ig G 11.7 g/l (5.4-16.1 g/l)
— Ig M 1.24 g/l (0.5-1.9 g/l)
— Ig A 2.1 g/l (0.8-2.8 g/l)
— CEC 33 units. (up to 50 units)
— Phagocytic reser 0.99 (>1)
— Phagocytic reser 0.7 (2 and >)
19. Fluorography – chest organs without pathology.
20. ECG – sinus rhythm, heart rate 83 beats. per minute
21. Echocardiography and Dopplerography