home Audience 2 Case history of pediatric juvenile rheumatoid arthritis. Medical history: rheumatoid arthritis. Full name: Zabodaev Nikolay Vasilievich

Case history of pediatric juvenile rheumatoid arthritis. Medical history: rheumatoid arthritis. Full name: Zabodaev Nikolay Vasilievich

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Department of Faculty Pediatrics.

Head Department Chuprov A.V.

Disease history

FULL NAME. patient: x

Clinical diagnosis: rheumatoid monoarthritis, subacute course, activity

I, without cardiac dysfunction

Concomitant diseases: hr. tonsillitis, decompensated form,

Follicular tonsillitis, stomatitis.

Curator: Korotkova E.V. course IV group 2 ped. f-t.

Assistant: Kedrova
K.S.

Novosibirsk - 1998

Passport information.
Patient's name: x
Date of birth: 10/18/1990.
Age: 7 years.
Gender: male.
Organized by: Studying at school, 1st grade.
Address: Zdvinsk
Referred to: regional clinic
Date of admission: 05/07/98
Directions: Rheumatoid arthritis, articular form.
Admissions: Rheumatoid arthritis, articular form, chronic disease. tonsillitis, compensation Form.
Ds clinical: rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction

Complaints

At the time of admission, the child complained of pain and swelling in the left knee joint, and headaches.
Anamnesis morbi.
He often suffered from respiratory diseases.
All winter I suffered from colds every month. The last time I had the flu was at the end of February, I went to school from 5.03.
On March 30, he consulted a doctor with complaints of swelling and pain, limited movement in the left knee joint (he was limping). The day before there was a joint injury (bruise). On April 6, he was hospitalized at the URB, as joint swelling and pain persisted. Anti-inflammatory therapy was prescribed there. Within 10 days there was some improvement, the boy was discharged home, and treatment was interrupted. Then pain in the joint reappeared, and bending was difficult. On May 07, he was admitted to the regional hospital for a routine examination.

Anamnesis vitae.

Born the second child from the second pregnancy. I went on maternity leave at 6 months. I followed the regime and ate normally. Childbirth, without complications. He immediately screamed, the scream was loud and strong. Birth weight 4250 g. The baby was put to the breast after 12 hours. Natural feeding until 1 year.
The umbilical cord remnant fell off on the 2nd day. Discharged on the 7th day. No diseases were noted during the neonatal period. He began to hold his head up at 2 months, at 4.5 months he began to stand with support, at 6.5 - crawling, at 7.5 - sitting independently, at 10 - standing independently, at 11 - walking. During the 1st year he was breastfed and suckled actively. From 2 months received apple juice (drop by drop). From 4 months received 5% semolina at 5 months. egg yolk (1/2), at 7 months. minced meat, meat broth at 12 months. - cutlet.
Complementary feeding was tolerated well, weaning time was 12 months. The child’s nutrition is currently adequate.

Vaccinated according to age, response to vaccinations is adequate. He tolerates medications well, there were no blood transfusions.

Allergic history is calm.

Epidemiological history: There was no contact with infectious diseases.

Family history:
The child's parents are healthy, no hereditary predisposition has been identified.

Admission status:

The condition is satisfactory, the position is active, behavior is adequate, consciousness is clear.

Condition of the skin: no pathological changes, increased sweating and skin moisture. Subcutaneous fatty tissue is moderately expressed.

Respiratory system: chest without pathological changes, auscultation - vesicular breathing, respiratory rate 18 per minute, no wheezing is heard. The boundaries of the lungs are within the age norm.

Cardiovascular system: The heart area is visually unchanged.
Heart rate – 80 per minute, blood pressure – 120/80 mmHg. Borders of the heart: left - along the midclavicular line, right - along the right sternum, upper - along the upper edge of the 3rd rib. On auscultation, a systolic murmur is heard at the apex. The first tone at the apex is weakened.
Digestive system: The abdomen is soft, palpation is painless. The liver protrudes 0.5 cm from under the lower edge of the costal arch.

Genitourinary system: the kidneys are not palpable, Pasternatsky’s sign is negative.

Osteoarticular system: when walking, the left leg is spared, the left knee joint is hot, swollen, increased in volume, flexion is limited, pain when moving. The muscular system is developed according to age.

Objective examination:

Common data.

The condition is satisfactory, the position is active, consciousness is clear, behavior is adequate. Orients himself well in time and space.
Meningeal symptoms (Kernig, Brudzinski: upper, lower, pubic) are negative, there is no stiff neck.

SKIN: pale, without pathological elements, moderate hair growth, straight nails. The venous network of the lower limb is expanded.
Skin temperature is normal. Humidity is slightly increased. The skin is elastic.
Symptoms of pinch, tourniquet and hammer are negative. Dermographism is mixed.
Appears after 15 seconds, disappears after 2 minutes. Visible mucous membranes are pink and moist.

SUBCUTANEOUS FATTY FIBER: sufficiently expressed, evenly distributed.
Upon palpation, the thickness of the folds in symmetrical areas is the same: on the abdomen - 1.0 cm, on the chest 0.5 cm, under the shoulder blades 0.5 cm, on the posteromedial surface of the shoulder - 0.5 cm, on the posteromedial surface of the thigh - 1 cm, in the cheek area - 1.0. Palpation - compaction and swelling are absent.
Tissue turgor is good.

MUSCULOSCAL SYSTEM:

The muscular system is sufficiently developed, symmetrically, the muscle relief is pronounced. Muscle tone is moderate, strength is sufficient. The head is round, the face is symmetrical, the bite is without pathology, the teeth are closely spaced without gaps.

An examination of the skeletal system revealed no gross deformations. The chest is conical in shape, the shape, mobility and size of the joints are not changed. There are no curvatures of the spine or limbs. The posture is correct (the waist triangles are symmetrical, the shoulders are at the same level, the angles of the shoulder blades are at the same level, the fingertips reach the hip at the same level).
The type of constitution is asthenic.

LYMPHATIC SYSTEM:

The submandibular lymph nodes are single, mobile, and have a dense elastic consistency. Dimensions 0.5x1 cm, painless. Cervical lymph nodes. Cervical lymph nodes are single, mobile, densely elastic consistency, size 0.3x0.5 cm, painless.
The axillary lymph nodes are single, mobile, and have a dense elastic consistency. Size 0.5X0.8, painless.

The remaining groups of lymph nodes (occipital, in the mastoid region, mental, tonsillar, posterior cervical, supra- and subclavian, thoracic, ulnar, popliteal) are not palpable.

Percussion size of the spleen is 5x6 cm. It was not possible to palpate the spleen.
RESPIRATORY SYSTEM:

The voice is clear, breathing through the nose is not difficult. Abdominal breathing type. NPV
20 per minute The depth of breathing is normal, the chest participates in the act of breathing normally, the movements are symmetrical. The ratio of pulse to respiration is 3:1.
The tonsils are not enlarged, protrude beyond the anterior arches, and are somewhat hyperemic. The chest is elastic and painless. Voice tremors are symmetrical on both sides, without any features.

Breathing is smooth and rhythmic. With comparative percussion over the entire surface of the pulmonary fields and in symmetrical areas of the lungs, a pulmonary sound is determined.

Topographic percussion of the lungs:

The lower border of the right lung - along the midclavicular line - 6th rib along the midaxillary line - 8th rib along the scapular line - 9th rib along the paravertebral line - at the level of the spinous process of the 11th thoracic vertebra

The lower border of the left lung - along the midclavicular line - along the midaxillary line - 8th rib along the scapular line
- 10th rib along the paravertebral line - at the level of the spinous process
11th thoracic vertebra

The height of the apex of the lungs posteriorly at the level of the spinous process
VII cervical vertebra. The width of the Krenig fields on the left and right is 4 cm. The mobility of the lower edge of both lungs along the scapular line is 6 cm. Symptoms of Arkavin,
Koranyas, Philosopher's cups - negative.

Auscultation reveals vesicular breathing. No wheezing or other pathological noises are heard. Breathing over the area of the trachea and bifurcation is unchanged, clear, and no adverse respiratory sounds are heard. Bronchophony is carried out equally on both sides and is not changed.

THE CARDIOVASCULAR SYSTEM:

Upon examination, the area of the heart was visually and palpably unchanged.
The apical impulse is determined in the 5th intercostal space along the left midclavicular line, limited (localized), of sufficient strength and height, rhythmic, non-resistant. The cardiac hump is absent. No systolic retractions are detected. No visible vascular pulsation is observed. Capillary pulse
Quincke is negative.

Palpation: The pulse is determined on the temporal, carotid, radial, femoral arteries, as well as on a. dorsalis pedis. The pulse on the radial artery is symmetrical, synchronous, frequency 70 beats per minute, rhythmic, tension and filling are sufficient, synchronous with the contraction of the heart.
The symptom of “cat purring” is negative.

Percussion:
Borders of relative cardiac dullness: left - along the midclavicular line, right - along the right edge of the sternum, upper - along the upper edge of the 3rd rib.
On auscultation, a systolic murmur is heard at the apex. The first tone at the apex and at the Botkin point is muffled.
Limits of absolute cardiac dullness:

Upper – third intercostal space.

Left - along the midclavicular line.

Right - along the left edge of the sternum.

The diameter of the heart is 9 cm.

The vascular bundle does not extend beyond the edges of the sternum.

Blood pressure 120/80 mm. RT., Art.

DIGESTIVE SYSTEM:

The oral cavity has a normal smell, the mucous membrane is hyperemic, the tongue is moist and pink, the tonsils are loose and hyperemic. There are no cracks or plaque.
The color of the visible mucous membranes is normal pink, there is no pigmentation or ulceration.
The gums are reddish, there is no bleeding or looseness.

The teeth are permanent, the number corresponds to age, no carious teeth were detected.

On examination: the shape of the abdomen is correct, there is no asymmetry.
Dilatation of the veins of the anterior abdominal wall, peristalsis, and divergence of the rectus abdominis muscles are not observed. No scars, pigmentation, or protrusions are observed. The abdominal wall participates in the act of breathing evenly.
Epigastric angle ~90o

Percussion of the abdomen reveals areas of tympany and dullness over the intestinal area. On superficial palpation the abdomen is soft and painless.

The sigmoid, blind, ascending and descending sections of the colon are palpated painlessly and mobile. Deep palpation: painless, parts of the intestine could not be palpated

Palpation of the liver according to Strazhesko: the liver protrudes 0.5 cm beyond the edge of the right costal arch along the midclavicular line. The edge of the liver is sharp, painless, the surface is smooth. Dimensions according to Kurlov: along the midclavicular line on the right - 9, along the midline - 8, along the edge of the left costal arch - 7.
Palpation at the point of projection of the gallbladder is painless. Murphy's symptoms
Ortner, Mussi - negative. Palpation of the pancreas is painless in the Choffard area, Desjardins point and Mayo-Robson point.
Mesenteric lymph nodes are not palpable. When auscultating the abdomen, intestinal peristalsis is heard. The child's stool is regular, shaped, sausage-shaped, and brown in color. In the last three days, no bowel disturbances were detected.

URINARY SYSTEM:
On examination: there is no renal edema; The lumbar region is not changed.
There is no bulging or hyperemia of the skin.
Palpation:

Palpation of the bladder is painless.

Pain points of the ureters are not determined.

Pain when urinating and urinary incontinence are absent.
The frequency of urination is 6-7 times a day, painless, independent.
Daytime diuresis predominates. Pasternatsky's symptom is negative on both sides.

EDOCRINE SYSTEM:

There is no impairment of growth and body weight, the subcutaneous fat layer is moderately developed and evenly distributed.

The thyroid gland is not palpable.

There are no secondary sexual characteristics, according to age.

General conclusion based on objective examination data:

No lesions of the skin, subcutaneous fat, musculoskeletal system, lymphatic system and blood system, digestive system and endocrine system, or urinary system were detected.

From the cardiovascular system - systolic murmur at the apex and at Botkin's point. The first tone at the apex is weakened.

There are no special features from the respiratory system.

Considering the duration of the disease, the clear connection with trauma, and the absence of signs of inflammation, there is no convincing evidence for rheumatoid arthritis.

For differential diagnosis and clinical diagnosis, it is necessary to carry out the following additional research methods:

1. General blood and urine analysis;

2. Biochemical blood test (total protein, protein fractions, seromucoid, sialic acids, fibrinogen);

3. Feces on Yaglist

5. R-gr. knee joints

6. ECG and ultrasound of the heart

7. CEC and ASL-O

Additional research methods.

Laboratory methods:
Complete blood count (09/17/1997):

|Red blood cells|Hb |CP |Platelets|Reticulocytes|ESR |
|4x1012 G/l|125 |1 |180 /l |0.7% |15 mm/h|

|Leukocytes|Basoph.|Eosin.|Young |Paloch|Segmen|Lymph.|Monocytes|
| | | | |. |. | | |
|7.9 T/l |1 |5 |0 |5 |67 |19 |3 |

Conclusion.

Red blood: ESR increased

White blood: no change

Conclusion: general urinalysis without any features

ReBiochemical blood test sample (04/16/1998):

(-lipoproteins – 3940; cholesterol – 4.6; triglycerides – 0.98; total protein – 78.2;

ALT-10
Seromucoid –0.01

Conclusion: All studied indicators are within age norms. No pathological abnormalities characteristic of any suspected disease were identified.

Immunological Blood test:

CEC - negative

ASL-O negative

Feces on i/g: --

Instrumental methods.

R-research

The left and right knee joints are unremarkable.

Ultrasound examination of the heart:

Conclusion: the heart cavities are not expanded, the walls are not thickened.
Slight marginal compaction of the right coronary and non-coronary leaflets.
Myocardial contractility is sufficient.

Impaired conduction through the atria, increased electrical activity of the left ventricle (stable over time). Sinus bradyarrhythmia 57-85 IM

Not convincing changes for congenital heart disease. Anomaly of pulmonary vein drainage.

General conclusion on complaints, anamnesis, objective examination and additional methods and differential diagnosis:
Rheumatoid arthritis should be differentiated from primary tuberculosis syndrome, rheumatism and deforming osteoarthritis. Rheumatoid arthritis, as well as primary tuberculosis, is characterized by the presence of functional systolic murmur at the apex, joint pain, and increased ESR. Rheumatoid arthritis differs from primary tuberculosis in the absence of anamnestic indications of the patient’s contacts with tuberculosis patients, and an increase in the titer of ASL-O and AST. Rheumatism is characterized by the presence of patients with rheumatism in the family, close contacts of the patient with patients with tonsillitis, palpitations at rest and after physical exercise. stress, the presence of skin manifestations (rheumatic nodules). Detection of increased titers of streptococcal antibodies in the blood, dysproteinemia, the appearance of C-reactive protein, an increase in seromucoid content. The diagnosis of osteoarthritis deformans can be based on an analysis of risk factors for this disease
(heredity, excess body weight), the presence of characteristic radiological changes.
Based on complaints of pain and swelling in the left knee joint, the status on admission (the left leg is spared when walking, the left knee joint is hot, swollen, enlarged, flexion is limited, pain when moving), we can assume a final clinical diagnosis -
Rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction. Concomitant diseases: chronic tonsillitis, compensated form, stomatitis.

Treatment plan for the underlying and concomitant disease:
Mode IIa (semi-bed), table No. 5 (hypochloride). Vitamin therapy (multivitamins) is indicated.
Anti-inflammatory therapy with non-steroidal drugs (aspirin up to 1g), cardiotrophics (digoxin).

Treatment:
Rp: Dragee "Revit"

S. 1 tablet 2 times a day.

Rp: Acidi acetylsalicilici 0.5

D.t.d. N50 in tab

Signa: 1 tablet 2 times a day for 2 months at a decreasing dosage.

# # #
Rp: Sol. Digoxini 0.025%-0.5ml

D.t.d. N20 in amp.

S: 0.5 ml 2 times i.v.

Observation diary:
5. The condition is serious due to fever. Symptoms of intoxication.

The child is lethargic. t-39.2
Poorly reduced by antipyretics, the skin is clean and dry. In the pharynx: bright hyperemia of the tonsils, purulent follicles, there is a moderate increase in the submandibular and anterior cervical lymph nodes up to 1 cm. Pain in the throat when swallowing is bothersome. In the lungs there is vesicular breathing, no wheezing. The boundaries of the heart are not changed. Soft systolic murmur at the apex, weakening of 1 tone at the apex, soft abdomen, slight pain on palpation in the duodenal zone. There was no chair. Urination is not difficult, painless. Taking into account the fever and changes in the nasopharynx, the child has clinical manifestations of follicular tonsillitis.
18.05 Condition without negative dynamics: the temperature remains at low-grade levels and drops to normal on its own. Symptoms of intoxication have decreased. The skin is pale, clean, dry. In the pharynx: bright hyperemia remains, swelling of the tonsils has decreased, purulent plugs on the tonsils remain. Breathing in the lungs is vesicular, heart sounds are loud, rhythmic, systolic murmur in L5-L4. The abdomen is soft, painless, physiological functions are normal.
19.05 Upon examination, the condition is of moderate severity, symptoms of intoxication, pale. In the pharynx: bright hyperemia, loose tonsils. Breathing in the lungs is vesicular, heart sounds are loud, rhythmic, systolic murmur in L5-L4.
The abdomen is soft, painless, physiological functions are normal. HELL
120/80 t-37.2
20.05 Upon examination, the condition is of moderate severity. Hyperthermia. Trouble in the throat when swallowing. The skin is pale, clean, dry. In the pharynx: bright hyperemia remains, the tonsils are loose. Breathing in the lungs is vesicular. Blood pressure 120/80, pulse 78. The abdomen is soft and painless.

Stage epicrisis:

The condition is of moderate severity. He was admitted to the department with manifestations of rheumatoid arthritis. Currently, the leading symptoms are symptoms of intoxication. Upon repeated echocardiography, there is no evidence of valve compaction, but a consultation with a cardiologist is planned to clarify the nature of the heart damage. The skin is pale, clean, the tongue is thickly coated with a greenish coating, the papillae are enlarged, there are purulent plugs in the tonsils, there is no fever. Auscultation: heart sounds are sonorous, rhythmic, the boundaries of the heart are not changed. The abdomen is soft and painless.
Recommended: Bed rest, diet No. 5. Therapy as planned. After 5-7 days, repeat the general blood test, immunologist. blood test (ASL-O), blood biochemistry (total protein, albumin, seromucoid, ALT, AST), fibrinogen,
GOS, CRP, repeat echocardiography. Consultation with an ENT doctor and dentist is recommended.
Literature:
1. The problem of rheumatoid arthritis Venblat M.E. Gravales E.M.
2. Pediatrician’s companion I.N. Usov.
3. Russian medical journal volume 6 No. 9. From the international Internet
(wide world web)

Curator's signature_____________________

Organized by: Studying at school, 1st grade.

Referred to: regional clinic

Date of admission: 05/07/98

Directions: Rheumatoid arthritis, articular form.

Admissions: Rheumatoid arthritis, articular form, chronic disease. tonsillitis, compensation Form.

Dsclinical: rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction

At the time of admission, the child complained of pain and swelling in the left knee joint, and headaches.

He often suffered from respiratory diseases.

Vaccinated according to age, response to vaccinations is adequate. He tolerates medications well, there were no blood transfusions.

Allergic history is calm.

Epidemiological history: There was no contact with infectious diseases.

The child's parents are healthy, no hereditary predisposition has been identified.

Admission status:

The condition is satisfactory, the position is active, behavior is adequate, consciousness is clear.

Digestive system: The abdomen is soft, palpation is painless. The liver protrudes 0.5 cm from under the lower edge of the costal arch.

Genitourinary system: the kidneys are not palpable, Pasternatsky’s sign is negative.

Percussion size of the spleen is 5x6 cm. It was not possible to palpate the spleen.

Reactive arthritis pediatric case history

On how to treat reactive arthritis in children, Komarovsky E.O.

Have you been trying to heal your JOINTS for many years?

Types of reactive arthritis in children

Based on the type of pathogen, reactive arthritis in children can be divided into:

Symptoms

Symptoms of reactive arthritis in children are based on the following signs:

1. General clinical signs:

2. Joint changes:

Reiter's syndrome is a common manifestation of reactive arthritis in children.

It begins 2-3 weeks after an infectious disease and is accompanied by signs:

Video: Symptoms of reactive arthritis

Diagnostics

There are certain criteria, the presence of which can make a diagnosis of reactive arthritis:

Therapeutic measures

Treatment tactics for reactive arthritis include several stages:

These include:

Prevention

These include:

Pediatric rheumatoid arthritis – long-term treatment required

Causes of the disease

Pathogenesis of the disease

What are the manifestations of the disease

The main symptoms are signs of joint damage.

The initial phase of the disease is exudative

Proliferative phase

Articular form of the disease

Articular-visceral form of the disease

Still's syndrome

This form of the disease is rapidly progressive, with frequent relapses and a poor prognosis.

Allergoseptic form

Individual visceral forms

The course of JRA in children can be rapidly progressive or slowly progressive.

Diagnosis of the disease

According to clinical signs:

Laboratory tests include x-rays and fluid tests:

Treatment approaches

Basic medications:

Disease prevention

The prognosis of the disease depends on the form and course of the disease.

Disease history
Juvenile rheumatoid arthritis, systemic form, allergic variant at onset, seronegative according to the Russian Federation, activity 0-1, Rg stage 2-1, NF-1-0

Ministry of Health and Social Development of the Russian Federation

State educational institution of higher professional education

FIRST MOSCOW STATE MEDICAL UNIVERSITY named after I.M. Sechenov

Department of Children's Diseases.

Completed by: 5th year student

Checked by: Ph.D., Associate Professor

1. Last name, first name, patronymic of the patient.

2. Age (year, month and birthday).01/24/1996 (14 years)

3. Date of admission to the clinic. 09/30/2010

4. Parents' occupation. Mother is a technician

5. Attends school

6. Address, telephone. —

7. Clinical diagnosis:

1. Complaints upon admission to the clinic about limited mobility in the hip joints

2. Does not make complaints about the day of supervision

1. From the first pregnancy due to pyelonephritis. Delivery on time

2. At birth, weight 3600 g, height 54 cm. He screamed immediately. First breastfeeding on the first day.

3. Breastfeeding up to 3 months, then artificial

4. Indicators of the child’s physical and psychomotor development are appropriate for his age. Behavior in the family, in the team - contact.

5. Past diseases. Otitis at 8 months. Rare ARVI. Biliary dyskinesia in 2000. Angina in 2003 Chicken pox.

Allergic reactions to amikacin - rash and seizures.

6. Preventive vaccinations - BCG, DTP, against polio according to age without reactions. Mantoux reaction 10g. – papule 5 mm.

7. Family history.

8. Material and living conditions are satisfactory

He is admitted for follow-up examination and therapy correction.

Objective research data on the day of supervision.

Date 10/7/10 Sickness day 8th Appointments:

Т° 36.6 1) table No. A1

Pulse 75 per minute 2) methotrexate 10 mg. 1r. on Tuesdays

3) folic acid 0.001 1r/d

4) calcium D3 1t 1r/d.

Blood pressure 120/70 mmHg.

General state child is satisfactory.

Eyes and ears – externally without visible pathology

Body weight 43.5 kg, body length 162.5 cm. Asthenic build.

According to the formula = 100 + 6 (n-4) = 100 + 6 (14-4) = 160cm. The actual body length exceeds the calculated one by 1.5%

According to the formula = n x 5 - 20 = 14x5 - 20 = 50kg. The actual body weight is 13% less than the calculated one.

Physical development corresponds to age, disharmonious (deviation in body weight 13%).

Skin and subcutaneous fat.

The skin is pale and dry.

Hair, fingers and nails without pathology.

The muscles are developed satisfactorily, symmetrically, muscle tone is preserved, and are painless on palpation. No muscle tightness

The fontanelles are closed, the sutures are closed, the chest is cylindrical, the limbs are straight, the spine is a violation of posture.

The chest is cylindrical in shape, no deformations are noted. Epigastric angle 60°.

Paravertebral

In the lungs, breathing is vesicular, carried out evenly in all sections, there is no wheezing. Vesicular breathing.

There are no visible changes in the chest in the area of the heart. Palpation in the heart area is painless.

Limits of relative dullness of the heart:

Right: at the right edge of the sternum in the 4th intercostal space.

Left: 0.5 cm medially from the left midclavicular line, in the 5th intercostal space.

Upper: located at the level of the middle of the 3rd intercostal space.

The boundaries of this child’s heart correspond to the age norm.

Digestive system and abdominal organs.

Gums without pathological changes. The salivary glands (parotid, submandibular, sublingual) are not changed.

On auscultation, normal bowel sounds are heard. The stool is formed, normal consistency, regular.

Liver and gallbladder:

The abdomen is symmetrical, there is limited protrusion in the area of the right hypochondrium and there is no restriction in breathing in this area.

Liver dimensions according to Kurlov are within normal limits (9/8/7)

On palpation, the lower edge of the liver at the edge of the rib is not pointed, the surface is smooth, the consistency is elastic, painless.

The gallbladder is not palpable.

There is no hyperemia or swelling in the kidney area.

The kidneys are not palpable. There is no pain on palpation in the area of the upper and lower ureteral points

Development of the genital organs according to the male type. Secondary sexual characteristics correspond to the age of the child.

Results of laboratory, instrumental and other special studies.

Case history of pediatric reactive arthritis

48. Reactive arthritis

Reactive arthritis in children

Symptoms of reactive arthritis in children

Treatment of reactive arthritis in children

Sick children in adolescence may be prescribed tetracycline and fluoroquinolone drugs.

In very severe cases, with a high level of inflammation, methotrexate and sulfasalazine are used.

Possible consequences

Parents should remember that timely treatment of reactive arthritis produces effective results.

If there is a problem

If the application does not launch on your phone, use this form.

Hereditary metabolic diseases are a monogenic pathology in which gene mutation leads to

Reactive arthritis

Criteria for diagnosing reactive arthritis.

1) elimination of infectious foci that support the articular process;

2) regulation of immunological reactivity;

5) stimulating therapy (vitamins, nonspecific adaptogens, anabolic steroid drugs) strictly according to indications;

Characteristics of the patient's complaints upon admission to the hospital (swelling and pain in the knee joint when walking). Clinical examination of the patient, analysis of symptoms, formulation and substantiation of the diagnosis. Recommended treatment for reactive arthritis.

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MINISTRY OF EDUCATION, SCIENCE AND SPORTS OF UKRAINE

Kharkov National University named after. V.N. Karazin

REACTIVE ARTHRITIS IN CHILDREN

1. Patient complaints upon admission

reactive arthritis knee joint

2. Objective research

3. Preliminary diagnosis

Start of supervision: 02.21.2003. End of supervision: 26.02. 2003. Curator: x

Passport part

Age 47 years

Gender: Male

Nationality Russian

Education: secondary

Profession: miller

Date of admission: 02/18/03

Home address: x history disease diagnosis anamnesis

The diagnosis with which he was sent to the clinic: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, stage II activity.

Preliminary diagnosis: Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.

Clinical diagnosis: Rheumatoid arthritis: polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.

Complaints: At the time of supervision: complaints of mild pain in the metacarpophalangeal, wrist, knee and shoulder joints, painful limitation of mobility and a slight increase in skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness. Upon admission: aching pain in the metacarpophalangeal, wrist, knee and shoulder joints, which occurs not only during movement, but also at rest; severe painful limitation of mobility and increased skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness; loss of appetite, dizziness.

History of the present illness: (Anamnes morbi) Considers himself sick since 1999, when for the first time there was a sharp pain in the left wrist and metacarpophalangeal joints of both hands, short-term stiffness in these joints, and general malaise. The occurrence of pain is associated with working conditions - constant hypothermia and dampness. He was hospitalized at the Central District Hospital of Asekeyevsky District, where he was diagnosed with rheumatoid arthritis. After 2 weeks of treatment (diclofenac, cannot indicate the dosage), the pain subsided. After being discharged from the clinic, I began to notice that the joints began to react to changes in the weather, and pain occurred in spring and autumn. In the spring of 2000, swelling and pain appeared in the shoulder and knee joints. The regional clinic sent him to the Regional Clinical Hospital, where he was prescribed prednisolone tablet. within one month, physiotherapeutic treatment. Joint pain disappeared and mobility increased. Spring 2001 was sent for spa treatment to a sanatorium in Pyatigorsk. 02/18/03 readmitted to the rheumatology department of the Regional Clinical Hospital due to an exacerbation of the disease: aching pain in the metacarpophalangeal, wrist, knee and shoulder joints, which occurs not only during movement, but also at rest; severe painful limitation of mobility and increased skin temperature over these joints. There is a crunch in these joints when moving; their swelling; morning stiffness until lunchtime; general weakness; loss of appetite, dizziness.

Life history: (Anamnes vitae) Born in ***, the third child in the family, grew and developed according to his age. He did not lag behind his peers in physical and mental development. I went to school at the age of 7, studied satisfactorily, and was involved in physical education in the main group. After graduating from school, he was drafted into the army and the navy. Married, has one child (daughter). Denies childhood diseases (measles, rubella, scarlet fever, diphtheria). Notes a hereditary predisposition to joint diseases: the mother had joint pain. There is a reaction to the administration of nicotinic acid - skin rash, ulcers on the mucous membranes. Denies tuberculosis, hepatitis, malaria, and sexually transmitted diseases. There were no blood transfusions. I have not traveled outside the region for the last 6 months. Bad habits: does not smoke, drinks alcohol in limited quantities. Living conditions are satisfactory, meals are regular.

Present condition (Status preasens) The patient's condition is satisfactory, consciousness is clear, the position in bed is active, the patient is available for contact. The physique is normosthenic. The patient's appearance corresponds to age and gender. Height 164 cm, weight 64 kg. The skin is dry, clean, the color of the skin is pale, the elasticity of the skin is preserved, the visible mucous membranes are pink and moist. Limitation of movement in the wrist, metacarpophalangeal, shoulder, knee joints. Synovitis of the wrist, metacarpophalangeal joints of both hands: swelling, increased skin temperature over the joint area, pain on palpation. There are no rashes, scratches, petechiae, or scars. Male pattern hair growth. Hair splits. The nail plates are of the correct shape, the nails are brittle, the nail plates do not peel off. Subcutaneous fatty tissue is moderately expressed and evenly distributed. There is no edema or acrocyanosis. Examination by organ systems:

Respiratory system: The nose is not deformed, breathing through the nose is free. The chest is cylindrical in shape, the collarbones are at the same level, the ribs run obliquely downwards, the intercostal spaces do not bulge or sink. Both halves of the chest evenly participate in the act of breathing and produce vocal tremor. Respiratory rate 16 per minute. Percussion above the pulmonary fields is a clear pulmonary sound. There are no local sound changes. Topographic percussion data: standing height of the apexes of the lungs - in front - 3 cm on both sides, in the back - at the level of the spinous process of the 7th cervical vertebra. The width of the Kernig margins is 5 cm on both sides. Mobility of the lower edge of the lungs along the midclavicular line is 5 cm on both sides. Vesicular breathing, no wheezing, no pleural friction noise. The lower borders of the lungs. Right Landmarks Left 6th intercostal space parasternal line 6th intercostal space midclavicular line 7th intercostal space anterior axillary line 7th intercostal space 8th intercostal space midaxillary line 8th -\-\-\-\\- \-\\\-\ 9th intercostal space posterior axillary line 9th -\-\-\-\-\-\-\-\ 10th intercostal space scapular line 10th -\-\-\- \-\\-\-\- 11th intercostal space paravertebral line 11th -\-\-\-\\-\-\-\

Cardiovascular system: The heart area is not changed. There is no pathological pulsation of blood vessels. There is no cyanosis, peripheral edema, or shortness of breath. The pulse is rhythmic, blood pressure in the right arm is 110/70 mm. rt. Art., on the left 110/70 mm. rt. Art. The pulsation of the vessels of the lower extremities is symmetrical and good. Apical impulse in the 5th intercostal space on the left, medially from l. medioclavicularis sinistra by 1 cm, width 1.5 cm, moderate strength and height. Boundaries of relative cardiac dullness: RIGHT LEFT 2nd intercostal space - along the edge of the sternum 2nd intercostal space - edge of the sternum 3rd intercostal space - 1 cm outward from the right edge of the sternum 3rd intercostal space - 1 cm from the edge of the sternum to the left 4th intercostal space - 1.5 cm outward from the right edge of the sternum 4th intercostal space -1.5 cm from the edge of the right sternum to the left 5th intercostal space -2 cm from the edge of the sternum to the left Borders of absolute cardiac dullness Right - 4th intercostal space 1 cm from the sternum to the left. Left - 5th intercostal space 2.5 cm from the sternum on the left. Upper - along the upper edge of the 4th rib along the parasternal line.

Digestive system. Pink lips. The oral mucosa is clean, moist, pink. The tongue is moist, slightly coated with a white coating at the root. The abdomen is of normal shape and size, evenly participates in the act of breathing, is soft, painless, and accessible to deep palpation. There is no ascites or visceroptosis. The sigmoid colon is palpated in the form of a dense cylinder, 2 cm wide, painless. The cecum is palpated in the form of a soft cylinder, 3 cm wide, painless. The transverse colon is palpated 2 cm below the navel in the form of a soft cylinder, 3 cm wide, painless. The edge of the liver is smooth, elastic in consistency, painless. The dimensions of the liver according to Kurlov are 10 x 8 x 7 cm. Palpation of the points of the gallbladder is painless. The stool, according to the patient, is filled once a day.

Urinary system: The kidneys are not palpable. The points of the kidneys and urinary tract are painless. There is no pain when tapping the lumbar region. Urine is light yellow in color and transparent. Urination is free, painless, 5-6 times a day. Daily diuresis is about 1200 ml. Doesn't urinate at night.

Hematopoietic system: There are no hemorrhages or hemorrhagic rashes on the skin. The mucous membranes are pale pink. Lymph nodes are not enlarged. The spleen is not palpable; percussion is determined from the IX to the XI rib along l. axillaris media sinistra. Tapping the flat bones is painless. Dimensions of the spleen according to Kurlov: diameter 4 cm, length 6 cm.

Endocrine system: Height 164 cm, weight 64 kg. Hairline corresponds to gender. General development is appropriate for age. The face is round, pale. Subcutaneous tissue is moderately developed and evenly distributed. Upon examination, the contours of the neck are smooth. The thyroid gland is not enlarged. There is no tremor of the hands, tongue, or eyelids.

Musculoskeletal system: Limitation of movement in the wrist, metacarpophalangeal, shoulder, knee joints. There is a crunch in these joints when moving; morning stiffness until lunchtime. Synovitis of the wrist, metacarpophalangeal joints of both hands: swelling, increased skin temperature over the joint area, pain on palpation.

Central nervous system: The patient is sociable, emotionally labile. Speech is clear, attention is maintained. Pain sensitivity is not reduced. There are no paresis or paralysis. Intelligence is average. Insomnia due to severe joint pain. The patient treats the disease adequately and easily comes into contact. Pulse 62 per minute. Muscle strength is age appropriate. Sweating during physical activity. There are no pathological symptoms. disease diagnosis history rheumatoid arthritis

Laboratory and instrumental studies: KLA: indicators February 18, 2003 February 28, 2003 normal red blood cells 4.46*10 /l 4.66*10 /l 4.0 - 5.0*10 /l hemoglobin 131g/l 119g/l 130 - 160 g/l color index 0.88 0.85 0.85 - 1.05 leukocytes 5.3*10 /l 6.0*10 /l 4.0-7.0 /l Rod nuclear. 3% 3% 2 - 4% Nuclear segment. 86% 85% 40 - 70% Monocytes 4% 5% 2 - 8% Eosinophils 0.50% 0.5% 0-1% Platelets 400*10 /l 219*10 /l 180 - 320*10 /l ESR 32mm /h 30mm/h 1 -15mm/h

Conclusion: accelerated ESR. OAM: indicators February 18, 2003 norm color light yellow light yellow density 1014 1004 - 1024 epithelial cells 0-1 in the field 0-3 in the field leukocytes 0-1 in the field to 4 in the field erythrocytes absent 0-1 in p/z reaction weakly acidic neutr-slightly acidic protein absent up to 0.033%

Conclusion: within normal limits. Biochemical blood test: 04/16/02. total protein 79 g/l normal: 65 g/l albumin 47% normal: 50-70% globulins 35% normal: 20-30% fibrinogen 15,000 mg/l normal: 10,000 mg/l urea 4.56 normal: total bilirubin 13 .9 norm: AlAT 0.05 norm: up to 0.42 AsAt 0.020

Conclusion: dysproteinemia: hypoalbuminemia, hyperglobulinemia; increased fibrinogen content. Immunological study: 02.18.03. rheumatoid factor - weakly positive (+) C reactive protein - weakly positive (+) X-ray examination: 02.21.03. On the provided photographs of both hands in a direct projection, diffuse osteoporosis is noted, brush-like lucencies in the heads of the middle fingers of the metacarpal bones, small bones of the wrist, narrowed joint spaces in the wrist joints, more on the left. The contours of the articular surfaces are unclear. Conclusion: stage II rheumatoid arthritis.

Clinical diagnosis and rationale

Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.

justification: morning stiffness before lunch in the wrist, metacarpophalangeal, shoulder, knee joints; arthritis of more than three joints; arthritis of the hand joints; symmetrical arthritis - the areas of the wrist, metacarpophalangeal, shoulder, knee joints have swelling of the periarticular soft tissues; presence of rheumatoid factor in blood serum; X-ray changes: photographs of both hands in a direct projection show diffuse osteoporosis, brush-like lucencies in the heads of the middle fingers of the metacarpal bones, small bones of the wrist, narrowed joint spaces in the wrist joints, more on the left, the contours of the articular surfaces are unclear.
Seropositive, because rheumatoid factor is detected in the blood serum
A slowly progressive course is indicated by the history of the disease and X-ray examination: during the course of the disease (3 years), no significant deformation of the damaged joints was detected; 2 new joints were involved in the process (shoulder, knee).
For the II degree of activity (medium), the following signs: pain in the joints not only during movements, but also at rest, stiffness continues until noon, severe painful limitation of mobility in the joints, moderate stable exudative phenomena. Hyperthermia of the skin over the affected joints is moderate. ESR - increased to 32 mm/h (normal = 15 mm/h), dysproteinemia: blood albumin - 47% when normal = 50-70%, the amount of globulins - increased to 35% (normal = 20-30%). Rheumatoid factor - words. positive (+); C - reactive protein - sl. positive (+).
X-ray stage II is determined according to the X-ray examination data: On the provided photographs of both hands in a direct projection, diffuse osteoporosis is noted, brush-shaped lucencies in the heads of the middle fingers of the metacarpal bones, small bones of the wrist, narrowed joint spaces in the wrist joints, more on the left. The contours of the articular surfaces are unclear.
Functional disorders I - slight limitation of movements in the joints, feeling of stiffness in the morning; professional suitability is preserved, but somewhat limited.

Treatment:
Rp.: Tab. Ampicillini 0.25 N. 20 D.S.: Take 2 tablets 4 times a day (regardless of meals) for 7 days
Rp.: Tab. Ibuprofeni 0.2 N.30 D.S.: Take 1 tablet 3 times a day after meals for 2 weeks
Rp.: Tab. Prednisoloni 0.005 N.20 D.S.: Take 1 tablet 2 times a day for 10 days.
Rp.: Chole conservata medicata 100ml D.S.: For compresses on the knee joints. Use for 6 days

Head Department Chuprov A.V.

Disease history

FULL NAME. patient: x

Clinical diagnosis: rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction

Concomitant diseases: hr. tonsillitis, decompensated form,

Follicular tonsillitis, stomatitis.

Curator: Korotkova E.V.

well IV group 2 ped. f-t.

Assistant: Kedrova K.S.

Novosibirsk - 1998

Passport information.

Patient's name:x

Date of birth: 10/18/1990.

Age: 7 years.

Floor: male.

Organized by: Studying at school, 1st grade.

Address: Zdvinsk

Directed by: regional clinic

receipt date 05/07/98

Ds directions: Rheumatoid arthritis, articular form.

Ds receipts: Rheumatoid arthritis, articular form, hr. tonsillitis, compensation Form.

Ds clinical: rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction

Complaints

At the time of admission, the child complained of pain and swelling in the left knee joint, and headaches.

Anamnesis morbi.

He often suffered from respiratory diseases.

All winter I suffered from colds every month. The last time I had the flu was at the end of February, I went to school from 5.03.

On March 30, he consulted a doctor with complaints of swelling and pain, limited movement in the left knee joint (he was limping). The day before there was a joint injury (bruise). On April 6, he was hospitalized at the URB, as joint swelling and pain persisted. Anti-inflammatory therapy was prescribed there. Within 10 days there was some improvement, the boy was discharged home, and treatment was interrupted. Then pain in the joint reappeared, and bending was difficult. 07.05 was admitted to the regional hospital for planned

examinations.

Anamnesis vitae.

Born the second child from the second pregnancy. I went on maternity leave at 6 months. I followed the regime and ate normally. Childbirth, without complications. He immediately screamed, the scream was loud and strong. Birth weight 4250 g. The baby was put to the breast after 12 hours. Natural feeding until 1 year. The umbilical cord remnant fell off on the 2nd day. Discharged on the 7th day. No diseases were noted during the neonatal period. He began to hold his head up at 2 months, at 4.5 months he began to stand with support, at 6.5 - crawling, at 7.5 - sitting independently, at 10 - standing independently, at 11 - walking. During the 1st year he was breastfed and suckled actively. From 2 months received apple juice (drop by drop). From 4 months received 5% semolina at 5 months. egg yolk (1/2), at 7 months. minced meat, meat broth at 12 months. - cutlet. Complementary feeding was tolerated well, weaning time was 12 months. The child’s nutrition is currently adequate.

Vaccinated according to age, response to vaccinations is adequate. He tolerates medications well, there were no blood transfusions.

Allergic history is calm.

Epidemiological history: There was no contact with infectious diseases.

Family history:

The child's parents are healthy, no hereditary predisposition has been identified.

Admission status:

The condition is satisfactory, the position is active, behavior is adequate, consciousness is clear.

Skin condition: no pathological changes, increased sweating and skin moisture. Subcutaneous fatty tissue is moderately expressed.

Respiratory system: chest without pathological changes, auscultation - vesicular breathing, respiratory rate 18 per minute, no wheezing is heard. The boundaries of the lungs are within the age norm.

The cardiovascular system: The heart area is not visually changed. Heart rate – 80 per minute, blood pressure – 120/80 mmHg. Borders of the heart: left - along the midclavicular line, right - along the right sternum, upper - along the upper edge of the 3rd rib. On auscultation, a systolic murmur is heard at the apex. The first tone at the apex is weakened.

Digestive system: The abdomen is soft, palpation is painless. The liver protrudes 0.5 cm from under the lower edge of the costal arch.

Genitourinary system: kidneys are not palpable, Pasternatsky’s sign is negative.

Osteoarticular system : when walking, it spares the left leg, the left knee joint is hot, swollen, increased in volume, flexion is limited, pain when moving. The muscular system is developed according to age.

Objective examination :

Common data.

The condition is satisfactory, the position is active, consciousness is clear, behavior is adequate. Orients himself well in time and space. Meningeal symptoms (Kernig, Brudzinski: upper, lower, pubic) are negative, there is no stiff neck.

LEATHER: pale, without pathological elements, moderate hair growth, straight nails. The venous network of the lower limb is expanded. Skin temperature is normal. Humidity is slightly increased. The skin is elastic. Symptoms of pinch, tourniquet and hammer are negative. Dermographism is mixed. Appears after 15 seconds, disappears after 2 minutes. Visible mucous membranes are pink and moist.

SUBCUTANEOUS ADIPOSE FIBER : sufficiently expressed, evenly distributed. Upon palpation, the thickness of the folds in symmetrical areas is the same: on the abdomen - 1.0 cm, on the chest 0.5 cm, under the shoulder blades 0.5 cm, on the posteromedial surface of the shoulder - 0.5 cm, on the posteromedial surface of the thigh - 1 cm, in the cheek area - 1.0. Palpation - compaction and swelling are absent. Tissue turgor is good.

MUSCULOSCAL SYSTEM:

LYMPHATIC SYSTEM:

The submandibular lymph nodes are single, mobile, and have a dense elastic consistency. Dimensions 0.5x1 cm, painless. Cervical lymph nodes. Cervical lymph nodes are single, mobile, densely elastic consistency, size 0.3x0.5 cm, painless. The axillary lymph nodes are single, mobile, and have a dense elastic consistency. Size 0.5X0.8, painless.

The remaining groups of lymph nodes (occipital, in the mastoid region, mental, tonsillar, posterior cervical, supra- and subclavian, thoracic, ulnar, popliteal) are not palpable.

Percussion size of the spleen is 5x6 cm. It was not possible to palpate the spleen.

RESPIRATORY SYSTEM:

The voice is clear, breathing through the nose is not difficult. Abdominal breathing type. NPV 20 per minute. The depth of breathing is normal, the chest participates in the act of breathing normally, the movements are symmetrical. The ratio of pulse to respiration is 3:1. The tonsils are not enlarged, protrude beyond the anterior arches, and are somewhat hyperemic. The chest is elastic and painless. Voice tremors are symmetrical on both sides, without any features.

Breathing is smooth and rhythmic. With comparative percussion over the entire surface of the pulmonary fields and in symmetrical areas of the lungs, a pulmonary sound is determined.

Topographic percussion of the lungs:

The lower border of the right lung is along the midclavicular line - 6th rib

along the scapular line - 9th rib

along the paravertebral - at the level of the spinous

process of 11th thoracic vertebra

The lower border of the left lung - along the midclavicular line -

along the midaxillary line - 8th rib

along the scapular line - 10th rib

along the paravertebral line - at the level

spinous process of the 11th thoracic vertebra

The height of the posterior apex of the lungs is at the level of the spinous process of the VII cervical vertebra. The width of the Krenig fields on the left and right is 4 cm. The mobility of the lower edge of both lungs along the scapular line is 6 cm. Symptoms of Arkavin, Koranya, and Philosopher's cups are negative.

THE CARDIOVASCULAR SYSTEM:

At inspection the heart area is visually and palpably unchanged. The apical impulse is determined in the 5th intercostal space along the left midclavicular line, limited (localized), of sufficient strength and height, rhythmic, non-resistant. The cardiac hump is absent. No systolic retractions are detected. No visible vascular pulsation is observed. Quincke's capillary pulse is negative.

Palpation: The pulse is determined in the temporal, carotid, radial, femoral arteries, as well as in a. dorsalis pedis. The pulse on the radial artery is symmetrical, synchronous, frequency 70 beats per minute, rhythmic, tension and filling are sufficient, synchronous with the contraction of the heart.

The symptom of “cat purring” is negative.

Percussion:

Limits of relative cardiac dullness:

left – along the midclavicular line,

right - along the right edge of the sternum,

upper - along the upper edge of the 3rd rib.

On auscultation, a systolic murmur is heard at the apex. The first tone at the apex and at the Botkin point is muffled.

Limits of absolute cardiac dullness:

Upper – third intercostal space.

Left - along the midclavicular line.

Right - along the left edge of the sternum.

The diameter of the heart is 9 cm.

The vascular bundle does not extend beyond the edges of the sternum.

Blood pressure 120/80 mm. RT., Art.

DIGESTIVE SYSTEM:

The oral cavity has a normal smell, the mucous membrane is hyperemic, the tongue is moist and pink, the tonsils are loose and hyperemic. There are no cracks or plaque. The color of the visible mucous membranes is normal pink, there is no pigmentation or ulceration. The gums are reddish, there is no bleeding or looseness.

The teeth are permanent, the number corresponds to age, no carious teeth were detected.

Upon inspection: The shape of the abdomen is correct, there is no asymmetry. Dilatation of the veins of the anterior abdominal wall, peristalsis, and divergence of the rectus abdominis muscles are not observed. No scars, pigmentation, or protrusions are observed. The abdominal wall participates in the act of breathing evenly. Epigastric angle ~90°

Percussion of the abdomen- areas of tympany and dullness over the intestinal area are identified. On superficial palpation the abdomen is soft and painless.

The sigmoid, blind, ascending and descending sections of the colon are palpated painlessly and mobile. Deep palpation: painless, parts of the intestine could not be palpated

Liver palpation according to Strazhesko: the liver protrudes 0.5 cm beyond the edge of the right costal arch along the midclavicular line. The edge of the liver is sharp, painless, the surface is smooth. Dimensions according to Kurlov: along the midclavicular line on the right - 9, along the midline - 8, along the edge of the left costal arch - 7. Palpation at the point of projection of the gallbladder is painless. Murphy, Ortner, Mussi symptoms are negative. Palpation of the pancreas is painless in the Choffard area, Desjardins point and Mayo-Robson point. Mesenteric lymph nodes are not palpable. When auscultating the abdomen, intestinal peristalsis is heard. The child's stool is regular, shaped, sausage-shaped, and brown in color. In the last three days, no bowel disturbances were detected.

URINARY SYSTEM:

Upon examination: no renal edema; The lumbar region is not changed. There is no bulging or hyperemia of the skin.

Palpation:

The kidneys are not palpable.

Palpation of the bladder is painless.

Pain points of the ureters are not determined.

Pain when urinating and urinary incontinence are absent. The frequency of urination is 6-7 times a day, painless, independent. Daytime diuresis predominates. Pasternatsky's symptom is negative on both sides.

EDOCRINE SYSTEM:

There is no impairment of growth and body weight, the subcutaneous fat layer is moderately developed and evenly distributed.

The thyroid gland is not palpable.

There are no secondary sexual characteristics, according to age.

General conclusion based on objective examination data:

No lesions of the skin, subcutaneous fat, musculoskeletal system, lymphatic system and blood system, digestive system and endocrine system, or urinary system were detected.

From the cardiovascular system - systolic murmur at the apex and at Botkin's point. The first tone at the apex is weakened.

There are no special features from the respiratory system.

Considering the duration of the disease, the clear connection with trauma, and the absence of signs of inflammation, there is no convincing evidence for rheumatoid arthritis.

For differential diagnosis and clinical diagnosis, it is necessary to carry out the following additional research methods:

1. General blood and urine analysis;

2. Biochemical blood test (total protein, protein fractions, seromucoid, sialic acids, fibrinogen);

3. Feces on me\worm

5. R-gr. knee joints

6. ECG and ultrasound of the heart

7. CEC and ASL-O

Additional research methods.

Laboratory methods:

Complete blood count (09/17/1997):

Conclusion.

Red blood: ESR increased

White blood: no change

General urine test (04/16/1998):

total quantity 150 ml, color - yellow

Specific gravity 1020.

Conclusion : general urinalysis without any features

Sample Re Biochemical blood tests (04/16/1998):

b-lipoproteins – 3940;

cholesterol – 4.6;

triglycerides – 0.98;

total protein – 78.2;

Seromucoid –0.01

Conclusion: All studied indicators are within age norms. No pathological abnormalities characteristic of any suspected disease were identified.

Immunological Blood test:

CEC - negative

ASL-O negative

Feces per i/g: --

Instrumental methods.

R- study

The left and right knee joints are unremarkable.

Ultrasound examination of the heart:

Conclusion: the cavities of the heart are not expanded, the walls are not thickened. Slight marginal compaction of the right coronary and non-coronary leaflets.

Myocardial contractility is sufficient.

ECG :

Impaired conduction through the atria, increased electrical activity of the left ventricle (stable over time). Sinus bradyarrhythmia 57-85 IM

ECHOKS :

Not convincing changes for congenital heart disease. Anomaly of pulmonary vein drainage.

General conclusion on complaints, anamnesis, objective examination and additional methods and differential diagnosis:

Rheumatoid arthritis should be differentiated from primary tuberculosis syndrome, rheumatism and deforming osteoarthritis. Rheumatoid arthritis, as well as primary tuberculosis, is characterized by the presence of functional systolic murmur at the apex, joint pain, and increased ESR. Rheumatoid arthritis differs from primary tuberculosis in the absence of anamnestic indications of the patient’s contacts with tuberculosis patients, and an increase in the titer of ASL-O and AST. Rheumatism is characterized by the presence of patients with rheumatism in the family, close contacts of the patient with patients with tonsillitis, palpitations at rest and after physical exercise. stress, the presence of skin manifestations (rheumatic nodules). Detection of increased titers of streptococcal antibodies in the blood, dysproteinemia, the appearance of C-reactive protein, an increase in seromucoid content. The diagnosis of osteoarthritis deformans can be based on an analysis of risk factors for this disease (heredity, excess body weight), the presence of characteristic radiological changes.

Based on complaints of pain and swelling in the left knee joint, the status on admission (the left leg is spared when walking, the left knee joint is hot, swollen, enlarged, flexion is limited, pain when moving), we can assume a final clinical diagnosis -

Rheumatoid monoarthritis, subacute course, activity I, without cardiac dysfunction. Concomitant diseases: chronic tonsillitis, compensated form, stomatitis.

Treatment plan for the underlying and concomitant disease:

Mode IIa (semi-bed), table No. 5 (hypochloride). Vitamin therapy (multivitamins) is indicated.

Anti-inflammatory therapy with non-steroidal drugs (aspirin up to 1g), cardiotrophics (digoxin).

Treatment:

Rp: Dragee "Revit"

S. 1 tablet 2 times a day.

Rp: Acidi acetylsalicilici 0.5

D.t.d. N50 in tab

Signa: 1 tablet 2 times a day for 2 months at a decreasing dosage.

Rp: Sol. Digoxini 0.025%-0.5ml

D.t.d. N20 in amp.

S: 0.5 ml 2 times i.v.

Observation diary :

16.05 The condition is serious due to fever. Symptoms of intoxication. The child is lethargic. t-39.2

Poorly reduced by antipyretics, the skin is clean and dry. In the pharynx: bright hyperemia of the tonsils, purulent follicles, there is a moderate increase in the submandibular and anterior cervical lymph nodes up to 1 cm. Pain in the throat when swallowing is bothersome. In the lungs there is vesicular breathing, no wheezing. The boundaries of the heart are not changed. Soft systolic murmur at the apex, weakening of 1 tone at the apex, soft abdomen, slight pain on palpation in the duodenal zone. There was no chair. Urination is not difficult, painless. Taking into account the fever and changes in the nasopharynx, the child has clinical manifestations of follicular tonsillitis.

18.05 Condition without negative dynamics: the temperature remains at low-grade levels and drops to normal on its own. Symptoms of intoxication have decreased. The skin is pale, clean, dry. In the pharynx: bright hyperemia remains, swelling of the tonsils has decreased, purulent plugs on the tonsils remain. Breathing in the lungs is vesicular, heart sounds are loud, rhythmic, systolic murmur in L5-L4. The abdomen is soft, painless, physiological functions are normal.

19.05 Upon examination, the condition is of moderate severity, symptoms of intoxication, pale. In the pharynx: bright hyperemia, loose tonsils. Breathing in the lungs is vesicular, heart sounds are loud, rhythmic, systolic murmur in L5-L4. The abdomen is soft, painless, physiological functions are normal. BP 120/80 t-37.2

20.05 Upon examination, the condition is of moderate severity. Hyperthermia. Trouble in the throat when swallowing. The skin is pale, clean, dry. In the pharynx: bright hyperemia remains, the tonsils are loose. Breathing in the lungs is vesicular. Blood pressure 120/80, pulse 78. The abdomen is soft and painless.

Stage epicrisis:

Recommended: Bed rest, diet No. 5. Therapy as planned. After 5-7 days, repeat the general blood test, immunologist. blood test (ASL-O), blood biochemistry (total protein, albumin, seromucoid, ALT, AST), fibrinogen, GOS, CRP, repeat echocardiography. Consultation with an ENT doctor and dentist is recommended.

Literature :

1. The problem of rheumatoid arthritis Venblat M.E. Gravales E.M.

2. Pediatrician’s companion I.N. Usov.

3. Russian medical journal volume 6 No. 9. From the international Internet

(wide world web)

Curator's signature_____________________

Ministry of Education and Science of the Russian Federation

Ministry of Health and Social Development of the Russian Federation

State educational institution

higher professional education

Samara State Medical University

Department of Faculty Pediatrics and Propaedeutics of Childhood Diseases

Head Department: Doctor of Medical Sciences,

Professor Keltsev V.A.

Teacher: Ph.D.

Ass. Zimnukhova S.I.

Disease history

Diagnosis: “Juvenile idiopathic arthritis, polyarthritis, RF negative, degree of activity 1, radiological stage II, functional insufficiency of the musculoskeletal system 1”

Diagnosis: “Artritis juvenilis idiopatica, polyarthritis, RF-negativis, gradus actionis 1, stadium roentgenologicum II, typus functionalis aegroti 1.”

Curator: student

Faculty of Pediatrics

Samara 2009

General information about the child

Date of birth, age

Home address

Mother's place of work

Father's place of work

Organization

receipt date

Diagnosis in the referral document

Preliminary diagnosis

Clinical diagnosis

housewife

student of SGPPC

25.05.2009 11:25

Juvenile idiopathic arthritis,

Juvenile idiopathic arthritis, polyarthritis, activity level 1.

Artritis juvenilis idiopatica, polyarthritis, degree actionis 1

Juvenile idiopathic arthritis, polyarthritis, RF-negative, activity degree 1, radiological stage 2, functional insufficiency of the musculoskeletal system 1

Artritis juvenilis idiopatica, polyarthritis, RF-negativis, gradus actionis 1, stadium roentgenologicum 2, typus functionalis aegroti 1

Complaints

At the time of supervision, no complaints

Anamnesismorbi

I fell ill in the summer of 2007, when pain first appeared in my right ankle joint. In the fall of 2007, he was hospitalized in the Regional Children's Hospital with complaints of pain in the lower back, knee, and ankle joints when moving, morning stiffness, short-term (disappears 30 minutes after getting out of bed), restless sleep, soreness of the calf muscles, lameness, where the diagnosis was made "Juvenile idiopathic arthritis." He was treated with sulfasalazine. In February 2008, he was treated at the Moscow Institute of Rheumatology, where, for health reasons, he began receiving the drug Remicade. Currently he is in the Regional Children's Hospital for planned treatment to receive Remicade.

Anamnesisvitae

Mother: 38 years old, healthy. The child’s mother visits medical institutions only when necessary. Denies tuberculosis, HIV infection, sexually transmitted diseases, and the presence of bad habits.

Father. 41 years old, healthy, visits medical institutions only when necessary. Denies tuberculosis, HIV infection, sexually transmitted diseases, and the presence of bad habits.

Heredity is not burdened.

The family is complete. Child from the first pregnancy. The course of pregnancy is toxicosis of the first half. The pregnant woman followed a daily routine, the food was nutritious and complied with the recommendations of the doctor monitoring the pregnancy. First birth, urgent, spontaneous, early rupture of amniotic fluid. Date of birth: 03/14/1993. BCG was done in the maternity hospital. The neonatal period was uneventful. The child did not lag behind in physical and mental development. Preventive vaccinations were given according to the calendar; there were no medical outlets. Social and living conditions of the child: the boy lives with his father and mother in a 3-room apartment. The apartment is dry, bright, comfortable. The child has a separate room.

According to the boy, his relationships with his peers are good and he has many friends. Denies the presence of bad habits. Mother and grandfather participate in raising the child.

The child’s daily routine: full sleep, spending an average of 4-6 hours in the fresh air every day, does not attend additional clubs or sections.

Epidemiological history - over the last 7-10 days there has been no contact with infectious patients.

Allergic history - intolerance to sulfasalazine is noted.

Status praesens communis

Noutdoor research

The general condition of the patient is satisfactory. Position active. Consciousness is clear. The facial expression is calm, the behavior is normal, the emotional status is appropriate for the age. The physique is correct, development is proportional.

Body temperature 36.8 0 C.

Body weight 64 kg, height 186 cm. BMI = 18.96. Mesasomatic type of development. Development is harmonious. Normostenic.

The skin is pale, normal turgor, elastic, clean. Hair and nails are smooth and shiny. Nail color is pink.

The mucous membranes are pale pink, clean, no rash. The tonsils protrude beyond the palatine arches, there are no plaques.

The subcutaneous tissue is of normal development, the thickness of the fat fold at the navel level is 1 cm, above the shoulder blades is 1.5 cm, there is no edema, tissue turgor is good.

The degree of muscle development is normal, the tone is normal, there is no contra-crown.

Posture is correct, development is proportional. The head is of correct shape, size corresponds to age, there are no deformations or softening of the bones. No rachitic changes were found. The shape of the chest is correct. Limbs of proportional length, smooth.

Cervical, axillary, inguinal, submandibular, occipital, subclavian lymph nodes cannot be palpated.

The joints are of normal configuration, painless, full range of motion, free, without pathological abnormalities.

Nervous system research

Sensitivity is not impaired, reflexes (abdominal and tendon) are positive, not changed, no pathological reflexion has been identified. Coordination of movement is not impaired. The gait is normal, the Romberg position is stable. No meningeal symptoms were detected.

Examination of the autonomic nervous system: pharyngeal reflexes without features, corneal reactions of the pupils to light are positive on both sides, dermographism is within normal limits.

Locomotor function is without impairment, behavior is normal, emotions are restrained.

Respiratory system

There is no cyanosis, no shortness of breath. The respiratory rate is 17 d/min, the rhythm is correct. The voice is normal, not hoarse. Nasal breathing is free.

The shape of the chest is normosthenic, there is no asymmetry. Retraction of the supraclavicular and subclavian spaces was not detected. The width of the intercostal spaces is 1 cm. The shoulder blades are adjacent to the chest. Movements of the chest are uniform and symmetrical. No pain was detected on palpation of the chest. Resistance is not increased, vocal tremors are uniform.

During comparative percussion, a pulmonary percussion sound is noted in all sections.

With topographic percussion: the height of the apexes of the lungs in front is 3 cm, in the back - at the level of the spinous processes of the VII cervical vertebra, the width of the Krenig fields is 4.5 cm on both sides.

Lower borders of the lungs:

	On right	Left

Medioclavicularis
Axillaris anterior

Axillaris posterior

		Spinous process of the XI thoracic vertebra

Mobility of the pulmonary edges:

Auscultation: vesicular breathing. There is no pleural friction noise.

Circulatory organs

Examination revealed no cyanosis, no deformations of the chest in the area of the heart and no visible pulsation of blood vessels.

On palpation: apex impulse in the 5th intercostal space along the midclavicular line of moderate strength, not diffuse, no tremors. Pulse 78 beats/min, regular, rhythmic, soft, sufficient filling.

The femoral artery pulse was preserved.

The heart configuration is normal. The vascular bundle does not extend beyond the edges of the sternum.

Auscultation: the rhythm is correct, heart sounds are clear, clear, ringing. No noise was detected.

Heart rate 68 beats/min.

Digestive organs

There is no bad breath. When examining the oral cavity: the tongue is moist, pink, there is no plaque, the tonsils extend beyond the boundaries of the arches, the palatine arches are unchanged. The oral mucosa is moist, pink, and clean. The gums are free of inflammation and do not bleed. The act of swallowing is not impaired.

The abdomen is not enlarged in size, is symmetrical, and participates in the act of breathing. Visible peristalsis of the intestines and stomach is not observed. No free fluid was detected in the abdominal cavity. Deep sliding palpation of internal organs according to Obraztsov-Strazhesko: the curvature of the stomach is located on both sides of the midline of the body, 3 cm above the navel, in the form of a roller lying on the spine and on the sides of it. The pylorus is defined in a triangle formed by the lower edge of the liver to the right of the midline, the midline of the body and a transverse line drawn 3 cm above the navel, in the area of the right rectus abdominis muscle. The abdomen is soft, painless, the sigmoid colon in the left iliac region is painless. The colon is painless. The pancreas is not palpable. There is no discrepancy of the rectus abdominis muscles or hernial orifices. Superficial palpation revealed no areas of pain. Shchetkin-Blumberg's symptom is negative. A portal blood flow disorder in the form of a “jellyfish head” was not detected. Auscultation: sound of intestinal peristalsis. The stool is formed, regular, once a day.

Hepatolienal system. There is no peripheral edema. With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch, has a dense elastic consistency, and is painless. Percussion dimensions of the liver according to Kurlov: 9x8x7. The spleen is not palpable. The gallbladder point is painless. Ortner's, Courvoisier's, Kera's, and Frenicus symptoms are negative.

urinary system. There is no swelling. No swelling was detected in the renal area. With deep palpation, the kidneys are not palpable. The symptom of effleurage is negative. The bladder is painless on palpation. Urination is painless, regular, 3-5 times a day.

Endocrine system. The thyroid gland is not palpable.

The genitals are formed correctly, according to age.

Preliminary diagnosis

Juvenile idiopathic arthritis, polyarthritis, degree of activity

Diagnosis

Arthritis juvenilis idiopatica, polyarthritis, gradus actionis 1.

05/25/2009 Curator E.N. Burakova

Survey plan

1. General blood test - carried out to identify the presence of infectious and allergic processes in the body.

2. General urine analysis - determine the physical properties, chemical composition, microscopy of sediment.

3. Feces for worm eggs

4. Biochemical blood test - quantitative analysis of biochemical blood parameters.

5. Immunological blood test

6. Blood test for rheumatoid factor

7. “Ro” of the knee and ankle joints - detect changes in the joints.

8. ECG - diagnosis of pathological conditions of the myocardium, its electrophysiological properties

9. EchoCG - assess the functional state of the heart, assess hemodynamics.

10. Examination by specialized specialists: ophthalmologist.

Results of additional research methods.

1.General blood test: 26.05.09 Norm:

Red blood cells 5.3 10 12 N 4-5 10 12 /l

Leukocytes 13 10 9 N 4-9 10 9 /l

Hemoglobin 149 g/l N 130-160 g/l

Color index 0.9 N 0.85-1

ESR 3 mm/h N 2-15 mm/h

Eosinophils 4 N 2-5%

Segmented 48 N 45-70%

Lymphocytes 44^18-38%

Monocytes 4 N 2-8%

2. General urine analysis: 26.05.09

Specific gravity - m/m

Protein neg N

Transparency neg N

Sugar negative N

Reaction is acidic N

Leukocytes 2-4 in field N

Flat 4-6 in field N

epithelium of vision

3. Blood chemistry: 26 .05.09

CRPL 1.16^0-1.00

ALAT 19.5 N 0-45

ASAT 19.3 N 0-45

Bilirubin 6 µm/l N 3.4-13.6

Seromucoid 10 units N 0-20.0

Fibrinogen 4 g/l N 2-4

INR 1.1 N 0.85-1.18

Prothrombin according to Quincke 85 N 70.0-120.0

4. "Ro» pelvic bones from 01/21/09

The x-ray shows signs of osteoporosis of the hip joints, narrowing of the gaps, and blurred edges of the left sacroiliac joint.

7 . Examination by narrow specialists:

Ophthalmologist's report: 02/21/09

Fundus: pale pink, ratio and caliber are normal.

Differential diagnosis

In this case, the leading syndrome is articular, which occurs in the following conditions: acute rheumatic fever, psoriatic arthritis, reactive arthritis.

Psoriatic arthritis manifests itself in the vast majority of patients against the background of existing cutaneous psoriasis. Any joints can be involved in the process; the disease begins with asymmetric monoarthritis or oligoarthritis, which is prone to recurrence. The skin over the joints has a characteristic bluish-purple color. Periarticular tissues are involved in the process. With a malignant course, exhaustion increases, myotrophy, myalgia, myositis, lymphadenopathy, hepatosplenomegaly, glomerulonephritis and amyloidosis are expressed.

If there are elements of psoriasis on the skin, there is no need for a differential diagnosis.

For acute rheumatic feverAnd Characterized by damage mainly to large joints of the extremities (knees, ankles, elbows), usually symmetrical. The lesion is flying, migrating - various joints are covered in 1-7 days, which is not typical for JIA. The joints are swollen, their contours are smoothed, passive and active movements are sharply limited, which is also observed in JIA, but in this case the skin over the joints is hyperemic and hot to the touch.

Also, unlike JIA, acute rheumatic fever is characterized by a sudden increase in temperature (38-39? C), symptoms of intoxication. Simultaneously with the damage to the joints, signs of rheumatic carditis are identified and become leading (severe general condition, pallor of the skin, shortness of breath, pain in the heart, palpitations, tachycardia, dullness of tones, systolic murmur at the apex, enlargement of the borders of the heart). There is also a characteristic connection with streptococcal infection.

Reactive arthrosis It occurs in two forms: postenterocolitic and urogenital.

Postenterocolitic reactive arthritis develops against the background of intestinal infections, usually after 1-3 weeks. The onset is acute, localized in the joints of the lower extremities, but the joints of the upper extremities can also be affected. Erythema nodosum, tendovaginitis, bursitis, and conjunctivitis often develop.

Urogenital reactive arthritis (Reith's disease) is characterized by a triad of symptoms: urethritis, conjunctivitis and arthritis. The disease begins with damage to the urethra and eyes, and subsequently changes in the joints develop.

Patients complain of pain when urinating, the appearance of mucous discharge from the urethra, especially in the morning. Eye damage is bilateral and manifests itself in the form of catarrhal conjunctivitis lasting from several days to 1.5-2 weeks. In childhood, uveitis, episcleritis, and keratitis are less common.

Joint damage is often asymmetrical, like oligoarthritis, affecting the joints of the legs with gradual involvement of the joints of the upper extremities and the process spreading from bottom to top - the “staircase symptom”.

Articular syndrome is characterized by persistent arthralgia, exudative phenomena against the background of a resolved general condition. Muscle atrophy develops in the early stages. Arthritis of the small joints of the feet is accompanied by “sausage-shaped” swelling of all fingers and a blue-purple coloration of the skin. Some patients show signs of damage to the spine, mainly the thoracic and lumbar regions, as well as the sacroiliac joint.

Quite often, Reith's disease is accompanied by damage to the skin and mucous membranes in the form of pustular, urticarial, blistering rashes and psoriasis-like elements. They can be localized on any area of the skin, and can be either focal or widespread. Keratoderma of the feet and erosive balanoposthitis are more common. Quite often, the skin and mucous elements become lakolized around the head of the penis.

In the chronic course of the disease and in its later phases, damage to the heart, kidneys, and aorta is detected.

Having carried out a differential diagnosis, the presence of acute rheumatic fever, psoriatic arthritis and reactive arthritis can be excluded in this patient.

Clinical diagnosis and its rationale

Juvenile idiopathic arthritis, polyarthritis, seronegative, degree of activity 1, radiological stage 2, functional insufficiency of the musculoskeletal system 1.

Diagnosis

Arthritis juvenilis idiopatica, polyarthritis, seronegativis, gradus actionis 1, stadium roentgenologicum 2, typus functionalis aegroti 1.

The diagnosis of juvenile idiopathic arthritis is made based on the following data:

Age of onset of disease is up to 16 years;

The duration of the disease is more than 2 years;

The duration of joint changes is more than 6 weeks.

Polyarthritis is characterized by more than 5 joints during the first 6 months of the disease, as was the case in our patient.

Activity level 1 is assigned based on the following data: in the UAC dated May 26, 2009, ESR is 3 mm/h.

X-ray stage II is determined based on the conclusion of the radiologist: the X-ray shows signs of osteoporosis + narrowing of the joint space.

Functional insufficiency of OPDA - 1 is diagnosed on the basis that the functional ability of the joints is preserved.

Etiology

The cause of JIA has not yet been established. Among the possible factors underlying the pathological process are discussed:

Infectious nature of the disease;

Violation of immune mechanisms with subsequent development of autoimmune reactions;

Stressful conditions;

Immunogenetic predisposition.

Pathogenesis

The pathogenesis of JIA is based on profound disturbances in the immune response with an imbalance in the quantitative composition of immunocompetent cells, with a violation of their functional activity and cellular cooperation.

The essence of the pathological process in JIA is systemic autoimmune inflammation, which affects the synovium of the joint with maximum intensity. It is assumed that in the early stages of JIA, joint damage is not associated with a specific immune response to an “arthritogenic” antigen, but with a “nonspecific” inflammatory reaction induced by various stimuli, which in turn (in genetically predisposed individuals) leads to a pathological reaction of synovial cells. Subsequently, as a result of the “recruitment” of immune cells (T- and B-lymphocytes, dendritic cells) in the joint cavity, the formation of an “ectopic” lymphoid organ occurs, the cells of which begin to synthesize autoantibodies to the components of the synovial membrane. Autoantibodies (rheumatoid factors, antibodies to fillagrin, glucose-6-phosphate dehydrogenase, etc.) and immune complexes, activating the complement system, further enhance the inflammatory response, causing progressive damage to joint tissues. At the same time, the activation and aggressive proliferation of synovial cells, as well as articular macrophages, is modulated by various colony-stimulating factors (CSF-GM, CSF-G), cytokines, products of arachidonic acid metabolism and other mediator substances, which are also produced by bone marrow cells of the myeloid lineage.

As a result of immune disorders, B lymphocytes produce aggregated IgG, which has the ability to enter into an immune reaction of the antigonene antibody type. Perceiving the altered IgG as a foreign antigen, the plasma cells of the synovial membrane produce rheumotoid factor (RF) antibodies - the IgG and IgM classes.

When rheumatoid factors and immunoglobulins interact, immune complexes are formed, which cause activation of the blood coagulation system, induce the production of cytokines (interleukins, tumor necrosis factor) and activate complement components, which have the ability to cause chemotaxis and cell damage. This leads to the development of an immune-inflammatory process in the tissues of the joints and internal organs.

Thus, the basis of the pathogenesis of JIA is immune-inflammatory reactions. This is evidenced by a number of signs: the identification in patients of various autoantibodies, rheumatoid factors, circulating and fixed in tissue immune complexes, lymphocytes sensitized to connective tissue components, polyclonal activation of B-lymphocytes, impaired production of cytokines, adhesion molecules, etc.

Plan lteachings

Actual treatment:

1. Mode- ward.

2. Diet- table No. 10. Purpose of prescription: sharp limitation of table salt and enrichment of the diet with potassium. Protein content is within the lower limit of the physiological norm, moderate restriction of fat and carbohydrates. Food is prepared without salt; salt-free bread is specially baked. The introduction of free fluid is limited. Culinary processing: pureed and cooked boiled or steamed.

3. Drug therapy:

a) basic therapy:

1. Rp.: Methotrexati 0.005

Methotrexate is a cytotoxic drug, an antagonist of folic acid, its action leads to disruption of DNA synthesis in the S-phase of the cell cycle. Reduces the production of anti-inflammatory cytokines. Monitoring the level of hemoglobin, leukocytes, platelets, bilirubin and transaminases is necessary.

Remicade suppresses the pathological effects of TNF-b, neutralizing both transmembrane TNF-b and soluble TNF-b in solution. Causes lysis of TNF-producing cells by complement fixation or antibody-dependent cytotoxicity.

b) other types of drug therapy:

3.Rp.: “Calcenova”

D.t.d. No. 27 in tab.

It is a source of calcium for proper mineralization of bones and teeth.

DiaryAnd

05/26/2009.

Body temperature 36.8 0 C. Respiratory rate 17 beats per minute. Heart rate 68 beats per minute.

At the time of supervision, the patient has no complaints, joint pain does not bother him, and his range of motion is full. At the time of supervision, the child’s general condition is satisfactory, consciousness is clear, position is active, facial expression is calm. On objective examination: the mucous membranes of the oral cavity, tongue, and gums are pink. Normal humidity. The tongue is moist and clean. The pharynx and tonsils are without plaque or rash. Percussion: pulmonary sound in the lungs. Auscultation reveals vesicular breathing in the lungs, no wheezing. When auscultating the heart, it is noted: heart sounds are sonorous, rhythmic, no murmurs are heard. The abdomen is soft, the liver is not enlarged. Stool and urine output are normal.

The child's condition is satisfactory. There are no complaints, no pain in the joints, the range of motion is full. Temperature 36.4? C. Breathing is vesicular, hemodynamics are stable (respiratory rate 27 beats per minute, heart rate 78 beats per minute). The mucous membranes of the oral cavity, tongue, and gums are pink. Normal humidity. The tongue is moist and clean. The pharynx and tonsils are without plaque or rash. The abdomen is soft and painless. The liver is not enlarged. Stool and urine output are normal.

The condition is satisfactory, no complaints. Temperature 36.7? C. Breathing is vesicular, hemodynamics are stable (respiratory rate 25 beats per minute, heart rate 77 beats per minute). The skin and mucous membranes are without any features. The abdomen is soft and painless. The liver is not enlarged. Stool and urine output are normal.

Epicrisis

Currently he is in the department of cardiac surgery and cardiorheumatology of the Regional Clinical Children's Hospital. She was admitted with complaints of pain in the lower back, knee, ankle joints when moving, morning stiffness, short-term (disappears 30 minutes after getting out of bed), restless sleep, soreness of the calf muscles, lameness. An objective examination at the time of supervision revealed no visible changes in the knee and ankle joints.

During the hospital stay the following studies were carried out:

UAC - leukocytosis (13*10 9 /l);

OAM - no pathology detected;

ECG pathology was not detected;

X-ray shows signs of osteoporosis of the hip joints, narrowing of the joint space and blurred edges of the sacroiliac joint.

Consultation with an ophthalmologist - no pathology was detected.

Based on complaints, history of the present disease, data from laboratory and instrumental research methods, a diagnosis of “Juvenile idiopathic arthritis, spreading oligoarthritis, activity degree 1, radiological stage 2, functional class of the patient 1” was made.

During his hospital stay, the child received the following treatment:

1. Rp.: Methotrexati 0.005

S. Dissolve the contents of the bottle in 5 ml of water for injection. Administer intramuscularly once a week.

2. Rp.: Sol. Natrii chloridi 0.9% - 250 ml

M.D.S. Administer intravenously 5 ml per hour. Every 30 minutes add 5 ml/hour. Maximum 25-30 ml per hour.

3.Rp.: “Calcenova”

D.t.d. No. 27 in tab.

S. 1 tablet 2 times a day

During the stay in the hospital, positive dynamics are noted. Currently, the child’s condition is satisfactory, there are no complaints, there is no pain in the joints, and the range of motion in the joints is full.

At the end of the course of treatment, the child will be discharged under the supervision of a local pediatrician and a district cardiologist, with the following list of recommendations:

1) observation by a pediatrician and cardiologist - monthly;

2) UAC - once every 3 months;

3) biochemical blood test - once every 3 months;

4) analysis of immunological parameters (CD3, CD4, CD8, CD16, CD95, CD4/CD8, IgA, IgM, IgG, CRP, RF, complement) - once every 6 months;

5) ECG - once every 3 months;

6) radiography of the affected joints once every 6 months;

7) FGDS - once every 6 months;

8) consultation with an ophthalmologist - once every 3 months;

9) examination using a slit lamp - once every 3 months;

10) hospitalization in the Regional Clinical Clinical Hospital for a full examination and correction of therapy - once every 4 months;

11) Continue the started treatment. Methotrexate 7.5 mg 2 times a day for 2 days, then a break of 5 days. Calcenov tablets, 1 tablet 2 times a day.

12) Treatment with Remicade should be repeated in a hospital setting every 4 months.

05/28/2009 Curator E.N. Burakova

WITHlist of used literature

1. Keltsev V.A. Juvenile idiopathic arthritis. - Samara, 2005.

2. Keltsev V.A. Rheumatoid arthritis in children. - Samara, 1991.

3. Keltsev V.A. Selected lectures on pediatric cardiology. - Samara, 2001.

4. Shchukin Yu.V., Bekisheva E.V. Greco-Latin terminology of internal diseases. - Samara 2006.

Case history of pediatric juvenile rheumatoid arthritis. Medical history: rheumatoid arthritis. Full name: Zabodaev Nikolay Vasilievich

Reactive arthritis pediatric case history

On how to treat reactive arthritis in children, Komarovsky E.O.

Types of reactive arthritis in children

Symptoms

Diagnostics

Therapeutic measures

Prevention

Pediatric rheumatoid arthritis – long-term treatment required

Causes of the disease

Pathogenesis of the disease

What are the manifestations of the disease

The initial phase of the disease is exudative

Proliferative phase

Articular form of the disease

Articular-visceral form of the disease

Still's syndrome

Allergoseptic form

Individual visceral forms

Diagnosis of the disease

Treatment approaches

Disease prevention

Disease history Juvenile rheumatoid arthritis, systemic form, allergic variant at onset, seronegative according to the Russian Federation, activity 0-1, Rg stage 2-1, NF-1-0

Case history of pediatric reactive arthritis

Reactive arthritis in children

Symptoms of reactive arthritis in children

Treatment of reactive arthritis in children

Possible consequences

If there is a problem

Reactive arthritis

Characteristics of the patient's complaints upon admission to the hospital (swelling and pain in the knee joint when walking). Clinical examination of the patient, analysis of symptoms, formulation and substantiation of the diagnosis. Recommended treatment for reactive arthritis.

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Clinical diagnosis and rationale

Diagnosis: Rheumatoid arthritis, polyarthritis, seropositive, slowly progressive course, stage II activity, radiological stage II, functional impairment I.

Disease history

Complaints

Disease history
Juvenile rheumatoid arthritis, systemic form, allergic variant at onset, seronegative according to the Russian Federation, activity 0-1, Rg stage 2-1, NF-1-0