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Keywords: a case history, a dermatovenerology, dermal diseases, a psoriasis, psorisais, psoriasis vulgaris, a psoriasis ordinary, a case history on dermal, dermatology, the diagnosis, a skin
the CASE HISTORY ON the DERMATOVENEROLOGY
the Clinical diagnosis: a psoriasis ordinary (psoriasis vulgaris)
the PASSPORT PART:
1. A surname, a name, a patronymic: ************ ******* *************
2. Age: 16 flying
3. An occupation: the student of college ¹ 10
4. A home address: **************
5. Date of entering: 23.10.02
6. Date of a curatio: 29.10, 30.10
7. The clinical diagnosis:
à) the basic diagnosis: the Psoriasis ordinary (psoriasis vulgaris), wide-spread, a progressing stage.
á) accompanying diseases: a vegetative dystonia, a chronic gastritis (in a stage of an exacerbation), a chronic adnexitis (in a stage of a remission).
COMPLAINTS of the PATIENT:
At entering: on numerous whitish the different size " »nO?a" on a body which amount is enlarged. An insignificant itch, " ?»«??a??N" from spots of silvery flakes at skblenii. Irritability, a nervousness.
Appreciable deterioration of appetite.
In day of a curatio: on retained whitish formations on a skin, irritability, a lability of mood. Blunt pressing pains in the right the hypochondrium, arisen after the patient has eaten a glass of fried sunflower seeds. ANAMNESIS MORBI:
Was ill for the first time. Counts itself the patient from the beginning of September 2002 years when for the first time has noticed at itself on a pilar part of a head in the field of a nape the pink skins of formation slightly raised above a surface. Has not given to them value, having decided that " a boring ¬«??" it is caused by shampoo. Approximately a week later has noted, that the similar phenomena are observed in temporal and parietal areas, symmetrically on the right and at the left.
Later on hair and a skin of a head has found out large white " »?a?O??¬?", which in the beginning has accepted for a dandruff. During the same period of time small pink formations (diameter from 2 up to 6-7 mm), covered serovato-white *quot have appeared; ?a?NO«?", on razgibatelnoj the surfaces of forearms especially expressed and large in the field of ulnar joints. Has noted, that from the struck plots of a skin at an insignificant scraping easily exfoliate rather large (1-2 mm and even up to 4 mm) white or silver-gray a plate, and the skin naked under flakes looks semidiaphanous.
Further similar defeats of a skin have appeared in the field of a knee joint, on hips, some plaques - on a belly. In the field of ulnar joints of a plaque began to be integrated as a result of merge of fineer. Has addressed in a dermatoveneral dispensary, and 23.10.02 it has been hospitalized in 2 dermal branch.
Up to the reference in a hospital it was treated by nothing. Occurrence of the disease to anything does not bind, in the childhood does not mark cases of any defeats of a skin.
Informs, that before the beginning of disease rather long time tested negative emotions, was in disturbed, emotionally astable condition. The allergological anamnesis is not burdened, medicinal preparations and foodstuffs transfers well.
ANAMNESIS VITAE:
Was born in family of employees the first child under the account. Grew and developed in conformity with the years.
In 1999 year the exacerbation of a gastritis is revealed. In this halter it was treated in a hospital.
In 2000 year very strong not stoped headaches which proceeded almost week have appeared. The patient has been hospitalized and passed treatment concerning a vegetative dystonia.
The attack has been stoped, since then did not repeat. In 2001 year - an appendectomia.
In 1,5-2 months after operation not strong long nagging pains in the bottom of a belly have appeared, marked appreciable morbidity in this area during a menses.
Has addressed to the gynecologist. The diagnosis a chronic adnexitis has been put. After the lead course of treatment of a pain completely have stopped, strong pains during a menses have ceased to disturb. A menses about 12 flying, a monthly cycle it was established at once (in 2-3 months from the beginning), makes 27 days. Duration ìåíñòðóàöèèé4 day; moderately plentiful, painless.
the Nephroptosis on the right - 2,5 sm, at the left - 2 see. The given pathology connect to the expressed acceleration and, as consequence, backlog of body height of internal organs from body height of a skeleton.
In an anamnesis - fracture of a tibial bone.
Body height of the patient - 176 see. (Volleyball) goes in for sports, exercise stresses transfers well, feels pleasure from occupations. Harmful habits are not present. The sugar diabetes, a tuberculosis, oncologic diseases at itself and denies relatives. Dermal diseases in family nobody suffers and did not suffer.
STATUS COMMUNIS:
the General condition satisfactory, the consciousness clear, on questions answers benevolently, in detail, correctly. Some emotional lability is marked.
the Respiratory system: respiration free, deep, equal, rhythmical. A percussion sound above all fields clear pulmonary, borders mild correspond to age norm, mobility of pulmonary edge satisfactory. At an auscultation above all pulmonary fields it is auscultated bronhovezikuljarnoe respiration. Rhonchuses and any other respiratory hums it is not revealed.
System of organs of a circulation: ÀÄ=110/70 mm of a mercurial pile, a heart rate=74 impacts in one minute.
Pulse is precisely palpated on a. radialis, rhythmical, good filling and a strain.
Percussion borders of heart correspond to age norm. Cardiac sounds rhythmical, clear, precise, intensifyings, accents of tones, and also pathological cardiac hums it is not revealed.
the Alimentary system: tongue is impose with a leaky whitish raid. At a palpation a belly soft, painless. Unpleasant sensations arise at pressing in epigastric area, weakly positive signs Kerte and Mayo - Robson are marked.
The liver is palpated on edge of a rib arch, edge equal, smooth, an elastic consistence. At a palpation mild morbidity is marked in the field of a projection of a gall bladder.
Genitourinary system: an emiction painless, usual on frequency. Sign Pasternatskogo negative from both sides. Secondary sexual attributes are well expressed.
Endocrine system: the isthmus of a thyroid gland up to 7-8 mm is palpated. Shares correspond on the size to a distal phalanx of the big finger of the patient, mobile, easily movable, an elastic consistence.
Nervous system: vision, ear, an olfaction, taste, tactile, pain and proprioceptive sensitivities are well advanced.
STATUS SPECIALIS:
Process inflammatory, wide-spread, symmetric. It is localized on a skin of a trunk, extremities, a pilar part of a head. It is submitted by a monomorphism eruption: miliarnymi, lentikuljarnymi papules (an initial element), plaques (the size up to 10 mm in diameter), the covered flakes (a secondary element) siver-white colour. The centers of a defeat of a skin represent sharply circumscribed, plainly the towering inspissations of rose-red colour covered with siver-white plates and flakes.
Papules are especially numerous they on razgibatelnyh surfaces of forearms, in the field of ulnar, knee joints, behind ears. In the field of ulnar joints besides fine elements (2-3 mm) large whitish plaques with rough edges up to 1-1,5 sm in diameter from which at a mild scraping rather large flakes (*quot are separated settle down; 2 mm). At a scraping of papules 3 diagnostic phenomena are taped: 1) a stearin stain (flakes as a stearine, easily disappear from a surface of papules); 2) a terminal film (after erasion of flakes the reddish, wet shining surface is bared); 3) bloody dew (on a smooth wet red surface there is a dot bleeding). Around of some plaques the pseudo-atrophic border (obodok Voronova) is noticed. On mucous oral cavities of rashes it is not revealed. At inspection of brushes of them of plural defects: Fine (length 1-1,5 mm) superficial strokes, excavations, points, as if from a nyxis a needle (a phenomenon of a thimble). Pains in the field of joints (both fine, and large), are not present an itch.
the LABORATORY DATA:
the General analysis of a blood:
a haemoglobin - 126 g/l
erythrocytes - 4,0*1012/ë
the CENTRAL PROCESSING UNIT - 0,9
a sedimentation rate - 3
leucocytes - 6,6*109/ë
relating to stab neutrophile - 3
segmentojadernye - 57 RW - negative
eosinocytes - 2
lymphocytes - 33
monocytes - 5 the General analysis of urine:
transparent, colour - straw-coloured, reaction - acidic, fiber - is not present
the Biochemical analysis of a blood:
a glucose - 5,5 mmole/l, nuclear heating plant - 54 nmole/l, ALT - 70 nmole/l, a bilirubin the general - 13,8 mkmole/l, a thymol turbidity test - 0,6.
the PRELIMINARY DIAGNOSIS:
On the basis
1) complaints of the patient to occurrence all over again on a pilar part of a head, then on razgibatelnyh surfaces of extremities of the whitish rashes raised above a skin which occurrence is accompanied by a mild itch, on deterioration of appetite,
2) the data of an anamnesis: a chronic gastritis, a vegetative dystonia, and also an emotional lability, a long presence before disease in conditions of a constant stress,
3) objective inspection and detection rose-red, precisely circumscribed, slightly raised above a skin, the papular rashes covered with a siver-white raid in the size from 2-3 up to 10-14 mm in diameter, defeats of nails on type " a phenomenon ?a»NO?O¬a",
4) detection of a characteristic psoriatic triad (the sign of a stearin stain, a terminal film, a dot bleeding)
is put the preliminary diagnosis: Psoriasis ordinary (psoriasis vulgaris), wide-spread, a progressing stage.
the DIFFERENTIAL DIAGNOSIS:
the Differential diagnosis carry out with a papular lues (similar appearance of an eruption), a rhematoid polyarthritis at artropaticheskoj the form of a psoriasis and absence of dermal rashes (strong joint pains, puffiness), with a congenital fish-skin disease and desquamative erythrosis Lejnera - at children (presence of a well defined appreciable ecdysis of a skin, branch from it flakes), with lymphomas of a skin, with red flat it is deprived, a leukoplakia, a soft leukoplakia - at adult (similar clinical pictures, for example, a kind of rashes for a red flat herpes, presence of flakes for a leukoplakia, etc.) .
the Papular lues: medno-red shades, density and the big depth zaleganija, absence of the expressed tendency to peripheric body height and triads of a psoriasis, and also presence of other clinical attributes of a lues and positive serological tests. (For a psoriasis: rose-red rashes, the tendency to ekstsentricheskomu to body height and predilection to formation of plaques, presence of a triad of a psoriasis, a negative serological test on a lues)
the Rhematoid polyarthritis: indicatings on absence of a psoriasis at relatives, presence of the rhematoid factor in a blood and defeats of large joints. (For a psoriasis: presence of a psoriasis at relatives, absence of the rhematoid factor in bloods, a defeat of fine joints)
the Congenital fish-skin disease: presence of a dermal pathology with dystrophias at a birth of the child.
(For a psoriasis: it is shown not at a birth, and later)
the Desquamative erythrosis: also it is shaped in 1-st month of life and it is accompanied dispepsicheskimi by frustration, an anemia, complications such as a pneumonia, an otitis, a pyelonephritis.
Lymphomas of a skin: presence of hematological changes, cells Sezari, a characteristic lymphocytic infiltrate in a derma. (For a psoriasis: absence of all it).
the Red flat herpes: the drawing of a defeat is characteristic. A leukoplakia: (For ïñîðèàçà:ïñèîðèàòè÷åñêèé the center is zonated by a crown of a hyperemia, and a surface of his grayish colour quaggier).
patients with a psoriasis on a mucosa of a mouth can have classical leukoplakia or the typical form of a red flat herpes.
the Circumscribed form of a soft leukoplakia: on a surface of the center there is an exfoliation of an epithelium as an ecdysis. (For a psoriasis: if the exfoliation takes place, it easily gives a phenomenon of a dot bleeding).
Taking into account, that at the patient of a rash look like rose-red, is precise otgranichennyh, slightly raised above a skin, the papular rashes covered with a siver-white raid in the size from 2-3 up to 10-14 mm in diameter, there are defeats of nails on type " a phenomenon ?a»NO?O¬a", the characteristic psoriatic triad (a sign of a stearin stain, a terminal film, a dot bleeding) is found out, and also the serological test on a lues is negative, the lues is excluded. As 16 flying sick already and a similar defeat of a skin is observed for the first time, diseases, more characteristic for small children, also are excluded (a congenital fish-skin disease, a desquamative erythrosis).
As the defeat of joints and at the patient is not present a mucous oral cavity, there is no drawing in the center of a defeat, rashes have the kind described above, there is a psoriatic triad, the pseudorheumatism, a red flat herpes, a leukoplakia, a soft leukoplakia are excluded. Taking into account absence of a lymphocytic infiltrate in a derma, the lymphoma of a skin is excluded.
the FINAL DIAGNOSIS:
the Psoriasis ordinary (psoriasis vulgaris), wide-spread, a progressing stage. A chronic gastritis in stages of an exacerbation, a vegetative dystonia, a chronic adnexitis in a stage of a remission, probably, a dyskinesia of biliferous ways.
the ETIOLOGY AND the PATHOGENY of DISEASE:
the Etiology, a pathogeny are unknown. Virus, hereditary, neurogenic, metabolic theories of a parentage of a psoriasis most wide-spread, any of which is not conventional. Apparently, disease has a multifactorial nature. In a pathogeny the certain role allocate to immunological, enzymatic and other biochemical infringements. Is conventional, that the psoriasis represents the systemic process formed at patients not only with immune infringements, but also expressed by the functional and morphological variations of some organs and systems.
In opinion of many researchers, changes are coded in frame of a gene. V.N.
Mordovtsev with co-authors (1977) have established a multifactorial mode of inheritance with incomplete penetranostju genes. It is shown, that antigens gistosovmestimosti Â13 and Â17 authentically more often meet at patients with a psoriasis only dermal displays, and Â17, Â27, Â33, Â40 - at patients with dermal displays in a combination to an arthritis.
Disease is observed in any age, not contagious. TREATMENT:
In a progressing stage -
antihistamine (Suprastinum, Tavegilum, Phencarolum) and giposensibilizirujushchie preparations (a gluconate and Sodium chloridum of a calcium of 10 %, Sodium hyposulphitum, Zinci sulfas of magnesium of 25 % in injections, Sodium thiosulfatum of 30 %),
vitamins (B6, B12, Â1, Â2, Â13, Â15, And, With, E, RR.), a cocarboxylase,
sedative therapy (preparations of Bromum, Valeriana, Elenium, etc.)
Haemodesum intravenously kapelno on 200-400 ml in a day or 2 times a week. Probably - Hydrolysinum, reopoligljukin, Polyglucinum, detoksitsirujushchie procedures: a haemodialysis, a hemosorption, gemofiltratsija, a ultrafiltration and a plasmapheresis.
Naruzhno - cream Unny, 2 % salicylic Unguentum of 2 %, on stray patches - " o?Oµ??aO", oO«O«¬«OO", " Lorindenm - A" and others kortikosteroidnye Unguentums.
In a stationary stage,it is especial at torpid current, the autohemotherapy, Pyrogenalum are shown, to an injection of a staphylococcal anatoxin or an antiphagin (at presence of the centers of a chronic infection), a ultra-violet irradiation, karsil, Essentiale, panzinorm forte.
Naruzhno: keratoplasticheskie Unguentums: 5-10 % ihtiolovaja, 2-5 % of serno-tar, 10-20 % naftalanovaja with addition of corticosteroids. On chronic plaques: Unguentums and creams with cytostatic preparations:
0,5-1 % metotreksaktom, 5 % ftoruratsilom, Unguentum Vishnevskogo and ASD, efirno-tar 5-10 % an admixture prepared on 70 % etilovom alcohol or 70 % a solution of Dimexidum.
It is shown:
a resort therapy - hydrosulphuric and radon sources (Matsesta, TShaltubo, Kemeri, Pyatigorsk, Kislovodsk, Talgi, Nemirov, Krainka, Mirgorod, etc.), sun baths and sea bathings.
physiotherapeutic treatment: PUVA-THERAPY, massage;
LFK.
At serious forms of a psoriasis apply kortikosteroidnye Hormonums inside, cytotoxic immunodepressants (biosupressin, Methotrexatum, etc.) . In last years for treatment of a psoriasis widely use a photochemotherapy, a hemosorption, plazmaferez.
the Diet with restriction of animal fats and carbohydrates, exception of acute dishes, alcohol. the FORECAST:
rather favorable under condition of keeping the regimen preventing relapses: a leaving of a skin, keeping of hygienic norms and demands, prophylaxis of infectious diseases, a balanced diet, prophylaxis of diseases of a gastrointestinal tract and treatment already available, the maximal downstroke of an emotional load. The dispensary observation and a maintenance therapy during winter and early vernal time, and also sanatorium treatment (the Mediterranean, the Southern coast of Crimea) is recommended. If there is an opportunity - resettlement in a zone of a subtropical climate (Crimea).
the Used literature:
1. J.K.Skripkin, A.L.Mashkillejson, G.JA.Sharapov. Dermal and venerologic diseases.
2. Computer disc " the Big medical encyclopedia - 2000".
the Signature of the curator: _____________
To discuss a material at a forum of a site Keywords: a case history, a dermatovenerology, dermal diseases, a psoriasis, psorisais, psoriasis vulgaris, a psoriasis ordinary, a case history on dermal, dermatology, the diagnosis, a skin
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