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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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rheumatic tests: uric acid - 589 μmol / l, CRP - 2, rheumatoid factor -
0, ASL-O - 125 units, total protein - 77.5 g / l, protein fractions - albu-
min - 53%, globulins A1 - 3%, A2 - 9%, beta globulins - 14%, gamma
globulins - 21%. 5. General urine analysis: relative density - 1015,
slightly acidic reaction, protein - 0.066 g / l, erythrocytes - 0-2 in eld
of vision, leukocytes - 0-2-4 in eld of vision. 6. Feces on the eggs of
the worm - negative. 7. Study of the synovial uid of the knee joint:
the presence of needle crystals located intracellularly and birefringent
light in a polarizing microscope). 8. Aspiration of the contents of tofus
- the presence of uric acid crystals. 9. Ultrasound of the kidneys - the
kidneys are typically located, mobility is preserved, the calyx-pelvis
complex is not changed. In the area of the cortical zone of the left kid-
ney, foci of slightly pronounced hyperechogenicity and signs of mi-
crolithiasis are traced. 10. Computed tomography of the kidney area:
foci of interstitial brosis and micro-calculi were found in the area of
the cortical layer of the left kidney. 11. Consultation of an urologist:
there is no data for microbial damage to the kidneys. The picture of
renal pathology does not contradict metabolic nephropathy.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 9
Patient N, 60 years old, a loader. Upon receipt of a complaint of
recurrent pain in the joints of the lower extremities, which sharply in-
tensied with prolonged walking, physical exertion, going down stairs,
a feeling of morning stiness in them for about half an hour, crackling
when moving in the knee joints, discomfort in the lumbar spine.
From the anamnesis it was found that he has been suering from
this disease for 12 years. The onset of the disease is gradual with
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lesions of the knee and ankle joints, as well as the lumbar spine. Oc-
casionally, after intense physical work in the area of the knee joints,
swelling was noted, which lasted for 7-8 days and disappeared after
limiting movements in the knee joints and the use of diclofenac oint-
ment. Recently, the condition has worsened, pains in the joints and
spine have become more intense and prolonged, a feeling of morning
stiness has joined.
On objective examination: the physique is correct, the nutrition
is increased, it is dicult to move due to pain in the knee and ankle
joints. The skin is not externally changed. Deformation of the knee
joints due to the predominance of proliferative changes, the volume of
active movements in them is somewhat reduced, the volume of pas-
sive movements is preserved. The ankle joints are not changed out-
wardly, the movements in them are preserved. There is crepitus and
crackling during movements in the knee and ankle joints. Tenderness
to palpation in the paravertebral region of the spine, in the knee and
ankle joints.
1. Complete Blood Count: RBC – 4,6х10
12
/L, Нb –123 g/L,
MCH – 27 pg/cell, WBC – 7,3х10
9
/L, neutrophils bands – 2%, neu-
trophils segments – 67%, lymphocytes – 20%, monocytes – 8%, eo-
sinophil – 1%, PLT – 214,0х10
9
/L, ESR –20 mm/h.
2. Fasting glucose - 4.9 mmol / l, prothrombin index - 90%.
3. Biochemical blood test: total protein - 79.2 g / l, albumin -
53%, globulins a1 - 4%, a2 - 9%, beta globulin - 9%, gamma globulin
- 25%, rheumatoid factor - 0 , uric acid - 335 μmol / L, ASL-O - 125
units, sialic acids - 2.36 mmol / L, cholesterol - 5.2 mmol / L, total
bilirubin - 12.4 μmol / L, CRP - 1.
4 General urine analysis - no change. 5. Feces on the eggs of the
worm - negative. 6. Synovial uid - slight opacity, no crystals, leuko-
cytes (less than 2000 cells / mm3, less than 25% of neutrophils).
7. Scintigraphy with technetium pyrophosphate: increasing the
concentration of the drug in the upper lumbar spine, in the knee joints.
8. Thermal imaging examination of the joints: during examina-
tion in infrared rays, zones of pronounced hypothermia in the area of
the knee joints are determined.
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133
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 10
Patient N, 47 years old, a recycling technologist, turned to the
local polyclinic in October with complaints of aching pains in the
metatarsophalangeal joints of the rst toes of both feet, the right ankle
and left knee joints, aggravated by the morning (upon awakening) and
during movements, limitation of range of motion in the above joints,
swelling of the legs and feet, episodic increase in blood pressure up to
160/110 mm Hg, aching pain in the right lumbar region.
He considers himself ill for the last 5 years, when, for the rst
time, against the background of complete well-being, severe burning,
throbbing pains appeared in the metatarsophalangeal joint of the rst
toe of the left foot at about two o’clock in the morning, as a result of
which the patient could not fall asleep again. Pain in the joint was ac-
companied by the appearance of its swelling, the skin over it turned
red, became hot, taut and shiny. The body temperature rose to 38.2°C.
The pain syndrome was so pronounced that it was not stopped by tak-
ing analgesics. In addition, there was a sharp restriction of movement
in this joint, pain when touching it, in contact with the sheet. By morn-
ing, the intensity of the pain had noticeably weakened, but the swell-
ing of the joint remained.
The patient did not go to the doctors, he did not receive any special
treatment; after 2-3 days, pains in the rst metatarsophalangeal joint
of the left foot stopped completely, and a few days later the swelling
of the joint also disappeared.
The second attack of the disease followed about 1 year later, with
the involvement of the right ankle in the process, the pain in the joint
was stereotyped, accompanied by an increase in body temperature up
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134
to 37.5 °C, malaise; in the prodromal period, the patient noted loss of
appetite, and thirst. He went to the doctor, the examination revealed
accelerated ESR up to 52 mm / h, hyperbrinogenemia (6.88 g / l),
hyperuricemia (uric acid in the blood 546 μmol / l), no changes were
found on the radiograph of the right ankle joint.
Later, the patient noted that the frequency of arthritis attacks was
previously 1 time per year, and over time, the frequency of exacerba-
tions of the disease increased to 3-4 times a year. In the last 3 years,
episodes of increased blood pressure have been observed, pain in the
lumbar region has appeared, in connection with which an ultrasound
scan of the kidneys was performed, which revealed a 13 mm stone in
the lower pole of the right kidney.
On objective examination (at the time of admission of the patient
to the rheumatology department): a patient with increased nutrition,
deguration of the ankle joints, more pronounced on the right, plus-
phalangeal joints of both feet, the skin over the joints is not changed,
without local hyperthermia. Joint movement with painful restriction.
Tofus up to 6 mm in diameter was found on the medial edge of the
right foot.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
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Chapter 6. STANDARD OF ANSWERS
FOR THE RHEUMATOLOGY SECTION
Clinical case No. 1
1. What is the preliminary diagnosis?
Reiter’s disease, exacerbation stage. Activity of the 2nd degree.
The functional ability of the joint is grade 2. Bilateral chronic con-
junctivitis.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Biochemical blood test for rheumatic tests (level of uric acid,
rheumatoid factor, ASL-O, protein fractions), ECG.
3. What is the patient’s management?
The results of the therapy carried out depend on the general well-
being of the patient and the stage of the pathology.
Antibacterial therapy - the appointment of broad-spectrum antibi-
otics from the group of tetracyclines: tetracycline, uoroquinolones:
levooxacin, macrolides: clarithromycin, erythromycin.
Long-term and intensive antibiotic therapy can lead to a side ef-
fect - a violation of the intestinal microora. To prevent this, simulta-
neously with taking antibacterial drugs, patient should take antifungal
drugs - Clotrimazole, Fluconazole.
Drugs from the NSAID group - Ibuprofen, Indomethacin, Diclof-
enac.
Detoxication - the introduction of colloidal and crystalloid solu-
tions, plasmapheresis.
Antihistamine therapy – Levocetirizine, Suprastin (chloropyra-
mine).
Glucocorticosteroids - betamethasone, prednisolone.
Cytostatic drugs - Methotrexate, Cyclophosphamide.
For arthritis, NSAID ointment is used topically.
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Balneotherapy and mud therapy.
4. Medical and labor expertise. Dispensary observation.
Terms of temporary disability in Reiter’s disease Acute course
- 30-60 days, subacute course II-III degree of activity - 35-65 days,
chronic course, exacerbation - 30-35 days.
Contraindicated types and working conditions: - work associ-
ated with heavy and moderate physical labor; - labor associated with
a forced position of the body, frequent bends, body vibration; - work
in unfavorable meteorological conditions (in hot shops, with high hu-
midity, gas pollution); - in the case of peripheral and Scandinavian
forms of the disease, work requiring precise and small movements,
with prolonged stay on the legs, is contraindicated.
Disability of the 3rd group is established if the patient has:
y moderate dysfunction of the spine and / or joints, with persisting
moderate or high degree of disease activity; Functional class II;
the presence of extra-skeletal manifestations of the disease with
moderate impairment of body functions; absence of complications
of the disease and / or therapy.
Disability of the 2nd group is established if the patient has:
y severe dysfunction of the spine and / or joints, with persisting
moderate or high disease activity; Functional class III; the presence
of extra-skeletal manifestations of the disease; the presence of
complications of the disease and / or ongoing therapy; leading to
severe dysfunction of the body.
Disability of the 1st group is established if the patient has:
y Signicantly pronounced dysfunctions of the body, signicantly
pronounced dysfunctions of the spine / joints; Functional class IV;
the presence of extra-skeletal manifestations of the disease; the
presence of complications of the disease and / or ongoing therapy,
leading to a signicantly pronounced dysfunction of the body.
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Clinical case No. 2
1. What is the preliminary diagnosis?
Ankylosing spondylitis, degree of activity 2, functional capacity
of the joint 2 degree.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Consultation with a neurologist
3. What is the patient’s management?
Treatment of ankylosing spondylitis is based on the same prin-
ciples as for rheumatoid arthritis, and should be systematically pro-
longed and adequate to the activity and severity of the disease. In the
late stage of the disease, with lesions of the hip joints, arthroplasty
is indicated (to improve self-care). Clinical examination of these pa-
tients allows for systematic anti-inammatory therapy to prevent ex-
acerbations, preserve spinal function and overall performance. During
periods of remission, X-rays of the joints and spine are performed
once a year. Treatment tactics: social rehabilitation, NSAIDs, intra-
articular administration of glucocorticosteroids and muscle relaxants.
4. Medical and labor expertise. Dispensary observation. The
criteria and approximate terms of temporary disability are similar to
those in rheumatoid arthritis (clinical and laboratory characteristics of
an exacerbation of the disease, conrmed by indicators of activity II
and III degrees. The duration of temporary disability, depending on the
severity of exacerbations and the eectiveness of the therapy, is from
40 to 90 days exacerbations, sick leave treatment should not exceed
4 months with subsequent referral to the medical and social expertise.
Contraindicated types and working conditions: - work associ-
ated with heavy and moderate physical labor; - labor associated with
a forced position of the body, frequent bends, body vibration; - work
in unfavorable meteorological conditions (in hot shops, with high hu-
midity, gas pollution); - in the case of peripheral and Scandinavian
forms of the disease, work requiring precise and small movements,
with prolonged stay on the legs, is contraindicated.
Disability of the 3rd group is established if the patient has:
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y moderate dysfunction of the spine and / or joints, with persisting
moderate or high degree of disease activity; functional class II;
the presence of extra-skeletal manifestations of the disease with
moderate impairment of body functions; absence of complications
of the disease and / or therapy.
Disability of the 2nd group is established if the patient has:
y severe dysfunction of the spine and / or joints, with persisting
moderate or high disease activity; functional class III; the presence
of extra-skeletal manifestations of the disease; the presence of
complications of the disease and / or ongoing therapy; leading to
severe dysfunction of the body.
Disability of the 1st group is established if the patient has:
y Signicantly pronounced dysfunctions of the body, signicantly
pronounced dysfunctions of the spine / joints; functional class IV;
the presence of extra-skeletal manifestations of the disease; the
presence of complications of the disease and / or ongoing therapy,
leading to a signicantly pronounced dysfunction of the body.
Clinical case No. 3
1. What is the preliminary diagnosis?
Nonspecic aortoarteritis, type IIa, subacute course, grade 2 ac-
tivity.
2. What additional tests would you recommend to the patient,
and what are the expected results?
y ECG
y ECHO-KG
y Color Doppler ultrasonography of the aorta and its branches.
3. What is the patient’s management?
Conservative therapy
For drug treatment, the following can be used:
1. glucocorticosteroids,
2. cytostatic drugs,
3. modern genetically engineered biological products,
4. non-steroidal anti-inammatory drugs,
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5. antiplatelet agents and anticoagulants (prevention of throm-
bosis),
6. antihypertensive therapy.
Surgery
In the presence of a critical narrowing of the main arteries, pa-
tients are indicated for surgical intervention in order to restore the
blood supply to the ischemic zone (catheter balloon angioplasty, if
possible - stenting, endarterectomy, bypass grafting).
4. Medical and labor expertise. Dispensary observation.
The average period of temporary disability after unilateral aor-
tofemoral and femoral-popliteal bypass grafting and thromboendar-
terectomy in atherosclerosis is 2.5-3 months, of which treatment and
examination before surgery - 25-30 days, surgery and postoperative
period - 20-25 days; follow-up treatment in the clinic - 15-20 days, in
the presence of edema - up to 30 days.
Temporary disability after amputation of a limb is determined by
the timing of the healing of the stump. As a rule, treatment with the
issuance of a sheet of temporary disability for more than 4 months
in a vascular patient is impractical: initial ischemic contractures in
the hip joint, stump defects, the condition of the other limb and con-
comitant damage to the vessels of the heart and brain determine a long
period of prosthetics and mastering of walking. Some patients, even
being prosthetic, cannot use a prosthesis: a short stump, ischemia of
the stump in Leriche syndrome, ischemic heart disease of III and IV
functional class, Chronic heart failure III-IV (NYHA).
Contraindicated types and working conditions:
y heavy and moderate physical labor;
y labor associated with the forced position of the torso, long walking,
frequent climbing stairs;
y work associated with pronounced psycho-emotional stress, fast,
prescribed pace of work;
y long-term operation in conditions of signicant cooling,
high humidity;
y local and general exposure to vibration;
y work with vascular poisons;
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y exposure to ionizing radiation.
Disability of the 3rd group is established if the patient has:
II degree of ischemia in the presence of segmental occlusions or
stenosis of arteries (over 65%), ankle-brachial index less than 0.75 -
0.25
After surgical revascularization with a preserved distal block,
with circulatory sub compensation.
Disability of the 2nd group is established if the patient has: III
or IV degree of ischemia, ankle-brachial index less than 0.25. After
surgical revascularization with a persisting distal block, with limited
trophic disorders (ulcer, necrosis), circulatory decompensation;
Amputation stumps of the thigh / lower leg of one limb and IIB,
III degree of ischemia of the other limb; in the presence of medical
contraindications for prosthetics; ischemia of the thigh stump; with
concomitant diseases with severe impairment of body functions
(Chronic heart failure III- IV(NYHA), respiratory failure stage III).
Disability of the 1st group is established if the patient has: III
or IV degree of ischemia, including bilateral trophic disorders, an-
kle-brachial index less than 0.25 in the presence of contraindications
for surgery.
Amputation stumps of both thighs; malformations or diseases of
the stumps; if it is impossible to use prostheses due to concomitant
diseases; ischemia of the stump
Clinical case No. 4
1. What is the preliminary diagnosis?
Systemic lupus erythematosus, SELENA-SLEDAI III (high de-
gree of activity). With damage to the blood system (anemia), skin (er-
ythema), lungs (pneumonitis), kidneys (nephritis), serous membranes
(pericarditis, pleurisy), musculoskeletal system (arthritis).
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory and instrumental research
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