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性别:男1 m" P! E, D5 L, X2 z5 n. r$ ~. |
, H) |' J$ S- N7 p- b1 Z2 L! w% b年龄:328 O6 ~& _/ X: f6 L8 ~
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体形:170斤、170cm. b4 M8 h7 f0 d5 ]! r" z0 D8 U
4 g& ?( k# k0 \0 O \- \锻炼:散步,偶尔跑) A! e5 q- e9 D" H. Q; A
9 W( D- R4 c f" |" u: V家族遗传:无6 v0 o& Q# `9 d' Y% G; H
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生活习惯:经常熬夜
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, z1 Q1 ~6 l5 R发病原因:加班到1点,连续2周) v3 s; X" R; _3 m" W) e" f/ `
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起病时间:2012/9/20 双手酸胀" r+ `" n! A, {' m
- H) v. h) o% w, q% \3 V* X L% v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, Y0 d( K! D, q0 D# z
用药: $ d8 i! X, q4 G7 T7 `' W) J; n9 J
12年11月7号-12年11月21号 Naproxen4 H. \3 ?* F" T
12年11月21号-27号 Metron pack 6 days
/ B- C# J; T% c q- K( X2012年12月7 Diclofenac Sodium 150 mg/day % i; W: c# y' Z8 N7 Q
检查:
# N4 e4 e$ b- z+ U! n& }" w12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;
6 l; o0 N5 v. P$ ]( T 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;
- j! M6 J4 E+ p. [7 p; ~12年12月7号 HLA-B27: 阴性( @( l! W$ z) X! \6 @* A) _: a
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0 v" A( p- n8 g. }* @12年11月20日 X-ray ?7 o# y, X4 \) i$ y
RIGHT HAND, THREE VIEWS: ) ~ q9 x( e$ }2 @
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There is arthropathy in the interphalangeal joint the thumb. There 9 x9 O% p+ L" i( K% E
are no fractures. No abnormal soft tissue calcifications are present. u2 r+ l( ]# P
There are no erosions.
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IMPRESSION: THERE IS MILD ARTHROPATHY IN THE INTERPHALANGEAL JOINT
4 W. }) X; B: Y. D. Q$ I. {& {2 _ OF THE THUMB. THERE ARE NO FRACTURES.
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4 {; ], n9 N9 aRIGHT HAND, THREE VIEWS:
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( D$ k" q9 R0 Y/ V2 \- H) HThere is arthropathy in the interphalangeal joint the thumb. There 2 s( n* ^1 I7 k
are no fractures. No abnormal soft tissue calcifications are present. / D* @* V! g, X3 Z1 h$ U& d
There are no erosions.
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- @5 P% k. w# Z6 J9 |7 OIMPRESSION: THERE IS MILD ARTHROPATHY IN THE INTERPHALANGEAL JOINT
3 t1 G( R! A+ J2 U! b OF THE THUMB. THERE ARE NO FRACTURES.
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