Traumatology and Orthopedics - Clinical case

3 january 2018

Clinical review

Case history of patient K., 56 years old:

  • The patient has been observed at the clinic since 2009
  • The main diagnosis - Rheumatoid arthritis, polyarthritis, seropositive, act 3, article 3, FN 2.

Characteristics of the articular syndrome

  • Morning stiffness more than 1 hour
  • Pain in symmetrical wrist, metacarpophalangeal, proximal interphalangeal joints of the hands, knee, ankle, metatarsophalangeal joints.

Medical history

  • Sick since 1979
  • The diagnosis was established and confirmed at the Research Institute of Rheumatology in the same year
  • In 2008, was observed at the Charite clinic in Berlin with a diagnosis of seropositive rheumatoid arthritis with secondary Sjogren's syndrome
  • In 2009, she was observed at the Genolier clinic in Switzerland. A comprehensive examination and treatment was carried out, which confirmed the presence of rheumatoid arthritis with a mild clinical Sjogren's syndrome.

Ongoing therapy

Life history

  • Lives and works in Moscow
  • Since 1977 he has suffered from autoimmune thyroiditis with subcompensated hypothyroidism
  • 2004 - Cholecystectomy
  • Suffers from gastric ulcer and duodenal ulcer, chronic duodenitis
  • Gynecological history: B2 R1 A1
  • Menopause since 1986
  • 2008 - bilateral pneumonia.

Since 2009, Medicina has been observed

  • July 2009 - applied to JSC "Medicine" in connection with pain in the left ankle joint - revealed aseptic necrosis of the scaphoid head, synovitis of the left ankle joint
  • A consultation with a rheumatologist was carried out and intra-articular and oral treatment with prednisolone was recommended, against the background of therapy with Humira with improvement of the condition
  • November 2009 - was admitted to the hospital with a hypertensive crisis.

Objectively

  • The condition is satisfactory, t - 36.6
  • Skin of normal color
  • Dry skin, mucous membranes and conjunctiva
  • Scleral vascular injection
  • Respiratory system - no pathology
  • Cardiovascular system - no pathology
  • Digestive system - no pathology.

St.localis:

  • Defiguration of 2-4 metacarpophalangeal joints
  • Ulnar deviation
  • Swan neck deformity of the fingers
  • Left ankle deflection.

Consilium

The head of the clinic drew attention to the prevailing place in the clinical picture of Sjogren's syndrome with a relatively low RA activity.

Recommended:

Conducting an immunological blood test for laboratory determination of the degree of activity of Sjogren's syndrome.


Immunological test data

  • SS-A/Ro >200 U / ml (norm: 0.0-25.0)
  • SS-B/La >200 U / ml (norm: 0.0-25.0).

Repeated consultation

Conclusion: Sjogren's syndrome is the leading one in the clinical picture of the patient's disease.

Specific therapy was prescribed.


Dynamic Surveillance

Against the background of the prescribed therapy, the patient notes an improvement in her condition.