SITUATIONAL PROBLEM K000939

1. Gout. Acute arthritis of the I metatarsophalangeal joint of the right foot, the first attack. Exogenous-constitutional obesity of the 2nd degree. Hyperlipidemia (hypercholesterolemia, hypertriacylglyceridemia).

2. The diagnosis of “gout” was established on the basis of the patient’s complaints of severe pain in the metatarsophalangeal joint of the first toe of the right foot, swelling of the first toe of the right foot, hyperemia of the skin over the joint, fever up to 37.5°C; anamnesis data (the day before he was visiting a friend, where he ate meat and red wine in large quantities, the pain arose for the first time, suddenly, at about 6 o’clock in the morning and was localized mainly in the region of the I metatarsophalangeal joint of the right foot); objective examination data (when examining the I metatarsophalangeal joint of the right foot: the skin over the I metatarsophalangeal joint is sharply hyperemic, hot to the touch, the swelling of the joint extends to adjacent soft tissues, palpation of the joint is sharply painful, movements and walking are almost impossible. Pain intensity on the VAS scale – 7 points); the stage of gout based on the history of the disease (pain occurred for the first time, suddenly) and on the basis of laboratory data (increased uric acid level). The diagnosis of “exogenous-constitutional obesity (IVF)” was established on the basis of BMI (>35.59 kg/m2). The diagnosis of “hyperlipidemia” was established on the basis of an increase in total cholesterol, an increase in TG levels and a decrease in HDL levels.

3. The patient is recommended: radiography of the I metatarsophalangeal joints of both feet – to determine the stage of gout; urinalysis + albuminuria – to detect urate crystals, kidney damage; puncture of the I metatarsophalangeal joint to study the joint fluid – the identification of sodium monourate crystals; rheumatological tests: rheumatoid factor, ACCP – to exclude rheumatoid arthritis; biochemical indicators: aminotransferases, blood creatinine

– for the purpose of personifying pharmacotherapy and clarifying the patient’s comorbid status.

4. Optimal treatment of gout requires a combination of non-pharmacological and pharmacological approaches and should take into account: a) specific risk factors (uric acid level, number of previous attacks, radiography); b) the stage of the disease (asymptomatic hyperuricemia, acute / intermittent arthritis, interictal period, chronic tophi gout); c) common risk factors

(age, sex, obesity, hyperuricemic drugs). Teaching the patient the right way of life (reducing body weight in obesity, diet, reducing alcohol intake, especially beer) is a key aspect of treatment. Dietary restriction of purine-rich animal products and weight loss reduce serum uric acid levels, and alcohol, especially beer, is an independent risk factor for gout. Treatment of an acute attack of gouty arthritis. NSAIDs and colchicine may be effective in the treatment of an acute attack of arthritis and are the first line of therapy. High doses of colchicine lead to side effects, and low doses (eg, 0.5 mg 3 times a day) may be sufficient in some patients. Removal of synovial fluid and administration of intra-articular long-acting glucocorticoids may be an effective and safe treatment for an acute attack of arthritis. Antihyperuricemic therapy is indicated for patients with acute attacks. Carrying out antihyperuricemic therapy is indicated for the ineffectiveness of non-pharmacological methods of treatment. The decision on such therapy should be made individually, taking into account the balance between benefits and potential risks, and agreed with the patient. The goal of antihyperuricemic therapy is to prevent the formation and dissolution of existing sodium monourate crystals, this is achieved by maintaining the level of UA below the serum urate supersaturation point (<360 μmol / l), since the prevention of the formation and dissolution of already existing sodium monourate crystals is possible when the specified serum level of uric acid is reached . Prevention of joint attacks during the first months of antihyperuricemic therapy can be achieved with Colchicine (0.5-1.0 grams per day) and / or NSAIDs (with gastroprotection when indicated). Both colchicine and NSAIDs have potentially serious side effects, and their use presupposes the need to balance potential benefits and harms.

In the presence of contraindications and / or ineffectiveness of NSAIDs and Colchicine for the prevention of arthritis attacks in the first months of antihyperuricemic therapy, it is possible to prescribe inhibitors of Interleukin-1. This patient was prescribed the following therapy – non-drug: nutrition for gout involves a decrease in total calories. It is necessary to reduce the intake of exogenous purines and animal fats. Fats reduce the excretion of uric acid by the kidneys.

You should be extremely careful when drinking any alcoholic beverages, including beer and red wine.

Excluded from the diet: liver, kidneys, fatty meats, meat broths, smoked meats, peas, beans, lentils, spinach, cauliflower, sprats, herring. You should limit the consumption of meat to 2-3 times a week, while it is better to use it in boiled form. Drug therapy: Colchicine 0.0005 g, 2 tablets every 2 hours, then 2 tablets on days 2 and 3; Day 4 – 1 tablet in the evening; the following days – 1 tablet in the evening with dinner until the attack stops. NSAIDs (COX-2 inhibitors (Nimesulide 100 mg, 1 tablet 2 times a day after meals), after stopping an acute gouty attack – Allopurinol 300 mg 1 tablet 1 time per day, take until the level of uric acid in the blood serum normalizes.

5. The patient needs to continue non-drug therapy: maintaining a balanced diet. Drug therapy: Colchicine, NSAIDs – cancel, as an acute gouty attack was stopped. The issue of prescribing antihyperuricemic drugs should be resolved after monitoring the level of uric acid in the blood serum.

CASE STUDY 14 [K001995]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

Patient N., 41 years old, turned to a polyclinic therapist with complaints of fever up to 38.5°C, weakness, sore throat when swallowing.

Anamnesis: she fell ill acutely, about a week ago – the temperature rose to 38 ° C, she began to worry about a sore throat when swallowing. She took antipyretics with a positive effect – the temperature dropped to 37 ° C, but the sore throat continued to bother. Concomitant diseases: observed by a rheumatologist with a diagnosis of primary osteoarthritis, a local form with damage to the right knee joint. Takes diclofenac 75 mg 2 times a day per os.

On examination: the patient’s condition is moderate. Body temperature 38°C. The skin is of normal color, without rashes. There are no peripheral edemas, when examining the right knee joint, no visible external changes are detected, a moderate limitation of the volume of active and passive movements in the joint is determined. When examining the oropharynx, there is hyperemia, swelling of the pharyngeal tonsils (more on the right), multiple purulent follicles, no raids. Submandibular lymph nodes are enlarged on both sides up to 1.5 cm, dense, moderately painful, not soldered to each other and surrounding tissues. Breathing in the lungs is vesicular, carried out in all departments, respiratory rate – 20 per minute. The borders of the heart are not changed. Heart sounds are rhythmic, clear. Heart rate=90 beats per minute. BP=100/70 mm Hg. Art. The abdomen is soft, painless on palpation. Liver, spleen are not enlarged. The symptom of tapping is negative on both sides. There is no dysuria. The chair is regular, decorated.

Questions:

1. Make a preliminary diagnosis, justify it.

2. With what diseases is it necessary to carry out a differential diagnosis?

3. Give treatment.

4. Assign an examination, justify.

5. Against the background of ongoing therapy, no improvement was observed, the patient came for a second outpatient appointment with a therapist. The result of a general blood test was obtained: hemoglobin – 118 g/l, erythrocytes – 3.8×1012/l, CP 0.93, reticulocytes – 0.8‰, platelets – 190×109/l, leukocytes – 1.0×109/l, stab – 1 %, segmented – 10%, eosinophils – 0%, basophils – 0%, monocytes – 3%, lymphocytes – 86%, ESR – 23 mm/h. Make a diagnosis. What is the further tactics of managing the patient?

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