SITUATIONAL PROBLEM K001987

1. Chronic tofus gout. Damage to the joints, kidneys (nephrolithiasis). Hypertensive disease stage II, arterial hypertension II degree, risk of cardiovascular complications 4 tbsp. metabolic syndrome. Dyslipidemia.

2. The diagnosis of “gout” was made on the basis of typical signs of the articular syndrome: paroxysmal inflammation of the joints of the foot, intense pain, swelling of the joints, in addition, the recurrent nature of the course and the presence of tophi are important. The diagnosis of “hypertension (AH)” was established on the basis of the patient’s complaints about the instability of blood pressure, the establishment of the degree of hypertension is based on blood pressure figures measured during admission. The stage of HD was established based on the presence of target organ damage.

(a heart). The degree of risk of cardiovascular complications was set on the basis of the presence of metabolic syndrome.

The diagnosis of “metabolic syndrome” was established on the basis of the presence of obesity, hypertension, dyslipidemia (increased TG levels and decreased HDL levels), fasting hyperglycemia.

3. The patient is recommended to have an X-ray examination of the feet, polarizing microscopy of the synovial fluid to visualize uric acid crystals, ultrasound of the kidneys to determine kidney damage, daily monitoring of blood pressure to assess the stability of the increase in blood pressure, the daily blood pressure profile; conducting an ECG; conducting echocardiography to assess the thickness of the walls of the myocardium, diastolic and systolic function; laboratory test: creatinine to determine GFR and staging CKD.

4. All patients need to follow the recommendations on nutrition – table number 6: restriction of products containing purines (meat), restriction of fat content in products, prohibition of alcohol intake.

For the relief of acute articular syndrome, 3 groups of drugs are used: NSAIDs (for example, Diclofenac 100 mg 2 times a day after meals), glucocorticosteroids (Diprospan 1.0 locally) or Colchicine 1 mg 3 times a day.

In the interictal period: it is necessary to continue to adhere to the diet, add Allopurinol 300 mg per day to the therapy until normalization of uric acid, followed by a dose reduction to a maintenance dose of 100 mg per day, NSAIDs for pain.

5. Angiotensin II receptor antagonists for the correction of blood pressure and Atorvastatin to reduce hyperlipidemia, since these drugs have a uricosuric effect. In addition, the choice of a drug from the group of angiotensin II receptor antagonists is based on its nephroprotective properties. From the same position, the use of a drug from the group of ACE inhibitors as an antihypertensive agent is justified. Ramipril has the most proven nephroprotective properties from the group of ACE inhibitors, from the group of angiotensin II receptor antagonists – Losartan.

CASE STUDY 134 [K001988]

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

Main part

A 47-year-old woman complains of weakness, fatigue, shortness of breath and palpitations with little physical exertion, pale skin, brittle nails, and heavy menstruation.

From the anamnesis it is known that the patient’s menstruation became abundant about 6 months ago, the gynecologist revealed a small-sized uterine fibroids, requiring only observation. The rest of the above complaints appeared 2-3 months ago with a slow increase; she noted an addiction to pungent odors (varnish, acetone), a desire to eat chalk (otherwise, the food is normal); occasional dizziness. Earlier, during two pregnancies and childbirth, mild anemia was noted. Was not a donor. On examination: satisfactory condition, average nutrition. The skin and mucous membranes are moderately pale, there are shallow cracks in the corners of the mouth, brittle nails, with pronounced longitudinal striation and emerging concavity. Vesicular breathing in the lungs, no wheezing. Heart sounds are slightly muffled, rhythmic, heart rate – 78 beats per minute, blood pressure – 100/60 mm Hg. Art. The abdomen is soft, painless on palpation in all departments. The liver and spleen are not palpable. Stool, diuresis without features.

In the general blood test: erythrocytes – 2.9 × 1012 / l, hemoglobin – 70 g / l, color index – 0.73; anisocytosis++, poikilocytosis++, microcytosis++; leukocytes – 3.8 × 109 / l, stab neutrophils – 1%, segmented neutrophils – 54%, eosinophils – 5%, lymphocytes – 33%, monocytes – 6%, basophils – 1%; platelets – 200 × 109 / l; ESR – 15 mm/h. Urinalysis – within normal limits.

Questions:

1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

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

4. What iron-containing drug would you recommend to the patient? What is the route of drug administration? Justify your choice.

5. After 1 month of regular therapy with an iron-containing drug, the patient’s state of health improved significantly; in the blood test, hemoglobin rose to 110 g/l. What is your next treatment strategy? Justify your answer.

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