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Diagnosis: Exacerbation of chronic hepatitis B


The history of the disease in relation to infectious diseases.

Diagnosis: IUD, manifestible arteritis, subacute flow, moderate severity, with damage to the locomotor system.

Complaints of the patient (at the time of admission and at the time of keration)

  1. For permanent weakness, fatigue
  2. Sweating
  3. Tearing pain in the head, Heaviness in the head
  4. elevated blood pressure (up to 210/110 mm Hg)

 Epidemiological history

The patient lives in a well-equipped apartment alone. Observes personal hygiene, the use of unwashed vegetables, fruits, not boiled water, raw milk is denied. Pets are not kept at home. Pediculosis denies.

May 6, 2003 was bitten by an Ixod mite in a cemetery, which could be on the patient about half an hour. The clam was removed from the patient, after which she was taken to a prophylactic point where the RNIF was performed, giving a negative result to the Borrelian antigens.

A reddish spot in the diameter of approximately 1 cm without edema was observed at the bite site.

After 21 days, NIFF was re-administered, which revealed the titre of 1: 160 Borrelian antigen. By this time, the patient already noted the severity in the head, weakness, sweating, knee pain, muscle aches.

Immunological status: angina – often in childhood (up to 2 classes); || 156 = == Professional harm – emotional stress.

Earlier, about 20 years ago, was using river fish, but after diagnosis of cholecystitis, the patient was advised not to have a river fish, which she has done since then. Beyond the Tomsk region in the next six months did not go.


Probable source of infection – Ixodic tick

Transmission mechanism – Transmissive

Infection transmission path – contact

VI. Anamnesis of life

The sick was born on August 20, 1942, was fed with breast. In physical and mental development it corresponded to age.

Porcine measles, frequent acute respiratory diseases, including angina (up to 2 classes). Immune childhood does not remember. The presence of bad habits denies. Menarche with 13 years of age, regular, 3 days in 28 days, painless. He has two children (2 children – 25 and 28 years old), healthy. Has transferred 2 pregnancies and 2 genera.

Transferred operations and diseases:

Appendectomy – 1970

Operation on the thyroid gland on a thyroid gland

Chronic colitis, chronic cholecystitis, cataract 0d

Urolithiasis – detected in 1992.

Tuberculosis, venereal, mental illness denies.

GB II stage, 3 degree

Family history

Children deny the presence of chronic diseases. The man suddenly died in 2002.

Objective Status

Status praesens communis

General condition of the patient of moderate severity. Body temperature 36,7. Consciousness is clear. The position of the patient in bed is active.

Lymph nodes: single, movable, elastic, painless, the skin above nodes is not changed, movable.

Thyroid gland is not enlarged.

Joints Shoulder, elbow, radial, interphalangeal, hip, ankle normal configuration, painless, with active and passive movement, no restriction of mobility, crackling and fluctuation is absent.

The development of the skeleton is correct, the head of the usual form is proportional to the other parts of the body, the ratio between the face and the body. brain section of the skull is correct;


Chest examination:

Type of respiration of the abdomen, depth and rhythm are preserved, the frequency of respiratory movements of 18 per minute, the auxiliary muscles in the act of respiration do not participate.

Palpation of the chest

Vocal jerking: over the symmetrical sections of the thoracic cavity of the anterior, posterior, and lateral segments, the voice tremor is carried out in the same way.

Auscultation of the lungs With forced exhalation and restful breathing during auscultation of the lungs in the wedge-and-orthostatic position, the breathing of the peripheral divisions ehkyh vezykulyarnoe. There is no haplot.


No apparent changes in the region of the heart are detected. Visible ripple in the region of the heart and the epigastric region is absent.

Upper thrust on 1 cm from the midlectric line, positive, limited, not strengthened. When palpation of pain points in the region of the heart is not revealed.

Arterial pressure

On the right hand 160/110 mm Hg. Art.

On the left hand 160/110 mm Hg. Art.

Pulse pressure 50 mm. ht Art.

Arterial pulse on the arterial arteries

The following pulse properties are noted:

  1. on both hands symmetrical, rhythmic.
  2. frequency 88 av . in mines
  3. pulse of moderate voltage
  4. pulse of normal size
  5. shape of pulse wave correct
  6. vascular wall not condensed

Belly soft, both sides are symmetrical, the abdominal wall participates in the act of breathing uniformly, hernial protrusions and postoperative scarring is not present. The muscle tone of the anterior abdominal wall is moderate. Subcutaneous venous network, visible peristalsis of the intestine, flatulence are absent. Thickness of the skin folds at the navel level 4 cm.

There are no data indicating the presence of free fluid in the abdominal cavity.

Palpation of the abdomen

Surface palpation: palpation of the abdomen soft, painless, The higurous protrusions are absent.

Deep palpation:

A) Sigmoid – is located correctly on the middle third of the approximate distance (perpendicular from the navel to the line joining the apex idiopathic bone and kelp bundle), diameter 2.5 cm, elastic; the wall is smooth, smooth; mobility is 3-4 cm, painless, there is no rash with palpation.

B) Blind gut – is located in the middle third of the distance from the navel to the ridge of the ileum, diameter 4-5 cm; elastic; the wall is smooth, mobility is sufficient (2 cm); painless, urticaria is determined.

B) Upward and downward colon – not palpated

D) The transverse colon is not palpable

Gastric examination

Percussion: The border of the lower edge of the stomach is 2 cm above the navel.

Auscultation: The border of the lower edge of the stomach corresponds to that in percussion. No splash noise is detected.

Palpation The wall of a large curvature of the stomach is even, elastic, movable (2 cm), painless. The gatekeeper is not palpable.

The pancreas: The zones of Schofar and Gubergrits are painless. Pain with palpation at the point of Meio-Robson is absent

Liver examination

With percussion

Upon arrival:

– Upper boundary – Upper edge 6 ribs.

– Lower border: the liver does not protrude beyond the edge of the edge arc.

The size of the liver by Kurlov:

Size Sm
On the median-clavicular line from the upper boundary of the absolute dullness of the liver to the lower limit 10
From the base of the mild process to the lower boundary of the median line 9
From the base of the false process to the left border 8

Palpation of the liver :

On arrival: the edge of the liver is smooth, slightly rounded, tight-elastic, painless.

Symptoms of Kerah, Murphy, Curvoise, Pekarsky, Boas, frenicus-negative symptoms.

Examination of the spleen

Percussion performed:

Upper boundary Upper edge of VIII rib
Lower boundary Уровень  XI межреберья
Front lower pole Does not go beyond the linea costoarticularis
Rear upper pole Under the blade line || | 561

Investigation of the kidneys

Not palpable. Pasternatsky’s symptom on both sides is weakly positive.

Investigation of the bladder

In the percussion of the bladder is not defined. The bladder is not palpable. Urinalysis is regular, painless.

Sex organs: By female type


Mental development corresponds to norm, sleep is bad (presomnitic insomnia); the mood is stable, the response to the surrounding is adequate. The attitude to your illness is adequate, contact with others is good. Tendons, pupillary reflexes without abnormalities. Pathological reflexes (Babinsky, Rossolimo, Gordon, Schefer negative), muscle ligaments of the nape of the nape, no symptoms of Kernig, Brudzinsky (upper, middle and lower) negative. Sample of Romberg: mild instability with closed eyes, swaying in the anterior-posterior fissure. : there is no mistaking, pain and tactile sensitivity is preserved. Violations of the higher brain functions (apraxia, agraphy, aphasia, agnosia) have not been revealed.

Preliminary diagnosis and its justification

SBB, manifestation zearthritic form, subacute flow, moderate severity, and damage to the locomotor system.

The diagnosis is based on

– complaints (weakness, fatigue , sweating, sensation of torsion of the head, headache, knee pain, muscle aches, elevated blood pressure ( max to 210/110 mm Hg) || | 603

– an epidemiological anamnesis (a bite of ixodic tick on May 6, 2003)

Laboratory research plan

  1. Detection of antibodies to Borrelia in serum using RNIF, IFA with AG Borrelia and PCR.
  2. UAC.
  3. OAM.
  4. OAM .|| 620
  5. Coagulogram (we are interested in PTI to determine the safety of the protein synthesis of the liver)
  6. Ultrasound of the abdominal organs Cavity.
  7. X-ray examination of knee joints.
  8. Wasserman’s reaction

Treatment plan and its justification

The treatment regimen should be ward. It is necessary to provide 8-9 hours of sleep, a calm atmosphere, to eliminate stressful situations.

Conducting in the food diet vitamins of groups B, C, E helps to stop lipid peroxidation and tissue hypoxia.

В As natural immunomodulators it is possible to use natural products containing ascorbic acid (lemon, kiwi).

Medicinal therapy: It is necessary to adhere to the principle of a minimum of medicines.

Etiotropic therapy

Ceftriaxone – in / m or in / in 2,0 1 times a day for 10 – 1 4 days.

You can not reduce the single dose of the drug and reduce the frequency of drug intake, since in order to obtain the therapeutic effect, it is necessary to maintain a sufficient concentration of antibiotic in the patient’s body at all times. With the development of relapse, the duration of etiotropic therapy should be doubled.

Pathogenetic therapy

  1. Riboxin – 1 tabl 3 p / d

The drug improves the synthesis of protein in tissues, including hepatocytes, promotes the elimination of hypoxia, improves all metabolic processes.

  1. Desensitizing therapy – suprastin 0.001 2 r / d throughout the course of treatment,
  2. Polyvitamins.
  3. 0.9% sodium chloride solution no more than 40 ml / kg of body weight per day. – To reduce intoxication.


XIII. Differential Diagnosis

For the final diagnosis of ICB, differential diagnosis is required between similar diseases, as infectious (with tick-borne encephalitis, rheumatic fever), and autoimmune (rheumatoid arthritis).

The epidemias in these two diseases are similar to drinking raw milk, a trip to nature, where it could be contacted Ixodic ticks: detection of it on the skin or it could remain unnoticed. The patient has a history of masturbating on 6.05.2003.

An important role in the diagnosis of CE is the determination of antibodies in the serum of the blood to the ECE virus, which was never detected in any patient’s blood test. At the same time, anti-Borrelia antibodies (titre 1/160) were detected, which allows the final diagnosis of “Ixodic tick-borne borreliosis”.

We will conduct differential diagnosis with rheumatism, the clinical picture of which is characterized by resemblance to LB with major joint damage (pain, swelling that leads to limitation of their mobility, reddening of the skin above the joints, migratory nature of the pains), but with rheumatism, the defeat of several large joints is characteristic, and with LB is usually mono – or oligoarthritis, my patient Only the knee joints are disturbed (soreness and some limited movement in them caused by pain)

Playing a role to clarify the diagnosis of epidemias: in rheumatic fever, a history of infection occurs 2-4 weeks ago, caused by the b-hemolytic streptococcus group AND; and at LB – the use of raw milk, trips to the forest masses, contact with a mosquito mite. In May 2003, the patient had a mucus mucous membrane, and in the last 1-2 months there was no pain in the infectious diseases.

Laboratory data are necessary for the diagnosis: rheumatism is characterized by an increase in ESR, an increase in CRP concentration, titres of antistriptolysin O in the blood. The LB criterion is the detection of a diagnostic titre of antibodies on B. Burgdorferi. (1:64 and more). My patient showed high titre antibodies to Borrelia with the help of NRIF = 1: 160. Laboratory studies for rheumatism have not been performed.

Based on the above diagnosis, rheumatism appears to be less confirmed clinically, epidemiologically and laboratory than the diagnosis of chronic bronchitis. here is the diagnosis of “IKB” authorized.

It is also necessary to differentiate the IVB with rheumatoid arthritis. This is an autoimmune disease, which is characterized by similar signs with the SBI: the deterioration of the general conditions, similar lesion of joints on both sides, presence of joint pains, ringed erythema. But rheumatoid arthritis differs by the presence of morning stiffness of the joints (about 1 hour), swelling and effusion in at least 3 joints, and in case of IBS, mono or oligoarthritis is characteristic. In my patient only 2 joints are struck – knees, without effusion, but with swelling, pain syndrome.

For a final diagnosis, a laboratory examination is required: in rheumatoid arthritis, the detection of elevated ESR and CRP is characteristic. The LB criterion is the detection of a diagnostic titre of antibodies on B. Burgdorferi. (1:64 and more). My patient showed high titre antibodies to Borrelia with the help of NRIF = 1: 160. Laboratory studies for rheumatoid arthritis were not conducted.

T.o. the diagnosis of “rheumatoid arthritis” is clinically unconfirmed, unlike the “IKB”, in whose favor the clinic says, the epidemnase and the laboratory data.

The final diagnosis and its justification

The underlying disease: IUD, manifestible arteritis, subacute flow, moderate severity, with damage to the locomotor system.


Concomitant diseases: chronic colitis; chronic cholecystitis; Urolithiasis; GB II st., 3 steps

The diagnosis is based on

 complaints (weakness, fatigability, sweating, sensation of rupture head, headache, knee pain, muscle aches, increased blood pressure ( max to 210/110 mm Hg)

 history of the disease (characteristic cyclicity in the development of the disease: gradual onset, deterioration of the general condition),

The manifest form is put, since There LB Clinical signs and availability of pathogen persistence in the blood.

subacute techenye raised in connection techenyem disease in 3-6 months

  1. XV. Forecast

The prognosis for life is relatively favorable, with adequate and timely therapy in the acute period of the disease.

In the event that the high titre of IgG antibodies to the pathogen will be maintained, the prognosis is unfavorable .

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