210-7-0风湿科示范病例-类风湿关节炎

病史简介：患者王某，女，67岁，因“右膝关节肿痛15年，加重1月”入院。

15年前，患者不明原因右膝关节疼痛，未进行正规检查治疗。

疼痛时，用止痛药（用药不详）、封闭治疗及拔火罐等方式缓解疼痛。

1994年因“脑出血”在当地医院住院治疗，当时基底节区出血50ml，住院期间查出患有糖尿病、高血压、高血脂。

出院后遗留右侧肢体瘫痪，11年来长期注射胰岛素及口服降压、降脂（用药不详）。

1月前患者因疼痛加重、右膝发僵、上下楼及下蹲困难。

在门诊经口服止痛药治疗无效且行走困难加重，故入院治疗。

专科查体：轮椅推入病房，生命体征平稳、查体合作，右膝关节明显肿胀，右小腿肌肉萎缩；右髌尖及髌骨边缘压痛；右膝关节内侧间隙压痛，右膝关屈伸活动痛，活动度受限，关节活动范围0°～30°，右伸膝肌力3级。

右髌股关节挤压征（+），浮碳试验（-）。

Lysholm评分4分。

2005年2月18号X线片（正侧位）示右膝关节骨赘形成，关节间隙明显狭窄。

患者自患病来，担心行走受限、右腿残疾，睡眠稍差，饮食尚可，二便未诉明显异常。

临床诊断：该患者的临床诊断是右膝OA，糖尿病，高血压病。

请问：1．患者存在哪些功能障碍？2．患者需要做哪些康复评定？3．请为患者制定一套康复治疗方案。

病史简介：任XX，男，54岁，因“反复双手、双膝关节疼痛5年，加重1月”入我院风湿科。

5年前，患者出现双手指各关节及双膝关节疼痛，伴双手手指关节及双膝关节肿胀。

当地医院治疗后（具体不详）疼痛有缓解。

此后，疼痛反复发作，疼痛时伴有关节的肿胀，自服药后（具体不详）疼痛可缓解。

入院前1个月，患者再次出现双手、双膝关节的疼痛，伴关节肿胀，自服药后疼痛无缓解。

活动时关节疼痛加重，行走困难。

为进一步诊治入我院风湿科。

既往史无特殊。

入院查体：生命体征平稳，扶入病房，痛苦面容。

内科查体无特殊。

专科查体：右尺骨鹰嘴外下方扪及一大小为0.5cm×1.0cm×1.0cm的硬结，质硬，无压痛，与周围皮肤无粘连。

风湿科1.系统性红斑狼疮：〔1〕患者丁乌也，女，29岁。

以“四肢关节疼痛伴面部红斑3月。

〞为主诉入院。

缘于入院3月前始无明显诱因出现四肢关节疼痛，以双手指，手腕、掌指、近端指间关节为甚，呈双侧对称，偶有肿胀，无晨僵。

伴遇冷水时出现双手皮肤呈白、紫、红变化，日晒后面颊部潮红。

无口腔溃疡，无排泡沫样尿、血尿，无躁动、梦想、猜疑，无鼻出血、牙龈出血、排黑色黏液便，无视物不清，曾就当地医院，诊为“风湿〞，行“中药〞治疗〔具体不详〕，治疗后病症无好转。

1个月前求诊我院，查免疫全套：IGG19.00g/L、补体C30.52g/L、补体C4107.00g/L、ANA (+)、ds-DNA353.41IU/ml；血常规：WBC4.2×109/L、RBC3.62×1012/L、HGB97g/L、PLT308×109/L。

血沉64mm/h；尿沉渣：尿蛋白〔＋〕，尿潜血〔＋〕；血生化：LD-L263IU/L,HBDH217U/L；诊断为“系统性红斑狼疮〞，给予“强的松、羟氯奎片、司特立、奥美拉唑〞等治疗。

病症有好转，但仍感四肢关节疼痛及肢体麻木。

今求诊我院，门诊拟“系统性红斑狼疮〞收住入院。

入院查体：T36.8℃P93次/分R20次/分BP125/80mmHg 神志清楚，全身皮肤粘膜无黄染，未触及浅表肿大淋巴结。

头颅无畸形，面颊部对称性、暗红色蝶形红斑，稍高于皮面，外表少许鳞屑。

口唇无溃疡。

颈软，气管居中，胸廓无畸形，双肺呼吸音清，未闻及干湿性罗音。

心率78次/分，律齐，各瓣膜听诊区无杂音。

无奇脉。

腹平软，无肠型及胃肠蠕动波，无表浅静脉曲张，无压痛、反跳痛，肝脾肋下未及，移动性浊音阴性，肝区及双肾区无叩痛，肠鸣音约3次/分。

无血管杂音。

肛门及外生殖器未见异常。

脊柱四肢无畸形。

棘突无压痛。

四肢关节无肿胀、压痛、双下肢无浮肿，四肢肌肉轻压痛、肌力正常。

生理反射正常，病理征未引出。

初步诊断：系统性红斑狼疮。

患者金某某，女性，47岁。

公务员，北京宣武区欢乐家园25-2-501。

2009年11月18日入院。

患者13年前患者无明显诱因出现双侧手足关节疼痛，未系统治疗，渐出现双膝、双肘、双肩等关节疼痛，晨起后加重，伴晨僵，持续超过1小时，至我院，诊为类风湿性关节炎。

先后于我院、中日友好等多家医院住院治疗，口服中药，消炎镇痛药为主治疗，曾服用甲氨蝶呤片（10mgqw）三年，疗效不佳，6年前出现双手、足关节畸形，膝关节强直，多关节活动受限。

05年5月曾因双手、双肩关节疼痛加重于我院风湿科住院，以中医为主治疗症状减轻后出院。

出院后病情尚稳定。

今年初因受凉后出现发热（39℃），咳嗽、咳痰，关节疼痛加重，伴胸腔积液、心包积液于中日友好医院诊治，诊断为：1.类风湿性关节炎，2.系统性红斑狼疮？给予强的松（35mgqd）口服，症状缓解，此后约两周减药半片，目前口服强的松8.75mg，4天前再次出现发热，体温最高达38.9℃，为求系统治疗，遂于今日再入我院，刻下症见：全身关节疼痛，以双手近指、掌指、腕、肘、肩等关节疼痛明显，伴发热、咳嗽、咽痒，无畏寒，无咯痰，饮食夜眠可，头发脱落明显，皮肤无光过敏现象，大小便正常。

患者既往否认肝炎，结核等传染病史，无高血压，糖尿病史，无外伤、输血史，03年5月份曾于我院骨科行第一跖趾关节人工关节置换术、第2－5跖骨头切除术、第1－5近趾间关节成形术，03年底于北京市第一人民医院行双膝关节人工关节置换术。

对青霉素、磺胺类药物过敏。

.体格检查：T38℃P94次/分R20次/分BP120/80mmHg神志清晰，精神正常，营养稍差，发育良好，扶入病房，自主体位，查体合作。

舌质红，苔黄，脉数。

全身皮肤粘膜未见黄染及出血点，浅表淋巴结未及肿大。

双瞳孔等大等圆，对光反射灵敏，耳鼻无异常分泌物，口唇无紫绀，咽部轻度充血，双侧扁桃体未见肿大。

颈部对称，气管居中，甲状腺无肿大，未见颈静脉怒张及颈动脉异常搏动。

类风湿关节炎医案朱良春案1：（类风湿关节炎）张某，男，48岁，工人。

1985年3月12日初诊。

患类风湿性关节炎已4年余，经常发作，发则周身关节游走肿痛。

遇寒更甚，气交之变增剧。

此次发作，症情同前，但局部有灼热感，初得凉稍舒，稍久则仍以温为适，口干而苦。

抗“O”为833u，血沉32mm/h。

苔薄黄，舌质红，脉细弦带数。

迭进温经散寒、蠲痹通络之品无效。

此寒湿痹阻经隧，郁久化热伤阴之证。

治宜泄化郁热，养血顾阴，佐以温经通络。

生地黄45g，肥知母12g，全当归10g，鸡血藤30g，广地龙10g，青风藤30g，制川乌8g，忍冬藤30g，土茯苓30g，虎杖20g，甘草6g，7剂。

3月20日二诊：药后自觉较适，关节热痛及口干苦减轻，苔薄舌红，脉细弦。

原方续服7剂。

3月27日三诊：关节热痛趋缓，口干已释，苔薄，脉细弦。

改服丸药巩固之。

益肾蠲痹丸3袋，每次6g，每日2次，食后服。

4月10日四诊：症情平稳，复查血沉18毫米／小时，抗“O”＜500u。

继服丸剂以善其后。

[注]：益肾蠲痹丸处方：熟地黄、当归、仙灵脾、鹿衔草、炙全蝎、炙蜈蚣、炙乌梢蛇(蕲蛇效更好，但价格较昂)、炙蜂房、炙地鳖虫、炙僵蚕、炙蜣螂虫、甘草等，共研极细末。

另用生地黄、鸡血藤、老鹤草、寻骨风、虎杖，煎取浓汁，泛丸如绿豆大。

每服8g，日2～3次，食后服。

妇女经期或妊娠忌服。

案2：（类风湿关节炎）杨某，女，33岁，工人。

1986年4月5日初诊：去年10月开始周身关节疼痛，怕冷恶热，血沉147mm/h，经常发热(37.5℃~38.2℃)，一度怀疑为红斑狼疮，但未找到LE细胞，嗣查类风湿因子(+)，乃确诊为类风湿性关节炎。

迭用抗风湿类药物无效，长期服用地塞米松(3片／日)以缓其苦。

目前关节肿痛、强硬，晨僵明显，活动困难，生活不能自理；面部潮红虚浮，足肿，腰痛，尿检蛋白(++~+++)，苔薄黄，舌质紫，脉细弦。

郁热内蕴，经脉痹阻，肾气亏虚，精微失固。

治宜清化郁热，疏通经脉，益肾固下。

类风湿关节炎首次病程记录内容患者：李先生年龄：45岁性别：男初步诊断：类风湿关节炎病程记录：第一次就诊时间：2018年10月15日主诉：双手、腕关节、膝关节肿痛、活动受限半年既往史：无特殊情况个人史：不吸烟，无饮酒史家族史：父亲有高血压和糖尿病史查体：生命体征平稳，皮肤温度对称，双肩压痛，无双下肢水肿，双手、腕关节、膝关节略肿胀，双腕关节活动受限，双膝关节有压痛，未见红斑、鳞屑，生理腱反射存在初步诊断：双侧手、腕、膝关节肿痛、活动受限，符合类风湿关节炎临床表现，需进一步检查明确诊断辅助检查：1. 血常规：白细胞计数正常，红细胞沉降率（ESR）升高2. C反应蛋白：2.8mg/L（正常范围 0.8 -3.1mg/L）3. 抗环瓜拉甜肽抗体（anti-CCP）：阳性4. 血清类风湿因子（RF）：阳性诊断：类风湿关节炎治疗方案：1. 激素治疗：泼尼松20mg/日2. 抗风湿药物：甲强龙25mg/周3. 保守治疗：热敷，局部按摩，适当休息，避免受凉4. 给予营养指导，合理膳食，增强身体免疫力复查计划：1. 定期复查血常规，肾功能、肝功能2. 关节炎症指标监测3. 加强心理疏导与康复锻炼4. 逐步减少激素用量，调整用药方案病程观察：2018年10月15日– 2019年01月15日患者按时服药，规律复查，关节肿痛逐渐减轻，活动范围逐渐增加，生活工作能力有明显提高2019年01月15日患者自述关节肿痛得到控制，无恶心、呕吐、腹泻等不适感，无皮疹、头痛、视物模糊等症状，自觉运动能力明显提升2019年03月15日患者自述食欲良好，无胸闷呼吸困难、尿频、尿痛等不适感，正常饮食，大便正常，睡眠良好综上，患者积极配合治疗，病情得到控制，生活质量明显提高。

结语：患者体现了较好的药物依从性，积极治疗态度，查体初步康复，复查计划合理，近期生活质量良好。

需进一步加强心理疏导，加强锻炼，保持良好的治疗状态。

以上病程记录仅供参考，具体治疗还需依据医师实际情况。

风湿科病例讨论记录范文Rheumatology Case Discussion Template.Medical History.Age: 55 years.Sex: Female.Occupation: Teacher.Chief Complaint: Bilateral knee pain and stiffness for the past 6 months.Past Medical History: None significant.Medications: None.Physical Examination.General: Mildly overweight, no acute distress.Musculoskeletal:Bilateral knee effusions.Range of motion:Right knee: Flexion 90 degrees, Extension 0 degrees.Left knee: Flexion 80 degrees, Extension 0 degrees.Tenderness to palpation over the medial and lateral joint lines.Neurologic: Normal.Cardiovascular: Normal.Respiratory: Normal.Laboratory Tests.Erythrocyte sedimentation rate (ESR): 45 mm/hr.C-reactive protein (CRP): 1.5 mg/dL.Rheumatoid factor: Negative.Anti-cyclic citrullinated peptide (anti-CCP): Negative.Antinuclear antibody (ANA): Homogeneous pattern, 1:80 titer.X-rays.Mild joint space narrowing and osteophyte formation in the bilateral knees.Diagnosis.Osteoarthritis (OA) of the knees.Differential Diagnosis.Rheumatoid arthritis.Other inflammatory arthritides.Treatment Plan.Medications:Nonsteroidal anti-inflammatory drugs (NSAIDs)。

关节炎的门诊病历范文英文回答：Patient Name: [Patient's Name]Age: [Patient's Age]Gender: [Patient's Gender]Date of Visit: [Date of Visit]Chief Complaint:The patient presents with joint pain and swelling in multiple joints.History of Present Illness:The patient reports experiencing joint pain and swelling for the past few months. The pain is worse in themorning and improves with movement. The patient also complains of stiffness in the affected joints, especially after prolonged periods of rest. The symptoms have gradually worsened over time, affecting the patient's daily activities and quality of life.Past Medical History:The patient has a history of rheumatoid arthritis, which was diagnosed five years ago. The patient has been on medication for the condition and has been regularly monitored by a rheumatologist.Family History:There is a family history of rheumatoid arthritis, with the patient's mother also being diagnosed with the condition.Social History:The patient is a non-smoker and does not consumealcohol. The patient works as an office assistant and does not engage in any strenuous physical activities.Physical Examination:On examination, there is swelling and tenderness in multiple joints, including the wrists, fingers, and knees. The affected joints are warm to touch and there is limited range of motion. There are no signs of erythema or skin changes.Diagnosis:Based on the patient's history, physical examination findings, and previous diagnosis of rheumatoid arthritis, the patient is diagnosed with exacerbation of rheumatoid arthritis.Treatment:The patient will be prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain andinflammation. Disease-modifying antirheumatic drugs (DMARDs) will also be initiated to slow down the progression of the disease and prevent further joint damage. The patient will be referred to a rheumatologist for further management and monitoring.Prognosis:With appropriate treatment and regular follow-up, the patient's symptoms can be managed effectively, improving their quality of life and preventing further joint damage.中文回答：患者姓名，[患者姓名]年龄，[患者年龄]性别，[患者性别]就诊日期，[就诊日期]主诉：患者多个关节疼痛和肿胀。

类风湿性关节炎病历书写模板范文Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the joints. It is characterized by inflammation, pain, swelling, and stiffness, which can lead to joint deformity and disability. As a healthcare professional, documenting accurate and comprehensive medical records is crucial in the management and treatment of patients with RA. In this article, I will provide a template and a sample case study of a patientwith RA, highlighting the key components that should be included in a well-written medical record.Patient Information:Name: John DoeAge: 55 yearsGender: MaleOccupation: AccountantChief Complaint: Joint pain and swelling, fatigueHistory of Present Illness:Mr. Doe presents with a three-month history of symmetrical joint pain and swelling, primarily affecting the small joints of the hands and feet. He reports morning stiffness lasting for more than an hour, which improves with movement. The pain and swelling have progressively worsened over time, limiting his ability to perform daily activities. He also complains of persistent fatigue, which has been affecting his work productivity.Past Medical History:Mr. Doe has a medical history significant for hypertension and hyperlipidemia, both well-controlled with medications. He denies any previous history of joint pain or swelling. There is no family history of autoimmune diseases.Physical Examination:On examination, Mr. Doe appears fatigued. He has tenderness and swelling in multiple joints, including the metacarpophalangeal, proximal interphalangeal, and metatarsophalangeal joints. There is limited range ofmotion due to pain and stiffness. The joints are warm to touch, and there is no evidence of erythema or skin changes. No other abnormalities are noted on systemic examination.Laboratory Investigations:Complete blood count reveals mild normocytic anemia. Rheumatoid factor (RF) is positive, and anti-cyclic citrullinated peptide (anti-CCP) antibodies are elevated. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated, indicating ongoing inflammation. X-rays of the hands and feet show erosions and joint space narrowing.Assessment and Plan:Based on the clinical presentation and laboratory findings, a diagnosis of rheumatoid arthritis is made. The patient will be started on disease-modifying anti-rheumatic drugs (DMARDs), specifically methotrexate, to control disease activity and prevent joint damage. Nonsteroidalanti-inflammatory drugs (NSAIDs) will be prescribed for symptomatic relief. Regular monitoring of disease activity, including joint examination and laboratory investigations, will be conducted to assess treatment response and adjust medications accordingly. The patient will be referred to a rheumatologist for long-term management and follow-up.Patient Education and Counseling:Mr. Doe will be provided with educational materials and counseling regarding the nature of rheumatoid arthritis,its chronicity, and the importance of adhering to the prescribed treatment plan. He will be advised on joint protection techniques, exercise programs, and the use of assistive devices to improve his functional abilities. The patient will also be educated about the potential sideeffects of medications and the need for regular follow-up visits to monitor disease progression and adjust treatment as necessary.In conclusion, documenting a comprehensive medical record for a patient with rheumatoid arthritis is essential for effective management and treatment. It should include patient information, history of present illness, past medical history, physical examination findings, laboratory investigations, assessment and plan, as well as patient education and counseling. By maintaining accurate and detailed medical records, healthcare professionals can ensure continuity of care and optimize outcomes forpatients with rheumatoid arthritis.。