For illustration, we present an extract from the medical history . Patient G., 12 years old (case history No. 13368) fell ill on June 20, 1967 with osteomyelitis of the tibia of the left leg, and was hospitalized in the children's surgical department of the Krasnodar City Emergency Hospital. Despite surgical treatment, the girl developed septicopia, and the infection spread hematogenously to the left TMJ. Pain, limitation of movements, swelling and hyperemia appeared in the area of the affected joint and the angle of the lower jaw. Erroneously, instead of acute arthritis of the left TMJ, a diagnosis of tetanus was made, and for one and a half months no treatment was carried out for acute arthritis of the TMJ.
The patient was discharged from the hospital with swelling in the area of the left TMJ and was sent to the surgical department of the regional dental clinic. Inflammation of the left parotid gland was suspected. After an X-ray examination carried out in January 1968, a deformity of the articular head of the left TMJ was revealed. With a diagnosis of “Deforming arthrosis of the left TMJ,” the patient was referred to us.
There was facial asymmetry due to swelling in the TMJ area on the left. Palpation revealed sharp pain in this area and swelling of a soft consistency. The excursion of the right condyle was greater than that of the left. When opening the mouth, the lower jaw shifted to the left. The distance between the cutting edges of the central incisors with the mouth open is 2–8 mm. The oral mucosa is without visible changes. The teeth are intact. The bite is orthognastic. No pathology was detected in the salivary glands and regional lymph nodes.
Body temperature 37.2° . The blood test showed moderate leukocytosis, shift of the leukocyte formula to the left, ESR 30 mm per hour.
On radiographs with the mouth closed, the right condyle has a rounded shape, the joint space is of moderate width, and the contours of the articular surfaces are not changed. On radiographs of the Left TMJ, the condyle and neck of the process are sharply expanded, the upper anterior part of the head is absent, the remaining surface is beveled, and the joint space is sharply narrowed. With the mouth wide open, both condyles are at the top of the articular tubercle. Diagnosis: left-sided subacute arthritis, post-infectious arthrosis of the TMJ.
The treatment is complex . Auxiliary orthopedic therapy was aimed at creating diastasis between the articular surfaces and preventing ankylosis in the joint. On February 14, 1968, plastic mouth guards were made for teeth 7654|4567 of the lower jaw; the bite was separated by 2.5 mm in the area of the first molars. Intramuscular injections of bicilin and butadione were prescribed, followed by UHF and electrophoresis with lidase.
A month later the swelling completely disappeared , mouth opening became free, and the hematogram returned to normal. On radiographs of the left TMJ, there are dense sclerotic areas on the anterior and posterior-superior surfaces. The head and neck are somewhat reduced in volume, the posterior-superior section is slightly elongated upward.
For three months, the patient did not notice any unpleasant sensations in the joint area. At the end of June 1968, she suffered from the flu, and the pain in the left TMJ returned again. There was slight swelling and pain on palpation, but jaw movements were free. A blood test showed only an acceleration of ESR. A course of anti-inflammatory therapy with physiotherapy was administered again, and after three weeks the process was completely stopped.
During a control examination of the patient in 1976, an unusual picture was revealed. Within eight years, complete regeneration of the left articular process occurred. The neck of the articular process narrowed, the head took on a rounded shape. The articular process of the left TMJ is smaller in size than the right one, but no deformation of the TMJ occurred. Every 2 years the patient undergoes a control examination of the TMJ.
Despite the death of the upper anterior section of the condyle , the growth zone was preserved in its posterior upper section. The increase in interalveolar height with plastic aligners and the creation of diastasis between the articular surfaces for a long time, apparently, served as the impetus and condition for the growth of the left condyle, and the relationship between form and function played a role in the formation of the articular head. The functional formation of the joint has occurred.
Table of contents of the topic “Arthritis and arthrosis of the mandibular joint”:
Diagnosis: Rheumatoid arthritis.
Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course - Case history. Download medical history [2. Kb] Information about work. DEPARTMENT OF FACULTY THERAPYHead.
Teacher Associate Professor x. Medical history x (4. Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, activity II degree, II. I. Beginning of supervision: 2. End of supervision: 2. Curator: x. Passport part. Full name x Age 4.
Rheumatoid arthritis is a systemic disease 1 History; 2 Epidemiology; 3 Etiology; 4 Pathogenesis; 5 Clinic. The more joints affected, the more advanced the stage of the disease. . Diagnostic criteria for rheumatoid arthritis and treatment plan
detected disease. Therapy, medical history.
Floor. Male. Nationality Russian. Secondary education Profession miller. Date of admission 1. Home addressx. 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, activity II degree, II.
. medical history [16.6 K], added 11/29/2010.
I. Clinical diagnosis: Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, activity II degree, II. I. Complaints: 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 the present illness: (Anamnesmorbi) Considers himself sick with 1.
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 2.00.0, the regional clinic sent him to the OKB, where he was prescribed prednisolone tablet. Joint pain disappeared and mobility increased.
In the spring 2.00.1. Pyatigorsk. 18.
OKB, due to 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.
Life history: (Anamnesvitae) Born in ***, the third child in the family, grew 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 did 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.
Housing and living conditions are satisfactory, meals are regular. Present condition (Statuspreasens) The patient’s condition is satisfactory, consciousness is clear, the position in bed is active, the patient is available for contact. The physique is normosthenic. The patient's appearance corresponds to age and gender. Height 1.64 cm, weight 6.
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, and 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.
Respiration rate 1. 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. The width of the Kernig fields is 5 cm on both sides. The mobility of the lower edge of the lungs along the midclavicular line is 5 cm. Breathing is vesicular, there are no wheezing or pleural friction sounds.
The lower borders of the lungs. Right Landmarks Left.
The cardiovascular system. 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 1. 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.
Borders of relative cardiac dullness: RIGHT-LEFT 2nd intercostal space - along the edge of the sternum. Limits of absolute cardiac dullness. Right – 4th intercostal space 1 cm. 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 palpable to 2 cm. The edge of the liver is smooth, elastic in consistency, painless. Liver dimensions according to Kurlov 1. Palpation of the gallbladder points is painless. The stool, according to the patient, is filled once a day. Urinary system. 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, transparent. Urination is free, painless, 5-6 times a day. Daily diuresis is about 1. He does not 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. Tapping the flat bones is painless. Dimensions of the spleen according to Kurlov: diameter 4 cm, length 6 cm.
Endocrine system. Height 1.64 cm, weight 6. 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. Limitation 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 6.2 per minute. Muscle strength is age appropriate.
Sweating during physical activity. There are no pathological symptoms. Laboratory and instrumental studies: UAC: indicators.
Rod nuclear. 3%3%2 - 4%Segmentonuclear. Monocytes. 4%5%2 - 8%Eosinophils.
Platelets. 40. 0*1. ESR3. 2mm/h. 30mm/h. Conclusion: accelerated ESR.
OAM: indicators. February 18 2. Conclusion: within normal limits. Biochemical blood test: 1. Al. AT 0.0. 5 norm: up to 0.4.
Ac. At 0.0. 20. Conclusion. Immunological examination: 1. C reactive protein – weakly positive (+) X-ray examination: 2. On the provided photographs of both hands in a direct projection, diffuse osteoporosis is noted, brush-shaped lucencies in the heads of the middle fingers of the metacarpal bones, small bones of the wrist, narrowed joint spaces in the wrist joints, more on the left. The contours of the articular surfaces are unclear. Conclusion: stage II rheumatoid arthritis.
Clinical diagnosis and rationale: Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, activity II degree (moderate activity), II. IO The diagnosis of “rheumatoid arthritis: polyarthritis” can be made due to the presence of the following diagnostic criteria: morning stiffness before lunch of the wrist, metacarpophalangeal, shoulder, knee joints; arthritis of more than three joints; arthritis of the hand joints; symmetrical arthritis – the areas of the wrist, metacarpophalangeal, shoulder, knee joints have swelling of the periarticular soft tissues; presence of rheumatoid factor in blood serum; X-ray changes: photographs of both hands in a direct projection show diffuse osteoporosis, brush-like lucencies in the heads of the middle fingers of the metacarpal bones, small bones of the wrist, narrowed joint spaces in the wrist joints, more on the left, the contours of the articular surfaces are unclear. O Seropositive, i.e.
DEPARTMENT OF FACULTY THERAPY No. 1 FACULTY OF MEDICINE
Last name, first name, patronymic of the patient: U. A.S.
Marital status: Married
profession, current nature of work: economist
Permanent residence: Moscow region, Mozhaisk
Date of admission to the hospital: 02/31/2011
1) For pain in the joints: in all proximal interphalangeal joints of the hands of both hands, in the metacarpophalangeal joints, in the wrist , elbow and shoulder joints of both hands, in the II-IV metatarsophalangeal joints and knee joints of both legs. The pain is of an aching nature, accompanied by swelling, aggravated by movement, does not stop throughout the day, is most intense in the morning, as well as in the second half of the night, sometimes disturbing sleep.
2) Stiffness in the movements of the arms and legs, observed in the morning during the first 1-2 hours after getting out of bed.
3) For aching pain in the epigastric region, of moderate intensity, occurring 4 - 6 hours after eating and stopping after eating and relieved by taking omeza.
FAMILY HISTORY AND HEREDITARY
Mother: died at the age of 92 from a myocardial infarction, suffered from hypertension.
Father: Died at age 75 from pancreatic cancer.
The patient has no brothers or sisters.
Son: 31 years old, healthy
Born in Mozhaisk in 1949, on time, he was the only child in the family. The mother's age at the time of her son's birth was 31 years. He was fed with his mother's milk and did not lag behind his peers in physical and mental development. Rickets denies. I went to school at the age of 7, graduated from the 10th grade, received a higher education, began working at the age of 23 at an enterprise as an economist, for the last few months I have practically not worked due to pain and limited movement in the joints.
There were no occupational hazards at work.
Social conditions are good. Varied, nutritious meals 3-4 times a day. Doesn't follow a diet.
He smoked for 40 years until 2008, averaging 1.5 packs of cigarettes per day.
I have never abused alcohol.
As a child, he suffered from measles, whooping cough, and chicken pox. I fell ill with acute respiratory infections 3-4 times a year.
In 1986, duodenal ulcer was diagnosed on endoscopy during clinical examination. It is difficult to determine the size of the ulcerative defect; he denies bleeding. He was treated at his place of residence, and remembers the drugs he was taking: omez and famotidine. After achieving remission, therapy was stopped. With a frequency of approximately once every 2 years, an exacerbation of the disease is noted: the appearance of aching pain in the epigastrium on an empty stomach. During an exacerbation, he usually takes Omez or Nexium. The last endoscopy was in September 2010.
In 2006 - right-sided inguinal hernia, plastic surgery of the anterior abdominal wall in the area of the right inguinal canal was performed
In 2006, colon diverticulosis with signs of diverticulitis
In 2008 - septoplasty, submucosal vasotomy of the inferior turbinates
In 2009, cataracts were removed from the right eye.
According to the patient, he is not burdened.
HISTORY OF THE PRESENT DISEASE
In 2002, at the age of 52 years, he first noticed swelling, pain and limitation of movements in the wrist, metacarpophalangeal, proximal interphalangeal joints of both hands, III proximal interphalangeal joints of both feet, morning stiffness of movements for 3 hours, as well as pain and limitation of movements in the left shoulder joint. He was consulted by a rheumatologist at his place of residence. X-ray of the hands: narrowing of the X-ray joint spaces of both wrist joints, cysts in the proximal interphalangeal joints of the hands of both hands, no erosive-destructive lesions. The condition is regarded as seronegative rheumatoid arthritis, it is recommended to take Plaquenil 200 mg/day, Naise 100 mg/day, and topical dolgot cream. With this therapy, the patient’s well-being and overall performance improved, and joint manifestations subsided. In May 2004, there was pain and swelling of the II-III-IV proximal interphalangeal and metacarpophalangeal joints of both hands, pain, limited rotation in the left shoulder joint, and therefore he was hospitalized at the FTC MMA named after. I. M. Sechenov. Based on the results of the examination, a diagnosis was made: rheumatoid arthritis, stage 1 seropositive arthritis, stage 3 activity, stage 2 FN. The clinic provided therapy: methotrexate 10 mg IM once a week, Plaquenil 400 mg IV, Movalis 15 mg/day, physiotherapy. A course of plasmapheresis of 10 sessions was also carried out due to the high level of RF in the blood and excruciating pain in the joints, which were poorly responsive to therapy. Discharged in satisfactory condition. Until September 2004, pain in the small joints of the hands and feet increased, decreased after taking NSAIDs, pain appeared in the right knee joint, and he noted a weight loss of 4-5 kg in 4 months. In September 2004, he was undergoing inpatient treatment at the FTC MMA. He received therapy with methotrexate 15 mg once a week, movalis 15 mg/day. Due to the activity of rheumatoid arthritis and the insufficient effect of basic therapy, Remicade was prescribed for 5 infusions of 200 mcg. Remicade therapy was completed by February 2005, and subsequently he received methotrexate 15 mg/week. In subsequent years, joint pain periodically intensified, and therefore he additionally took NSAIDs (Movalis, Nise). The condition worsened in June 2009, when methotrexate was discontinued due to a cold. I relieved joint pain for a long time by taking Movalis and Nimesil. He was hospitalized in the CTO and PS. Therapy was carried out: general regimen, table No. 5, Arava 20 mg in the morning, Movalis 15 mg in the morning, Omez 20 mg at night, physiotherapy, physical therapy. He was discharged with improvement and felt satisfactory for 6 months.
In November 2009, pain appeared and began to increase in the wrist joints, small joints of the hands and feet, and stiffness of movement in these joints. Last hospitalization in the CTO and PS in December 2009, therapy with Arava 20 mg/day. The condition has worsened since the beginning of 2011, when pain, swelling and limitation of movements in the wrists, small joints of the hands and feet, and in the ankle and knee joints of both legs began to increase. He was admitted to the CTO and PS for examination and selection of therapy.
Noteworthy is the nature of the complaints related to the joints:
- joint pain, accompanied by swelling, relatively more intense in the morning and in the second half of the night, is typical for arthritis, as well as morning stiffness during the first few hours after waking up.
- symmetrical damage to the small joints of the hands and feet, as well as the wrist, ankle and knee joints
— from the anamnesis it is known that the described complaints actually persist for many years, periodically intensifying and receding under the pressure of the therapy.
Thus, already at the first stage of the diagnostic search, there are sufficient grounds for making a diagnosis of “rheumatoid arthritis” in accordance with 4 diagnostic criteria:
1) Arthritis of 3 or more joints
2) Morning stiffness for at least 1 hour
3) Arthritis of the joints of the hand (at least 1 group of joints)
4) Symmetrical arthritis
Complaints of aching pain in the epigastric region, appearing on an empty stomach and relieved by eating or taking omez (a proton pump inhibitor) in themselves suggest a peptic ulcer of the duodenum or antrum, which is all the more likely given the presence of a history of duodenal ulcer .
Assessment of the patient's condition : satisfactory,
Facial expression: does not represent painful manifestations
Body temperature - 36.6 C
Skin color: normal.
Coloring of mucous membranes: normal
Elasticity (turgor) of the skin: normal.
There are no rashes, pigmentation, bruises and subcutaneous hemorrhages, scars, scratches, ulcers, bedsores, spider veins.
Skin moisture: normal
Hair: male hair type.
Nails: normal shape, with longitudinal striations. Nail color is normal.
Degree of development: moderate.
Lymph nodes (cervical, parotid, submandibular, jugular, supraclavicular, axillary, ulnar, inguinal) are not enlarged, not palpable, and there is no pain at the site of projection.
It is moderately developed, there is no pain on palpation, no differences in diameter were detected when measuring the limbs. The muscles are in good tone, with the exception of the forearm muscles, which look somewhat atrophic. There is no involuntary muscle tremors.
There is mild swelling in the area of the metacarpophalangeal joints and proximal interphalangeal joints of both hands.
Sum of circumference lengths of the proximal interphalangeal joints of the II-V fingers of the left hand = 262 mm
Sum of circumference lengths of the proximal interphalangeal joints of the II-V fingers of the right hand = 266 mm
The skin temperature over the joints was not changed. The gait is normal. Performs simple everyday tasks with hands (washing, combing hair, fastening buttons, writing). There is moderate pain with active and passive movements in the small joints of the hands, wrists, elbows and knees.
Nose : normal shape and size, no deformation of the soft tissues of the nose. There is no herpetic rash. The condition of the nasal mucosa is good. Breathing through the nose is not difficult. There is no feeling of dryness in the nose, no discharge. The sense of smell is preserved. There is no pain at the root and dorsum of the nose, at the sites of projections of the frontal and maxillary sinuses.
The larynx is of regular shape, painless when palpated, there is no pain when speaking or swallowing.
normosthenic (epigastric angle is 90°), symmetrical, without visible deformations.
Both halves of the chest are evenly involved in the act of breathing.
The chest circumference at rest is 85 cm, when inhaling 89 cm, when exhaling 82 cm.
Breathing type: mixed. The number of respirations is 16 per minute.
Voice tremors are normal.
On palpation, the chest is painless, transverse and longitudinal loads are not accompanied by pain. The elasticity of the chest is reduced due to ossification of the costal cartilages.
Comparative percussion: clear pulmonary sound
Topographic percussion: the height of the apexes above the clavicles is 2.5 cm on the left and right, posteriorly at the level of the spinous process of the VII cervical vertebra.
Lower border of the lungs: right left
along the midclavicular line VI -
along the anterior axillary line VII VII
along the midaxillary line VIII VIII
along the posterior axillary line IX IX
along the scapular line XX
along the paravertebral line at the level of the spinous process of the XI thoracic vertebra.
Mobility of the lower pulmonary border (in cm)
along the midclavicular line _________6____________________
along the midaxillary line_____8_____________________
along the scapular line__________6_________________________
Auscultation of the lungs: vesicular breathing, no wheezing.
There are no visible pulsations of the carotid, subclavian and other arteries. No jugular venous pulsation is detected. There is no epigastric pulsation.
On examination, the chest in the area of the heart is not deformed. The apex beat is not visually detected.
On palpation, the apex beat is not detected.
Indrawing of the chest at the site of the apical impulse, systolic and diastolic tremors, and the symptom of “cat purring” at the apex of the heart are absent above the aorta. The heartbeat is not detected.
Limits of relative dullness of the heart:
Right - along the right edge of the sternum.
Left—V intercostal space 1.5 cm medially from l. medioclavicularis sinistra.
Upper—lower edge of the third rib along the l. parasternalis sinistra.
The tones are clear and rhythmic.
Auscultation revealed no pathological noises.
On palpation, the arteries and veins are elastic, elastic, painless. The pulse value in both arms is the same, the pulse is of satisfactory tension, rhythmic, 72/min.
Blood pressure - on the right arm
systolic 120 mm. rt. Art.
diastolic 70 mm. rt. Art.
systolic 120 mm. rt. st
pulse 50 mm. rt. Art.
Appetite is good, thirst and dry mouth are not a concern. Chewing, swallowing, and passage of food through the esophagus is free. Heartburn, belching, nausea and vomiting are not observed. The stool is regular, the act of defecation is painless, the passage of gases is free.
The tongue is moist and clean. The pharynx is pink in color. The tonsils do not protrude beyond the palatine arches. The abdomen is of normal shape and symmetrical.
The abdomen is of a regular rounded shape, symmetrical, the anterior abdominal wall is involved in the act of breathing. There is no divergence of the rectus abdominis muscles, and there is no visible peristalsis of the stomach and intestines.
Superficial indicative palpation of the abdomen.
The skin is moderately moist, the abdomen is soft and painless; There is no discrepancy between the rectus abdominis muscles. The Shchetkin-Blumberg symptom is negative.
Moscow Medical Academy named after. I. M. Sechenova
Department of Internal Medicine No. 4
Performer: 4th year student l/f
Teacher: Yurazh V. Ya.
Last name, first name, patronymic of the patient: Solovyov Mikhail Nikolaevich
Age: 74 years
Profession: retired, disabled group II (previously worked as a loader)
Residence: Moscow, st. Bnekhskaya 5 - 179
Time of admission to the clinic: November 8, 2001 at 15.50
Date of supervision: 29.11.01.
The patient's complaints at the time of admission: Shortness of breath that occurs with slight exertion, lying with a low pillow, mainly at night. Cough with mucus production. Increasing swelling of the legs, enlargement of the abdomen due to fluid accumulation. Periodic pain in the heart area, of a compressive nature, of moderate intensity, without irradiation, occurring without connection with physical activity, and not going away after taking nitroglycerin. Frequent rises in blood pressure up to 200/100 mm. rt. Art.
History of the present disease: A patient aged 17 years in 1947 suffered from rheumatism for which he was hospitalized. After 3 years, mitral valve disease was diagnosed. After this, the patient was not bothered by complaints, he led a normal life, worked as a loader. From the age of 55 years, the patient’s condition began to deteriorate: rises in blood pressure appeared (hypertension was diagnosed), periodic pain in the heart region, shortness of breath, swelling, and atrial fibrillation appeared. The patient began to be observed at the district clinic and undergo treatment 2 times a year in the hospital. The last hospitalization was in February 2001 in City Clinical Hospital No. 63. The above complaints during hospitalization developed within 3 weeks.
Anamnesis vitae: Born in the countryside, in a village in the Kursk region. Lived in a private house. The living conditions were poor, the food he received was irregular (he was in occupied territory during the war). In terms of education, I completed only 4 classes at a comprehensive school. Since 1946 he has lived in Moscow. At the moment, living conditions are good, he lives in a separate apartment, with a family.
Previous illnesses: In childhood I suffered from measles, rubella, mumps (without complications). He often suffered from colds and sore throats. At the age of 41, he was hospitalized in the urology department with a diagnosis of urolithiasis, right-sided renal colic; as a result of treatment, the stone passed on its own; there were no further complaints about urolithiasis. At the age of 56, an operation was performed - hernia repair for a hernia of the white line of the abdomen.
Hereditary and family history: Denies the presence of inherited diseases. My father died at the age of 50 from esophageal cancer. The mother died tragically.
Allergic manifestations: to medications, foods, plants and animals are absent.
Bad habits: Smokes since age 12, currently smokes one pack of cigarettes a day.
Occupational hazards: Worked as a loader at a brick factory, loading coal.
Condition : moderate.
Position : active at the time of supervision, forced orthoptic upon admission.
Facial expression: normal.
Temperature: 36.7 0 C
Skin : clean, normal moisture, acrocyanosis, the color of visible mucous membranes is cyanotic. Subcutaneous fat is of moderate development, evenly distributed. There was marked pastiness of the legs, and upon admission there was pronounced peripheral edema on the legs and feet. The skin on the lower extremities is pale, smooth, and tense.
in the joints, skeletal or muscular systems .
Lymph nodes : normal, not visible during examination.
Respiratory organs : Complaints are stated above. On examination, breathing through the nose is free. Respiratory rate is 22, breathing rhythm is correct. The chest is normosthenic in shape. The right and left halves are symmetrical, move synchronously when breathing, and are painless on palpation. On palpation, chest rigidity is noted. Vocal tremor is weakened in the lower parts on both sides. The boundaries of the lungs are expanded. Limitation of excursion of the lower pulmonary border. On percussion, dullness of pulmonary sound in the lower sections. On auscultation, breathing is harsh. In the lower parts of the lungs, moist, small-caliber, silent rales are heard. At the time of admission, moist, ringing, fine-bubble rales were heard in the upper lungs on the right (which was also confirmed x-ray). Bronchophony: voice tremors are locally weakened on both sides in the lower lungs.
Circulatory organs : Complaints are stated above. When examining the neck area, pulsation of the carotid arteries is noted. When examining the area of the heart: the chest in the area of the heart is not changed, there is no cardiac hump, there is no cardiac impulse. There is no local ectopic pulsation in the precordial region. The apical impulse is determined in the 6th intercostal space 1.5 cm outward from the midclavicular line, according to the characteristics: diffuse, high, intensified. There is no pulsation in the epigastric region or liver area.
Percussion boundaries of relative cardiac dullness:
right: 1 cm outward from the right edge of the sternum
left: 1.5 cm outward from the midclavicular line.
upper: 1 cm to the left of the left sternum line at the level of the 2nd rib.
I and II sounds are weakened at all points of auscultation. III and IV sounds are not heard. At the apex, a pansystolic murmur is heard, blowing, soft, timbre, high frequency, conducted to the axillary region. Also at the apex, a protodiastolic, decaying noise of a blowing timbre is heard. During auscultation at the Botkin-Erb point, a protodiastolic, decreasing murmur of a soft, blowing timbre is heard. The heart rhythm is incorrect, heart rate is 64 per minute. Pulse rate – 62 per minute, pulse deficit 2. Rhythm disturbances in the form of atrial fibrillation are evident. Blood pressure in the right arm is 160/90 mm. Hg, on the left arm 155/90 mm. rt. Art., with a working blood pressure of 140/80 mm. rt. Art. The pulse on the radial arteries is the same, the vascular wall is smooth. Characteristics of the pulse: arrhythmic, high and fast, satisfactory filling and tension. Vein examination: the saphenous veins of the head, neck, chest, abdomen, thighs are not dilated or tortuous.
Digestive system: Complaints of hernial protrusion, periodic cramping pain in the right groin area.
Upon examination, the symmetrical abdomen participates evenly in breathing. In a standing position at the medial part of the inguinal fold, there is an oval-shaped hernial protrusion, measuring 10 x 8 cm. The painful protrusion does not descend into the scrotum on palpation; upon percussion, there is dullness of the percussion sound. In a horizontal position, the hernia is reduced; on examination, the superficial ring of the inguinal canal is widened, a positive symptom is a cough impulse.
On palpation the abdomen is soft and painless; on percussion there is tympanitis. On auscultation, normal peristaltic sounds are heard. Stool tends to be constipated.
At the time of admission, the abdomen was enlarged in size due to accumulated fluid, and the shape of the abdomen was convex. On percussion there is a dull sound in the lower parts.
Liver examination: Complaints of a periodic feeling of heaviness in the right hypochondrium. There is no connection with the food taken.
When examining the liver area, there is no bulging or pulsation in the liver area. There are no cutaneous venous collaterals. Currently, the liver protrudes from under the edge of the costal arch by 2 cm, at the time of admission it protruded by 6 cm. On palpation, the liver is enlarged, smooth, soft, with a rounded edge, painless.
On palpation, the spleen is not palpable and painless.
Gallbladder: No complaints, not detectable on palpation, painless.
Urinary system : no complaints, urination is free. The kidneys are not palpable. Pasternatsky's symptom is negative on both sides.
Endocrine system: no pathology, the thyroid gland is not changed.
The patient is correctly oriented in space, time and his own personality. Contactable, willing to communicate. Perception is not impaired. Attention is not weakened. Memory is reduced. Intelligence is average. Thinking is not impaired. The mood is even, the behavior is adequate. Nervous system: no motor disorders, sensitivity preserved. There are no meningeal or focal signs.
Preliminary diagnosis: Rheumatism, inactive phase. Combined mitral-aortic heart disease: mitral insufficiency, atrial fibrillation. Aortic insufficiency. GB II. NK IIb. Chronic bronchitis in remission, pulmonary emphysema. Right-sided upper lobe focal pneumonia. Right-sided reducible direct inguinal hernia.
Rationale for the preliminary diagnosis: After suffering from rheumatism (to which frequent sore throats and fasting predisposed), the patient has evidence of mitral heart disease. For mitral valve insufficiency: expansion of the borders of the heart to the left and up (hypertrophy and dilatation of the left ventricle and atrium), weakening of the first sound, systolic murmur at the apex, soft, conducted to the axillary region. Atrial fibrillation. For mitral valve stenosis: protodiastolic murmur at the apex, enlargement of the right border of the heart, decompensation in the systemic circulation. There is also evidence for aortic valve insufficiency: pulsation of the carotid arteries, high and rapid pulse, protodiastolic, decreasing noise at the V point of auscultation, although there are conflicting data: there is no decrease in diastolic pressure. Stage IIb circulatory failure is indicated by pronounced hemodynamic disturbances in the systemic circulation (peripheral edema, ascites, liver enlargement) and in the pulmonary circulation (congestion in the lungs). For chronic bronchitis in remission: smoking since the age of 12, hard breathing, absence of dry wheezing, purulent sputum discharge. For pulmonary emphysema, expansion of the borders of the lungs, weakened breathing, decreased excursion of the lower pulmonary border. For right-sided upper lobe focal pneumonia: a presuming factor is congestive changes in the lungs, moist, ringing, fine-bubble rales in the upper parts of the lungs on the right. For a right-sided, reducible, direct inguinal hernia, abdominal examination data.
Medical history in rheumatology Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, grade II activity, radiological stage II, functional impairment I.
Case history according to pulmonology Diagnosis: Idiopathic fibrosing alveolitis. Cellular lung stage. Moderate erythrocytosis.
Case history according to pulmonology Diagnosis: right-sided lower lobe pleuropneumonia in the stage of resolution. Right-sided postero-inferior lobe encysted pleurisy stage. DN-0.
Medical history according to pulmonology Diagnosis: Chronic obstructive bronchitis, exacerbation phase. Rheumatism. Inactive phase. Mitral heart disease with predominant stenosis. Condition after commissurotomy. Circulatory failure IIB. concomitant diseases - no complications - Pulmonary emphysema. Diffuse pneumosclerosis. Atrial fibrillation, tachysystolic form.
Medical history in pulmonology Diagnosis: Bronchial asthma of moderate severity, mixed form Concomitant diseases: emphysema of pulmonary tissue
Medical history in pulmonology Diagnosis: Acute community-acquired right-sided focal pneumonia in the lower lobe
Case history in pulmonology. Diagnosis: focal pneumonia of the lower lobe of the right lung. D.N. – 1 tbsp.
Case history in pulmonology. Diagnosis: Main disease: Left-sided encysted purulent pleurisy. BK-. Complications of the underlying disease: Respiratory failure stage II. Concomitant diseases: retinal angiopathy of both eyes, optic nerve atrophy of the left eye.
Case history in pulmonology. Diagnosis: acute focal pneumonia localized in the lower parts of both lungs.
Case history in pulmonology. Diagnosis: Recurrent obstructive bronchitis, chronic tonsillitis in subcompensated form, adenoids of I-II degrees.
Rheumatology as an independent scientific and practical discipline was formed almost 80 years ago in connection with the need for a more in-depth study of diseases of this profile, caused by their wide distribution and persistent disability.
detection of rheumatoid factor and various autoantibodies
detection of lymphocytes sensitized to connective tissue
the presence of histological signs of immune inflammation;
ineffectiveness of anti-inflammatory therapy and good effect from the use of immunomodulators. Although there is currently no convincing evidence in favor of the infectious nature of RA, this issue continues to be actively debated.
There is a point of view according to which a certain role in the disease is assigned to viral infection, especially the Epstein-Barr virus, which is localized in B lymphocytes and disrupts the synthesis of immunoglobulins, as well as hepatitis B and rubella viruses.
Rheumatoid arthritis (articular form)
Rheumatoid arthritis with visceral lesions (serous membranes of the lungs, blood vessels, heart, eyes, kidneys, nervous system)
Juvenile rheumatoid arthritis.
B. According to clinical and immunological characteristics
^ B. DURING THE DISEASE
^ D. BY RADIOLOGICAL STAGES OF DEVELOPMENT
^ E. BY THE DEGREE OF PRESERVATION OF FUNCTIONAL ACTIVITY
There are three degrees of activity of rheumatoid arthritis:
^ EXAMPLE OF DIAGNOSIS: Rheumatoid arthritis, predominantly articular form. Seronegative. II degree of activity. Slowly progressive course. X-ray stage P. Functional joint failure of degree II.
Now let us dwell in detail on the clinical characteristics of individual symptoms. INITIAL PERIOD
The joints, as a rule, are increased in size, their contours are smoothed. This occurs due to the formation of effusion in the joint capsule, sometimes a symptom of fluctuation is determined.
^ DURING THE DEPLOYED PICTURE OF ARTICULAR FORM RA DISEASE
Patients are concerned about general weakness, apathy, worsening sleep, and almost complete loss of appetite. There is weight loss and persistent subfibrillation. Against this background, joint damage typical of RA occurs.
Lesions of various joints have certain characteristics:
The most common occurrence is “ULNAR DEVIATION” of the hand - deviation of all fingers towards the ulna (towards the little finger), while the hand takes on the shape of a “WALRUSE FIN”.
A characteristic deformity in the form of a “SWAN NECK” is a flexion contracture in the metacarpophalangeal joints.
In the form of a “BUTTONNERE” - flexion in the metacarpophalangeal joints and hyperextension in the distal interphalangeal joints.
The above deformations are a consequence of the destruction of the articular surfaces of the joints, muscular dystrophies and damage to the tendons, which “pull” the finger phalanges in different directions.
RADIAL JOINT. Damage to the wrist joints leads to their fusion into a bone block, which is tantamount to ankylosis. Sometimes subluxation of the ulnar head occurs.
THE ELBOW JOINT is involved in the process with a sufficiently long history of the disease, which is often accompanied by flexion contracture, the elbow is fixed in a position of semi-flexion, semi-pronation, and is sometimes accompanied by symptoms of compression of the ulnar nerve.
Arthritis of the SHOULDER JOINT is relatively rare and is accompanied by swelling and widespread pain, which significantly limits movement.
KNEE JOINTS are often affected and already at the onset of the disease. It is characterized by profuse effusion and inflammatory swelling of the periarticular tissues. Upon palpation in the popliteal fossa, a synovial protrusion “BAKER CYST” can be identified. The patient is in a forced position with bent knees. If you do not change the position, the joint very quickly becomes fixed in this position and flexion contracture occurs. When the intra-articular ligaments are weakened, the “DRAWER” symptom is determined.
^ RHEUMATOID ARTHRITIS WITH VISCERAL MANIFESTATIONS
^ Lesions of the pleura and pericardium are one of the most common visceritis. More often they are dry, less often exudative. As a rule, they occur latently and are determined after the fact in the form of pleural or pericardial adhesions, detected during X-ray examination. Sometimes patients are bothered by moderate pain in the side when breathing and coughing. Rarely, polyserositis occurs with a detailed, clear clinical picture. A feature of pleurisy of this etiology is the presence of rheumatoid factor and low glucose levels in the exudate, a good effect from hormonal therapy and a significant increase in ESR (up to 50 mm/hour).
^ Kidney damage in PA is one of the causes of death in these patients. It develops 3-5 years after the onset of the disease and manifests itself in the form of three types of lesions: renal amyloidosis, focal nephritis and pyelonephritis.
^ Rheumatoid vasculitis is a very characteristic manifestation of RA. It is accompanied by damage to internal organs, skin symptoms (polymorphic hemorrhagic rash, multiple ecchymosis), nasal and uterine bleeding, cerebral and abdominal syndrome, and neuritis. Always combined with a high titer of rheumatoid factor in the blood.
^ Heart damage is relatively rare and manifests itself mainly in the form of myocardial dystrophy. Sometimes symptoms indicating the presence of myocarditis are observed (moderate pain in the heart area, shortness of breath, enlargement of the borders of the heart, decreased sonority of the first tone, systolic murmur above the apex). The peculiarity of such carditis is scanty symptoms and a long, persistent, relapsing course.
In some cases, the endocardium is affected, leading to relative mitral valve insufficiency.
^ Lung damage can manifest as chronic interstitial pneumonia, with relapses during exacerbation of rheumatoid arthritis. It is manifested by cough, shortness of breath, low-grade fever, dullness of percussion sound and fine wheezing in the lower parts of the lungs. A special feature is the good effect after a course of corticosteroids and the lack of dynamics during long-term antibacterial therapy.
^ Damage to the nervous system - rheumatoid neuropathy - is one of the most severe manifestations of RA. It can manifest itself in the form of polyneuritis, accompanied by severe pain in the limbs, motor and sensory disorders, and muscle atrophy. In severe cases, paresis and paralysis may occur. Cerebrovascular accidents are caused by vasculitis of cerebral vessels.
^ Liver damage is observed in 60% -80% of patients. Accompanied by an increase in pathological functional tests: thymol, sublimate, formol.
Changes in the gastrointestinal tract manifest themselves in the form of hypoacid gastritis (flatulence, coated tongue, heaviness in the epigastric region). The possibility of developing this condition as a result of long-term drug therapy for RA cannot be ruled out.
Eye involvement is rare. As a rule, these are iritis and iriocyclitis.
The most severe variant of the clinical course of the disease. Some authors designate it as malignant RA. As a rule, it occurs in young people. The onset is acute, the articular syndrome is significantly expressed with the rapid involvement of cartilage and bones in the process. This is accompanied by high fever of the hectic type with chills and heavy sweats, weight loss, anemia, visceritis and vasculitis. The disease progresses rapidly. In 50% of patients, damage to internal organs becomes the leading factor in the clinical picture, and the symptoms of arthritis seem to recede into the background. Sometimes, when massive therapy with corticosteroids is prescribed, transformation of the disease into its usual form is possible. All laboratory tests indicate the highest degree of activity. Rheumatoid factor and, in some cases, single lupus cells are often detected in the blood. Blood cultures are always sterile.
More frequent onset and course of mono-oligoarthritis with damage to large joints (knees, hips, spinal joints).
2. Frequent eye damage.
More favorable prognosis.
In patients with rheumatoid arthritis, when examining a clinical blood test, the following may be observed:
^ RHEUMATOID FACTOR - although it is not specific only for RA and is found in chronic hepatitis, liver cirrhosis, syphilis, tuberculosis, in healthy people (2% - 5%), its determination in RA still has important diagnostic value. With this disease, Rheumatoid factor is detected in 85% of patients. It is determined using the Vaalery-Rose reaction.
nom synovial fluid;
pain in the joint when moving or palpating it;
joint swelling or effusion without bone growths;
swelling in at least one other joint (the interval of involvement of new joints should not exceed 3 months);
symmetry of joint damage;
subcutaneous rheumatoid nodules;
typical x-ray picture (osteoporosis, cartilage destruction, abnormalities);
detection of rheumatoid factor in serum or synovial fluid (Waaler-Rose reaction);
10. morphological signs of rheumatoid arthritis;
In this case, the first 4 criteria must be at least 6 weeks old. If 7 criteria are present, a diagnosis of classic rheumatoid arthritis is made, if 5 are present, definite, and if 3 criteria are present, probable.
localization of RA in the II and III metacarpophalangeal and proximal interphalangeal joints;
morning stiffness in joints for more than 30 minutes;
epiphyseal osteoporosis on x-ray;
changes in synovial fluid characteristic of RA.
The main principles of RA treatment are:
rehabilitation of chronic foci of infection;
anti-inflammatory therapy depending on the degree of activity
immunosuppressive therapy in cases of visceritis and lack of effect from anti-inflammatory drugs
local therapy of affected joints, including surgical methods of treatment
Fast-acting non-specific anti-inflammatory drugs (steroidal or non-steroidal)
Basic or slow-acting drugs that have a deeper and more stable effect on the rheumatoid process. The use of basic therapy is the basis of RA treatment.
Among the means of rapid anti-inflammatory action, corticosteroids come first. The mechanism of their action is to strengthen cell membranes, desensitizing and anti-inflammatory effects. The most commonly used are: prednisone and prednisolone 10-20 mg/day; dexamethasone 2-3 mg/day, triacinalone 12-16 mg/day. Hormones can be combined with gold drugs and immunosuppressants. With long-term use, in order to avoid withdrawal symptoms, it is necessary to reduce the dose of corticosteroids by 1/4 tablet every 5-6 days.
Voltaren (25-50 mg 3-4 times a day)
This is primarily a decrease in oxidative phosphorylation, which leads to inhibition of ACE synthesis, which is necessary for the inflammatory response and a decrease in the intensity of inflammation.
Drugs in this group have a stabilizing effect on the permeability of cell membranes, which prevents the release of proteolytic enzymes from the cell and inhibition of inflammatory mediators.
Reduce the synthesis of prostaglandins involved in maintaining the inflammatory response.
All drugs have a toxic effect on the gastrointestinal tract, and therefore they are contraindicated in patients with peptic ulcer disease. It should be noted the development of leukopenia and agranulocytosis after taking the drugs.
Recently, new representatives of this group have appeared, significantly superior to their predecessors in anti-inflammatory action and practically devoid of side effects. These include: ketoprofen, tolectin, piroxicam, revodina, etc.
In severe, torpid RA, in articular-visceral form, pseudoseptic syndrome, the best method of basic therapy is immunosuppressants. Either antimetabolites that block the synthesis of nucleic acids (methotrexate, azothioprine) or alkylating agents that denature nucleoproteins (cyclophosphamide, leukeran) are used.
Azathioprine and cyclophosphamide 100-150 mg/day, maintenance – 50 mg/day
leukeran 2 mg 3-4 times a day, maintenance – 2 mg/day
methotrexan 2.2 mg 2 days in a row (1st day 1 time, 2nd day 2 times a day) with a break of 5 days, a total of 7.5 g per week, long-term.
The effect of the drugs occurs within 2-3 weeks; after improvement, maintenance doses are prescribed for several years. It must be emphasized that all drugs in this group reduce the body’s resistance to infections, and therefore there is a real danger of developing pneumonia, pyoderma, etc.
Recently, more and more people have started to use immunoregulators, in particular, Levamisole (Decaris) enhances the function of T-lymphocytes.
intra-articular injection of hydrocortisone 30-50 mg every 2-3 days No. 5-7
ultrasound, UHF, paraffin, azokerite
surgical treatment – synovectomy
- chronic systemic inflammation of the joints, mainly the spine, with limitation of its mobility due to ankylosed intervertebral joints and calcification of the spinal ligaments.
the presence of HLA-B27 on the surface of cells makes connective tissue more sensitive to the infectious agent
The infectious agent, under the influence of the B27 antigen, is modified, converted into an autoantigen, and stimulates the development of the autoimmune process.
The mechanisms of cartilage metaplasia and tissue ossification in BD have not yet been elucidated. There is a point of view according to which these processes develop under the influence of a special substance that can transform the differentiation of connective tissue cells into cartilage and bone. This substance was isolated from injuries to the epiphyses of young animals, from the anterior parts of the spinal cord, the epithelium of the prostate gland and bladder. Probably, in this regard, it is possible to establish a connection between infection of the genitourinary organs and the development of BD.
CENTRAL FORM, in which only the spine is affected, is divided into two types:
a) kyphosis type - lordosis of the lumbar and kyphosis of the thoracic spine, in these kyphosis of the thoracic spine and hyperlordosis of the cervical spine;
RHIZOMELIC FORM, (rhiso - root) in which, in addition to the spine, the “root” joints (shoulder and hip) are affected.
PERIPHERAL FORM. Along with the spine, peripheral joints (elbows, knees and ankles) are affected.
SCANDINAVIAN SHAPE. Characterized by damage to the small joints of the hand.
Some authors also distinguish 5 - the visceral form of BD, in which, along with damage to the spine and joints, damage to internal organs is detected, but this form is not recognized by everyone.
According to stages, based on radiological signs, they are distinguished:
With the CENTRAL FORM of BD, the onset is imperceptible and the diagnosis is made after several years. Pain appears first in the sacral joint, and then in the lumbar and thoracic spine (from bottom to top). They occur during physical activity and prolonged stay in one position, radiating either to the left or to the right thigh. Pain in the spine intensifies in the second half of the night, and in the sacroiliac joint towards the end of the working day. Posture is not changed, gait becomes constrained only in severe pain. When the thoracic spine is damaged, intercostal neuralgia appears, the pain intensifies with a deep breath, coughing, and has a shingles character.
In women , ankylosing spondylitis has its own characteristics; it begins unnoticed, has a very slow and benign course with long-term remissions. Clinically, sacroiliitis is manifested only by minor pain in the sacrum.
With ankylosing spondylitis, damage occurs to the eyes, cardiovascular and nervous systems, lungs and kidneys:
eye damage is expressed in iritis, uveitis, iridocyclitis, which occurs in 20% -30% of patients. In addition to these so-called primary lesions, secondary ones are also observed - keratitis, cataracts
damage to the cardiovascular system is manifested by aortitis and damage to the aortic valves with the development of their insufficiency
characterized by the development of renal amyloidosis, which ends in uremia and renal failure
complications from the nervous system are primarily radiculitis (cervical, thoracic and lumbar).