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性别:男
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* N h) K v6 r1 \5 ]- u年龄:32
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# m5 Q- Q: P* y' P5 K9 R体形:170斤、170cm
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锻炼:散步,偶尔跑9 k3 n0 [; g# M O+ S4 T: v% o
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家族遗传:无" ?2 G; t" p/ Z5 n9 s2 Z% ]
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生活习惯:经常熬夜; Y/ p& [8 ?# i% l
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发病原因:加班到1点,连续2周
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5 y9 \+ e9 g8 G起病时间:2012/9/20 双手酸胀- s5 t- h2 |6 k) T1 [
/ `7 ^4 R9 n( e) _% ^现在情况: 手指微肿, 大腿跟及臀部最为难受, 双膝,双脚有类似症状,目前疼痛可以忍受1 @# R8 n! |* L: z' v U/ ^8 S
用药: ' W+ ?- \* d) H& b! p9 b, d7 s# m0 n; K
12年11月7号-12年11月21号 Naproxen
. o& u% Z. A7 k3 p: Y12年11月21号-27号 Metron pack 6 days. N& d2 J, H7 _9 G9 h
2012年12月7 Diclofenac Sodium 150 mg/day
9 l; j# Q5 f: L! n检查:/ ^& X' }) D B) U7 j4 }
12年11月7号 RF Neg <10; CRP:0.3 (0-0.5) mg/dl; ESR:2 (0-20) MM/HR; ANA:Neg; Lyme: 10, <120 U/ml;
* ?0 o- I. e& Y8 [7 N( m- c WBC 9.2 (4.5-11) x1000/ul; Hematocrit 44, 41-53%; Hemoglobin 14.9 (13.5-17.5) G/DL; plateletes 244 150-400 x1000ul; RBC 4.96 4.5-5.9 mill/ul; MCV 89 80-98; MCH 30 26-34 PG; MCHC 34 30-36 G/DL; RDW 13 11.5-14.5 %; MPV 8 7.4-10.4 UM3;
9 j% I, D+ P6 {7 @8 {' z12年12月7号 HLA-B27: 阴性
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12年11月20日 X-ray 2 V. E0 l& T( _/ ^# n
RIGHT HAND, THREE VIEWS:
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There is arthropathy in the interphalangeal joint the thumb. There - j8 p, p% b2 }- P+ K6 e
are no fractures. No abnormal soft tissue calcifications are present. 6 p- _* k# D: b. Y7 [& c; [; A) l
There are no erosions. ; K" W* c1 T# d$ l2 O3 a
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IMPRESSION: THERE IS MILD ARTHROPATHY IN THE INTERPHALANGEAL JOINT 3 `$ Z2 h* I1 F' Y: Q- h8 `
OF THE THUMB. THERE ARE NO FRACTURES. $ C" u% q1 x3 m" i& `
! z7 S5 \' B8 }5 @2 I; ARIGHT HAND, THREE VIEWS: / d, {+ c! b5 P" g
3 ^3 J( S9 F: hThere is arthropathy in the interphalangeal joint the thumb. There / T1 L. p: c6 v& _, z" D
are no fractures. No abnormal soft tissue calcifications are present. - ^% c' a* l% _+ `8 F4 {
There are no erosions. 8 h4 t' P! N3 s9 t9 k! g Z% |
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IMPRESSION: THERE IS MILD ARTHROPATHY IN THE INTERPHALANGEAL JOINT
( R; Y. b% ^6 E5 w+ I4 ? OF THE THUMB. THERE ARE NO FRACTURES.
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