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History of the disease in rheumatology. Diagnosis: rheumatoid arthritis.

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History of the disease by rheumatology

Diagnosis: rheumatoid arthritis, polyarthritis, seropositive, slow progressing current, II degree activity, II radiological stage, functional disorders.

Passport part

Age of 47 years

Gender: Male || | 121

Education: secondary

Profession: miller

Entry date: February 18, 2003

The diagnosis with which was sent to the clinic: rheumatoid arthritis, polyarthritis, seropositive, slowly progressing current, activity of II degree.

Preliminary diagnosis: rheumatoid arthritis : polyarthritis, seropositive, slow progressing current, II degree activity, II radiologists esophageal stage, functional disorders I.

Clinical diagnosis: rheumatoid arthritis: polyarthritis, seropositive, slowly progressing current, II degree activity, II radiological stage, functional disorders I.

Complaints: On moment of kering: complaints of weak pains in the pharyngeal, phalanges, knee and shoulder joints, pain limitation of mobility and a slight increase in the temperature of the skin above these joints. Crisp in these joints is observed during movement; their swelling; morning stiffness before lunch; general weakness. Upon arrival: painful pains in the pharyngeal, phalangeal, raccoon, knee and shoulder joints, which arise not only during movement but also in rest; marked pain limitation of mobility and an increase in the skin temperature over these joints. Crisp in these joints is observed during movement; their swelling; morning stiffness before lunch; general weakness; loss of appetite, dizziness.

Anamnesis of the present disease: (Anamnes morbi) She considers herself ill since 1999, when she first experienced a sharp pain in the left lumbosacral and pharyngeal phalangeal joints of both hands, a brief stiffening in these joints, noted a general malaise. The occurrence of pain relates to the conditions of labor – constant supercooling and dampness. He was admitted to the Central Hospital of the Askeyevsky District, where he was diagnosed with rheumatoid arthritis. After 2-week treatment (diclofenac, dosage can not be specified) pain has subsided. After discharge from the clinic, he began to notice that the joints began to react to the change of weather, and pain arises in spring and autumn. In the spring of 2000 there was a swelling and pain in the shoulder and knee joints. The regional polyclinic was sent to the OKB, where prednisolone was designated Tab. within one month, physiotherapy treatment. Joint pains have disappeared, mobility has increased. Spring 2001 was sent to the spa treatment in the sanatorium of Pyatigorsk. February 18, 2003 Re-hospitalized in the rheumatologic department of the OKB, in connection with the exacerbation of the disease: painful pains in the pharyngeal, phalangeal, radiolucent, knee and shoulder joints, which arise not only during movement but also in rest; marked pain limitation of mobility and an increase in the skin temperature over these joints. Crisp in these joints is observed during movement; their swelling; morning stiffness before lunch; general weakness; loss of appetite, dizziness.

Anamnes vitae: (Anamnes vitae) Born in ***, the third child in the family, grew and developed according to age. Not lagged behind peers in physical and mental development. I went to school with 7 years old, I studied satisfactorily, I was engaged in physical education in the main group. At the end of the school he was called into the army for a fleet. Married, has one child (daughter). Children’s diseases (measles, rubella, scarlet fever, diphtheria) are denied. Notes the hereditary predisposition to joint diseases: the mother had joint pains. There is a reaction to the administration of nicotinic acid – skin rash, ulcers on the mucous membranes. Tuberculosis, hepatitis, malaria, venereal disease is denied. There was no blood transfusion. Outside the area the last 6 months did not go. Bad habits: do not smoke, alcohol consumes in limited quantities. Housing and living conditions are satisfactory, regular meals.

Present state (Status preasens) The condition of the patient is satisfactory, consciousness is clear, the position in the bed is active, the patient is contacted. The body is normostenic. The appearance of the patient corresponds to age and sex. Height 164 cm, weight 64 kg. The skin is dry, clean, the color of the skin is pale, skin elasticity is preserved, visible mucous pink, moist. Limitation of movement in the radiculosic, malignant, phalangeal, shoulder, knee joints. Synovized raccooplastic, hepatic phalangeal joints of both hands: swelling, increased skin temperature over the joint area, pain in palpation. Coughs, scalds, petechia, no scarring. Caprine for men. Hair is interrupted. Nail plates of the correct form, nails are brittle, nail plates do not crack. Subcutaneous fatty tissue is expressed moderately, distributed evenly. Fetuses, acrocyanosus no. Inspection on systems of organs:

Respiratory system: Nose is not deformed, breathing through the nose, free. Thoracic cell is cylindrical, the collarbone is on the same level, the stroke is obliquely down, the intercostal gaps do not explode and do not void. Both halves of the chest are uniformly involved in the act of breathing, make a voice trembling. Respiratory rate 16 per minute. Percussion over the lung fields is a clear lung sound. There are no local sound changes. The data of topographic percussion: the height of standing of the upper lungs – in front – 3 cm on both sides, at the back – at the level of the spinal cord of the 7th cervical vertebra. The width of the Kernig fields is 5 cm on both sides. The motility of the lower edge of the lungs on the midlectric line is 5 cm on both sides. Breath of vesicular, wheezing, pleural frictional noise is absent. Lower boundaries of lungs. 

Cardiovascular system: The region of the heart is not changed. There is no pathological pulsation of vessels. Cyanosis, peripheral edema, shortness of breath. Rhythmic pulse, arterial pressure on the right arm 110/70 mm. ht Art., on the left 110/70 mm. ht Art. The pulsations of the vessels of the lower extremities are symmetrical, good. Upper thrust in the V intercostal space to the left, intrinsic to l. Medioclavicularis sinistra 1 cm, 1.5 cm wide, moderate strength and height. 

System of digestive organs. Lips are pink. Mucous membrane of the mouth is clean, moist, pink. The tongue is wet, slightly covered with a white patch at the root. The abdomen of the usual form and size, uniformly participates in the act of breathing, soft, painless, accessible to deep palpation. 

Urinary system: The kidneys are not palpated. The points of the kidneys and urinary tract are painless. There is no pain in sensation when swaying through the lumbar region. Urine of light yellow color, clear. Urination is free, painless, 5-6 times a day. Daily diuresis about 1200 ml. At night, do not urinate.

System of organs of hematopoiesis: On the skin of hemorrhages, hemorrhagic rash is not present. Mucous membranes are pale pink. Lymph nodes are not enlarged. The spleen is not palpable; Percussion is determined from IX to XI by l. axillaris media sinistra. Chewing on flat bones is painless. Dimensions of the spleen according to Kurlov: 4 cm wide, 6 cm long.

Endocrine system: Height 164 cm, weight 64 kg. The hair cover corresponds to the floor. General development corresponds to age. The face is round, pale. Subcutaneous tissue is developed moderately, distributed evenly. When examining the contours of the neck are even. The thyroid gland is not enlarged. Tremor of hands, tongue, age is absent.

Musculoskeletal system: Limitation of movement in the radiculous, malignant, phalanges, shoulders, knee joints. Crisp in these joints is observed during movement; morning stiffness before lunch Synovitis of raccoat, pharyngeal and phalangeal joints in both hands: swelling, increase in skin temperature over the joint area, pain in palpation.

Central nervous system: Patient contact, emotionally labile. Speech is clear, attention is preserved. Pain sensitivity is not reduced. Parets and paralysis are not present. Intellect is average. Insomnia due to severe pain in the joints. The patient’s illness relates adequately, easily comes into contact. Pulse 62 per minute. Muscular strength corresponds to age. Flow discharge under physical activity. No pathological symptoms. disease diagnosis anamnesis rheumatoid arthritis

Conclusion: dysproteinemia: hypoalbuminemia, hyperglobulinemia; increased fibrinogen content. Immunological study: February 18, 2003 rheumatoid factor – slightly positive (+) C reactive protein – slightly positive (+) X-ray examination: 21.02.03. In the images of both brushes in the direct projection, there is diffuse osteoporosis, cystiform irradiation in the heads of the middle fingers of the palpous bones, small bones of the wrists, narrowed articular gaps in the radius of the joints, narrowed to the left. The contours of the articular surfaces are fuzzy. Conclusion: rheumatoid arthritis stage II.

Clinical diagnosis and justification

Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slow progressing current, II degree activity, II radiological stage, functional disorders I.

rationale: morning stiffness up to dinner of raznozapyastnyh, hexagonal, phalanges, shoulder, knee joints; arthritis of more than three joints; arthritis of the joints of the brush; symmetrical arthritis-areas of raccooplastic, malignant, phalangeal, shoulder, knee joints have swelling of periarticular soft tissues; presence of rheumatoid factor in serum; X-ray changes: in the images of both brushes in the direct projection there is diffuse osteoporosis, chesty-like irradiation in the heads of the middle fingers of the macular bones, small bones of the wrist, narrowed articular gaps in the radiographs, more left, contours of the articular surfaces are unclear.


Seropositive, since Rheumatoid factor
in the serum of the blood is detected The data on the history of the disease and the X-ray examination are indicated on the slow progressing course: during the course of the disease (3 years) no significant deformation of the damaged joints was detected, 2 new joints (shoulder, knee) were involved in the process.


For the II stage of activity (mean) the following symptoms: joint pain not only during movements but also in rest, stiffness lasts until noon, expressed pain limitation of mobility in the joints, moderate stable exudative phenomena. Hyperthermia of the skin over the affected joints is moderate. SLE – elevated to 32mm / h (norm = 15mm / h), dysproteinemia: blood albumins – 47% at normal = 50-70%, number of globulins – increased to 35% (norm = 20-30%). Rheumatoid factor – sl. positive (+); C – reactive protein – sl. positive (+).


The II-stage stage is determined from the data of the X-ray examination: On diffused osteoporosis, sphincter irradiation in the heads of the middle fingers of the palpous bones, small bones of the wrists, narrowed articular gaps in the radicular joints, the left is larger on the images provided by both hands in the direct projection. The contours of the articular surfaces are fuzzy.


Functional disorders I- slight limitation of movement in the joints, feeling of stiffness in the morning; Professional fitness is preserved, but somewhat limited.

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