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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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161
1. All patients, if it is impossible to study the synovial uid by the
method of polarizing microscopy, it is necessary to conduct an ultra-
sound examination of the joints.
2. It is not recommended to carry out X-ray examination of joints
in the early stages of the disease. X-rays are helpful in the dierential
diagnosis and may show typical signs of chronic gout, but are not
helpful in the early diagnosis of gout. In acute gouty arthritis, X-ray
changes, as a rule, are determined after 7-10 years from the onset of
the disease, are not always detected even in patients with chronic ar-
thritis and refer to late manifestations of the disease. Radiography is
quite justied for the dierential diagnosis with injuries, other diseas-
es of the musculoskeletal system, etc. Formation of intraosseous tophi
often occurs simultaneously with subcutaneous tophi, therefore, x-ray
examination is also used to determine the severity of tophi.
3. Conducting computed and magnetic resonance imaging is rec-
ommended only if you suspect an atypical location of the tophi. Their
presence can be established using computed tomography: the presence
of soft tissue deposits of intermediate density, intraosseous erosions
(tophus) and magnetic resonance imaging: the presence of soft tissue
deposits on T1 or T2 sequential images.
3. What is the patient’s management?
1. Conservative treatment. The goal of conservative therapy is the
relief of acute or chronic arthritis and further prevention of arthritis
attacks, as well as the prevention of the formation and dissolution of
the existing crystals of monosodium urate.
When prescribing treatment, a combination of non-pharmacolog-
ical and pharmacological methods is more eective than monothera-
py. When prescribing therapy, it is necessary to take into account the
clinical phase of the disease (acute attack of arthritis, chronic arthritis,
tophus form), serum uric acid level and the frequency of arthritis at-
tacks, the presence of comorbid diseases and risk factors for hyperuri-
cemia.
NSAIDs or colchicine or glucocorticoids are recommended for
all patients as the rst line of treatment for acute arthritis.
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Intra-articular or intramuscular administration of glucocorticoids
is recommended, medium doses of oral glucocorticoids are prescribed
with rapid withdrawal (30–35 mg of prednisolone per day for 3-5 days
with complete withdrawal of the drug within 10–14 days).
In patients with severe tofus gout, a serum uric acid level of <300
μmol / L is recommended. Long-term (over several years) mainte-
nance of serum uric acid levels below 180 μmol / L is not recom-
mended.
For patients with normal renal function, allopurinol is recom-
mended as the rst line of therapy. It is also recommended to prescribe
the drug in an initially low dose (50-100 mg daily), followed by an
increase (if necessary) of 100 mg every two to four weeks, which is
especially important in patients with renal insuciency.
In patients with impaired renal function, it is recommended to
adjust the maximum dose of allopurinol depending on the glomerular
ltration rate. In case of the development of adverse reactions associ-
ated with the use of allopurinol, as well as if the target level of uric
acid in the blood serum is not achieved when using the maximum
permissible doses of allopurinol, it is recommended to prescribe other
xanthine oxidase inhibitors (febuxostat).
Febuxostat can be used in patients with mild to moderate renal
failure, its eectiveness in inuencing serum uric acid levels when
using medium doses of drugs exceeds that of allopurinol. In patients
with gout with reduced renal function, febuxostat is more likely than
allopurinol to achieve the target uric acid level.
2. Surgical treatment of gout is not the main one; removal of tophi
is recommended in cases when they lead to the development of severe
complications (eg, tunnel syndromes, spinal compression), function-
al disorders.
4. Medical and labor expertise. Dispensary observation.
Temporary disability. Issuance of a certicate of incapacity for
work is advisable in the following cases: with severe pain syndrome,
which can be stopped only with the help of drugs; with the develop-
ment of complete or partial immobility or stiness in the aected joint
or group; with a signicant decrease in the patient’s performance, both
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163
due to the gouty arthritis itself, and due to the accompanying symp-
toms.
The maximum period for which a sheet is opened at a time is
15 days. When issued by a paramedic, the maximum duration is 10
days. If during this time the attack has not been stopped, the patient is
referred to a medical commission. Taking into account all extensions,
an employed citizen can be on sick leave with breaks for no more than
10 months. In case of an unfavorable prognosis, after 4 months with-
out interruption, the patient may be referred for a medical and social
examination to resolve the issue of permanent disability (disability).
Permanent disability
Group III is established for patients with permanent, moderately
severe functional disorders, which lead to a moderate limitation of
working capacity and quality of life. This group allows you to live
without outside help, not depending on other people. Help from social
services is needed.
II group of disability. It is established for a certain category of
patients who, in comparison with group I, have minor functional im-
pairments. In the area of the joints, limitation of the range of motion is
partial. Such people do not require outside supervision and are capable
of self-service. This group allows you to work subject to a certain
work schedule with a reduction in the length of the working day, addi-
tional breaks, norms, and so on (transition from III degree of disability
to II and even I).
Group I is the most dicult in terms of the quality of physical
condition. It includes people who are not able to serve themselves in
everyday life, to move without assistance (the presence of III degree
of limitation of life activity). In the area of the joints, a complete limi-
tation of the range of motion. For them, special conditions are created
that allow them to carry out certain labor activities. Example: People
with disabilities in wheelchairs may be able to perform certain types
of work at home.
Dispensary observation. A family doctor or general practitio-
ner observes gout (acute and chronic gouty arthritis). Observation
frequency: with minimal activity - 2 times a year. Examinations by
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164
doctors of other specialties: Therapist, urologist - 2 times a year, sur-
geon, orthopedist - according to indications. Name and frequency of
laboratory and other diagnostic tests: general blood analysis and gen-
eral urine analysis - 2 times a year, uric acid - 2 times a year, urea or
creatinine, liver function tests, liver enzymes, total bilirubin - once
a year. X-ray of the joints - once a year. According to indications - ul-
trasound examination of the kidneys.
The main medical and recreational activities. Recommendation
for rational nutrition (table number 6: low calorie intake, restriction of
meat, sh products, animal fats, sugar), inadmissibility of taking al-
coholic beverages. Drug treatment - drugs that reduce hyperuricemia,
taking NSAIDs, physiotherapy, spa treatment using sulfurous, radon
baths (in the absence of contraindications). According to indications -
inpatient treatment. Rehabilitation of the focus of intestinal infection.
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Chapter 7. GASTROENTEROLOGY SECTION
Clinical case No. 1
Patient N, 25 years old, a sound engineer, turned to the family
doctor at the polyclinic with complaints of pain in the epigastric re-
gion and slightly to the left of the midline, arising 1-1.5 hours after
eating and ceasing after evacuation of food from the stomach. Late,
“hungry” and nocturnal pains are also observed. Pain sensations, as
a rule, are aching in nature and are of moderate intensity. And also
often disturbed by heartburn, sour belching, nausea, irritability, weak-
ness, loss of appetite.
The above complaints appeared about ve months ago. In the last
month, dizziness began to be noted, especially with a change in body
position, weakness increased. The wife noticed the pallor of the skin.
The patient ate irregularly, dry food for a long time, periodically noted
pain in the stomach, but did not consult a doctor. From the anamnesis
of life it is known that chronic diseases - underweight, astigmatism
of the left eye, atopic dermatitis. Heredity is burdened by the mother:
duodenal ulcer, by the father: chronic colitis. I was not sick with tuber-
culosis. ARVI is sick 1-2 times a year. Smokes 1 pack a day.
On objective examination: body mass index - 16. The skin and
mucous membranes are pale, clean. In the area of the lower leg - vari-
cose veins. Vesicular breathing, no wheezing. Heart sounds are clear,
rhythmic. BH - 15 per minute. Heart rate 68 in 1 minute, BP 110/70
mm Hg. Art. Tongue moist, slightly coated with white bloom. The ab-
domen is painful on palpation in the epigastrium, there is also a slight
muscle tension, a positive Mendel’s symptom. The liver is not en-
larged, the symptoms of cholecystitis are negative. Stool - a tendency
to constipation.
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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. 2
Patient N, 32 years old, a DJ, turned to the family doctor at the
polyclinic with complaints of dull, aching pain in the right hypochon-
drium, which usually occurs 1-3 hours after eating abundant, espe-
cially fatty food, and fried foods, a feeling of bitterness in the mouth ,
belching with air, nausea, bloating, erratic stools.
From the anamnesis it is known that chronic diseases - obesity of
the 1st degree, chronic cystitis. Heredity is burdened by the mother:
hypertension of the 2nd degree, by the father: chronic otitis media of
the left ear. She suered from tuberculosis at the age of 3, was ob-
served by a phthisiologist for 2 years, after which she was removed
from the register. ARVI is sick 1-2 times a year. Smokes 1 pack a day,
drinks energy drinks. The above complaints have been troubling for
5 years.
On objective examination: body temperature is 37.2 °C. The gen-
eral condition is satisfactory. The skin and visible mucous membranes
are clean, pink in color. The subcutaneous fat is overdeveloped. BH
15 per minute, heart rate 78 per minute, blood pressure 130/80 mm
Hg. Art. Lungs and heart without pathology. The tongue is coated with
a yellowish brown coating. The abdomen is soft, moderately pain-
ful on palpation in the right hypochondrium. The liver and spleen are
not palpable.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
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3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 3
Patient N, 25 years old, animator, turned to the family doctor at
the polyclinic with complaints of dull, bursting pains around the na-
vel, arising 3-4 hours after eating, bloating, strong rumbling in the
abdomen, abundant loose stools 2-3 times a day, weakness, fatigue,
weight loss.
The above complaints have been troubling for 2 years. Milk intol-
erance is noted. The deterioration of the condition is provoked by the
intake of spicy food. From the anamnesis it is known that he denies
chronic diseases. Heredity is not burdened. I did not suer from tuber-
culosis. ARVI is sick 3-4 times a year. Does not smoke, does not drink.
On objective examination: body temperature is 36.9 ° C. The
condition is satisfactory. The skin and visible mucous membranes
are clean, pale, dry. In the corners of the mouth, “seizures” are deter-
mined. The subcutaneous fat layer is underdeveloped. BH 13 per min-
ute, heart rate 81 in 1 minute, blood pressure 110/70 mm Hg. There is
no pathology on the part of the lungs and heart. Tongue moist, coated
with a whitish bloom. The abdomen is soft, moderately painful in the
umbilical region.
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. 4
Patient N, 33 years old, a hotel administrator, turned to the family
doctor at the polyclinic with complaints of chills, weakness, headache,
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168
fatigue, nausea, intense pain in the right hypochondrium that arose
last night after consuming fatty meat and continued with short inter-
ruptions throughout the night. The pain intensies when changing the
position of the body, turning, bending.
From the anamnesis it is known that at the age of 7 years the
patient suered from hepatitis A, after which, for several years, she
noted episodes of pain in the right hypochondrium after fatty foods,
sometimes accompanied by vomiting. At the age of 19, when analyz-
ing bile obtained with duodenal intubation, a large number of leu-
kocytes were found in portions B and C. She was repeatedly treated
in sanatoriums, took choleretic drugs. According to the patient, the
repeated ultrasound of the biliary tract “revealed sand”. I felt satisfac-
tory. The patient has a history of 6 pregnancies that ended in normal
urgent labor. The patient is currently 20 weeks pregnant.
Heredity is not burdened by the mother: at the age of 46, she was
diagnosed with calculous cholecystitis. She did not suer from tuber-
culosis. ARVI is sick 1-2 times a year. Does not smoke, does not drink.
On objective examination: hypersthenic constitution, increased
nutrition (body mass index - 33 kg / m2), clean skin, icterus sclera,
body temperature 39 ° C. BH 18 per minute, heart rate 100 per minute,
blood pressure 135/85 mm Hg. There is no pathology on the part of
the lungs and heart. The liver does not protrude from under the cos-
tal arch, soft-elastic consistency, palpation is sharply painful. Sharply
positive symptoms of Georgievsky - Mussey, Ortner, Murphy, Lep-
ene. The abdomen is slightly distended. The spleen is not palpable.
Complete Blood Count: RBC – 4,2х10
12
/L, Нb –140 g/L, MCH –
27 pg/cell, WBC – 15х10
9
/L, neutrophils bands – 11%, neutrophils
segments – 53%, lymphocytes – 19%, monocytes – 12%, eosinophil –
5%, PLT – 220,0х10
9
/L, ESR – 17 mm/h.
Total bilirubin - 2.6 mg / dL, direct - 0.5 mg / dL. Fibrinogen -
4.82 g / l. Total protein - 82 g / l, albumin - 5.6 g / l. ALT - 24 IU, AST
- 18 IU, g-HT - 160 IU, alkaline phosphatase - 380 IU / L.
With esophagogastroduodenoscopy - gastroesophageal reux, no
other pathology was revealed.
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With ultrasound of the abdominal organs: the liver is enlarged by
1 cm, the contours are even, the parenchyma is of normal echogenici-
ty. Intrahepatic bile ducts are dilated, ductus choledochus - 6 mm. The
gallbladder is enlarged to 5 cm in diameter, the walls are thickened,
a “double contour” is revealed, an ultrasonic symptom of Mussey. In
the neck of the gallbladder there is an echo-dense shadow of 1.5 cm in
size. The pancreas is of normal size and shape, echogenicity is normal.
The pancreatic duct is not dilated.
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. 5
Patient N, 53 years old, a watchmaker, turned to the family doc-
tor at the polyclinic with complaints of pain in the epigastric region
arising 20-30 minutes after eating, belching with air, and a decrease in
body weight by 3 kg over the last month.
From the anamnesis it is known that the rst signs of the disease
appeared in the fall 3 years ago (pains began to appear in the epigastric
region 30-40 minutes after eating, independently took drotaverine and
maalox with a short-term eect), was not examined, drew attention to
the seasonality of pain (in spring and autumn). The last deterioration
in the state of health - during the last month, the pains were of the
same character, at the height of the pains, irradiation to the back was
observed. There was an eructation of air. To clarify the diagnosis and
treatment, he entered the clinic.
On objective examination: the general condition is satisfactory.
The skin and visible mucous membranes are slightly pale. In the
lungs, vesicular breathing, no wheezing, rhythmic heart sounds, clear,
blood pressure - 140/80 mm Hg. Pulse - 80 beats / min. The abdomen
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170
is soft, moderate muscle tension in the epigastrium, local pain in the
epigastric region. The liver and spleen are not enlarged.
Complete Blood Count: RBC – 3,8х10
12
/L, Нb –108 g/L, MCH –
27 pg/cell, WBC – 15х10
9
/L, neutrophils bands – 8%, neutrophils seg-
ments – 54%, lymphocytes – 20%, monocytes – 11%, eosinophil –
1%, PLT – 180,0х10
9
/L, ESR – 15 mm/h.
With esophagogastroduodenoscopy - the esophagus is not
changed, the cardia is closed completely. The stomach expands well
with air. On the lesser curvature, in its middle third, there is a stel-
late whitish scar with a distinct convergence of folds. There is also
a fresh ulcer with edematous, inammatory-altered edges, measuring
6x8 mm. There is a blood clot deep in the ulcer. The duodenal bulb is
not changed. A biopsy of the mucous membrane from the edges of the
ulcer was performed. Histological examination: a picture of atrophic
gastritis with symptoms of intestinal metaplasia of the epithelium, the
edge of the ulcer, caught in the cut, with signs of chronic inamma-
tion. HP was detected in a small amount. The pH-metry was not per-
formed due to the nature of the localization of the ulcer.
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. 6
Patient N, 15 years old, a schoolboy, turned to the family doctor
at the polyclinic with complaints of nausea, repeated vomiting, joints,
weakness, anorexia.
From the anamnesis it is known that the patient was not in contact
with infectious patients, 3 months ago he was treated by a dentist. The
above complaints arose 3 days ago with an increase in temperature
t.me/medicina_free
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