ANSWERS ON QUESTIONS

Main part

Patient Zh. 47 years old was admitted to the rheumatology department with complaints of

aching pains in the metatarsophalangeal joints of the I toes of both feet, right ankle

and left knee joints, worse in the morning (at the time of awakening) and with

movements, limitation of range of motion in the above joints, puffiness

legs and feet, an occasionally detected increase in blood pressure to 160/110 mm RT. Art. (regularly

HELL does not control, does not receive therapy), aching pain in the right lumbar region.

He works in the office, leads a sedentary lifestyle. Diet does not comply.

Hereditary history: a mother of a 70-year-old patient suffers from hypertension,

type 2 diabetes, the father died at the age of 65 from myocardial infarction.

Considers himself ill for the past 5 years, when for the first time amid a complete

the strongest burning, throbbing pains in the area appeared

metatarsophalangeal joint of the first toe of the left foot at about two in the morning, as a result of which

the patient could not fall asleep again. Joint pain was accompanied by the appearance of it

swelling, the skin over him reddened, became hot, stretched and shiny.

Body temperature increased to 38.2 ° C. The pain syndrome was not stopped by taking

Paracetamol In addition, there was a sharp restriction of movements in this joint,

soreness when touching it, in contact with the sheet. By the morning

the intensity of the pain noticeably weakened, but the swelling of the joint persisted. To the doctors

the patient did not apply, was not treated with anything; after 2-3 days of pain in I

metatarsophalangeal joint of the left foot stopped completely, after a few days

later the swelling of the joint also disappeared.

A second attack of the disease followed after about 1 year, with involvement in

process of the right ankle joint. Joint pains were similar

accompanied by general phenomena in the form of subfebrile condition, malaise, in

the prodromal period, the patient noted loss of appetite, hypersalivation and thirst.

I went to the local GP, the examination revealed accelerated ESR

up to 52 mm / hour, hyperfibrinogenemia (6.88 g / l), hyperuricemia (uric acid in the blood -

546 μmol / L), hypercholesterolemia (total cholesterol - 7.2 mmol / L, lipid fractions

not studied), fasting glycemia - 6.0 mmol / l, on the radiograph of the right

Ankle joint changes not detected. 150 was prescribed Indomethacin

mg / day, against the background of which pain regressed.

Subsequently, the patient noted that the frequency of arthritis attacks was previously 1

once a year, and over time, the frequency of exacerbations of the disease increased to 3-4 times

year. In the last 3 years there have been episodes of increased blood pressure, pain

lumbar region, in connection with which an ultrasound of the kidneys was performed, which revealed a stone in

the lower pole of the right kidney is 13 mm in size.

On examination: the general condition is satisfactory. Body temperature 36.7 ° C. Height

- 166 cm, weight - 94 kg. Waist circumference - 107 cm. Ankle joint configuration,

more pronounced on the right, I metatarsophalangeal joints of both feet, skin over the joints

not changed, without local hyperthermia. Joint movements with painful

restriction. Tofus up to 6 mm in diameter was found on the medial edge of the right foot. IN

Lungs vesicular breathing, wheezing is not heard. NPV - 16 per minute.

Percussion sound clear lung over all lung fields. Heart sounds

muffled, the rhythm is correct, noises and additional tones are not heard. HELL -

160/80 mmHg Art., heart rate - 88 beats per minute. The abdomen is soft, painless. Liver

percussion along the edge of the costal arch. There are no peripheral edemas.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. The drug of which group of drugs would you recommend to the patient

for the treatment of the disease? Justify your choice.

5. Choose the tactics of patient management in the interictal period. Justify your

a choice.

Situational task 139 [K001970]