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1、精选优质文档-倾情为你奉上主诉：多关节肿痛4年半，伴腰痛及双下肢无力1周。现病史：患者于4年半前无明显诱因出现双手掌指及近指关节肿痛，伴晨僵，时间大于1小时，颞颌关节疼痛，口服中药3月无明显效果，自行间断口服“地塞米松”及非甾体抗炎药，上述症状可缓解。2013年7月因关节肿痛加重，双肘关节伸直受限，双腕关节活动受限，心悸、气短，就诊于“北京协和医院”查RF、CCP阳性，炎性指标升高，诊断“类风湿关节炎”，给予口服“甲泼尼龙、甲氨蝶呤、雷公藤、白芍总苷胶囊”病情缓解。3年半前因多关节肿痛，于我科住院诊断“类风湿关节炎、骨质疏松(重度)”，给予静点“亚甲基二磷酸盐”、激素、口服“阿法骨化醇、来氟米
2、特”等药物后病情好转出院，出院后坚持用药。1周前双下肢无力感及腰痛，在当地医院诊断“脑梗塞”，应用改善脑供血药物，未见明显疗效，今为复查及进一步治疗门诊以“类风湿关节炎”收入院。患者自发病以来，饮食及睡眠一般，体重无明显变化，偶有尿路刺激症状，便秘，口眼干，无光过敏、雷诺现象、口腔溃疡。既往史：否认高血脂病史，预防接种史不详，否认结核、肝炎等传染病史，否认外伤史,否认手术史，否认精神病史，否认药物、食物过敏史。无输血及血液制品史。个人史：无吸烟史；无饮酒史。家族史：无家族遗传病及传染病史。体 格 检 查体温36.1 脉搏106次/分 呼吸20次/分 血压146/83mmHg一般情况：发育正常，
3、营养良好，神志清晰，查体合作，自主体位。皮肤黏膜：无异常浅表淋巴结：未触及肿大。头部：无异常。颈部：无异常。胸部：肺部无异常。心脏：心率106次/分，律齐，各瓣膜听诊区未闻及病理性杂音。腹部：无异常神经系统：无异常专科情况：腰椎轻度叩击痛，关节肿痛阴性，双腕关节活动受限，双肘关节伸直受限。辅 助 检 查(2014-3 本院)RF 1460U/ml；CRP 34.1mg/L；ESR36mm/h；CCP阳性。肺CT印诊：考虑：双肺间质性炎症。脊柱骨密度示L2 T：-3.1，重度骨质疏松。双手正位片印诊：双手及双腕关节明显骨质疏松。 Principle action： The swollen and
4、 painful multi-joint lasted for 4 .5 years, which was accompanied by lumbago and weakness of both lower limbs for 1 weeks.History of present illness：There was no obvious cause of swelling and pain in both palms and proximal finger joints 4.5 years ago. These parts are inflexible concomitantly in the
5、 morning, and the time is longer than 1 hours. Temporomandibular joint was painful. Oral Chinese medicine was taken for 3 months but it had no obvious effect. Patient took orally dexamethasone and non-steroidal anti-inflammatory drugs intermittently. The symptoms could be relieved. In July 2013, the
6、 patient was aggravated by swollen and painful joint. The extension of double elbows was limited. The activities of double articulatio carpi were limited. Palpitation and shortness of breath were observed in Peking Union Medical College Hospital and RF and CCP were positive. Inflammatory index incre
7、ased. Rheumatoid arthritis (RA) was diagnosed. Oral administration of Methylprednisolone, methotrexate, tripterygium wilfordii and paeoniflorin capsules relieved the illness. 3. 5 years ago, the patient was admitted to our department because of multiple joints with swellings and pain. Rheumatoid art
8、hritis and osteoporosis (severe) were diagnosed. After taking the methylene diphosphonate , hormone , oral alfacalcido & leflunomide and other drugs, the patients were discharged from the hospital. After discharged , patient adhered to medication. 1 weeks ago, both lower limbs had weakness and osphy
9、algia. In the local hospital, cerebral infarction was diagnosed. No obvious effect was observed in the treatment of cerebral blood supply drugs. For review and further treatment, outpatient service treated the patient for “rheumatoid arthritis” Since the patients illness, whose diet and sleep were g
10、eneral. There was no significant change in weight. Symptoms included urinary tract infection and constipation. Both mouth and eye had dryness. There were not light allergy, Raynauds phenomenon and oral ulcers.Past history: denying the history of hyperlipidemia. The history of vaccination was unknown
11、. Deny the history of tuberculosis and hepatitis. Deny the history of trauma. Deny the history of surgery. Deny the history of mental illness. Deny the history of drugs and food allergies. There was no history of blood transfusion and blood products.Personal history: no smoking history and no alcoho
12、l history.Family history: there was no history of familial genetic diseases and infection.Physical examinationThe body temperature was 36.1 degrees centigrade. A pulse was 106 beats per minute. Breath was 20 times / min. Blood pressure was 146/83mmHg.General situations: there were normal development
13、, good nutrition, clear consciousness and physical examination with cooperation on independent body position.Skin mucous membranes: no abnormality.Superficial lymph nodes: non palpable swelling.Head: no abnormalities.Neck: no abnormalities.Chest: no abnormalities in the lungs. Heart: heart rate of 1
14、06 beats per minute, the heart rate was neat. The area of each valve auscultation was without pathological murmur.Abdomen: no abnormalities.The nervous system: no abnormalities.Specialty: the lumbar had mild percussion pain. The swelling and pain of Joint was negative, and joint activities were limi
15、ted. The extension of double elbow was limited.Supplementary Examination(2014-3 hospital) RF 1460U / ml; CRP 34.1mg / L; ESR36mm / h; CCP positive. Pulmonary CT clinic: consider: interstitial inflammation of the lungs. Spine bone density showed L2 T: -3.1, severe osteoporosis. Hands diagnosis: hands and double wrist had obvious osteoporosis. 专心-专注-专业