抗脊椎炎:从国际功能分类、生命和健康限制的角度描述临床病例

Р. Р. Ахунова, Г. Р. Ахунова
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The patient was evaluated laboratory parameters, electrocardiography, echocardiographic examination, ultrasound examination of hepatobiliary zone and kidneys, radiography of pelvic bones, lumbar spine, ankle, knee, foot joints, magnetic resonance imaging of sacroiliac joints. Results . During the examination, a clinical diagnosis was established: as. 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引用次数: 0

摘要

目的:从国际功能分类、生活和健康限制的角度出发,结合临床情况、环境因素和个人因素对强直性脊柱炎(AS)患者的身体功能进行评估。材料和方法。患者,26岁,因休息时腰椎和颈椎周期性疼痛而在治疗科住院;活动时踝关节、膝关节疼痛;走路时脚跟疼痛;脊柱晨僵持续30分钟;体重减到11公斤。在过去的一年。对患者进行实验室参数评估、心电图、超声心动图检查、肝胆带及肾脏超声检查、骨盆骨、腰椎、踝关节、膝关节、足关节x线片检查、骶髂关节磁共振检查。结果。在检查过程中,建立了临床诊断:as。形成康复诊断:b280.3、b710.2、b780.1、b130.1、b134.0、b455.3、s760.1、s740.0、s750.1、d230.2、d410.3、d450.3、d850.1、d760.1、d920.2、d475.2,确定患者有剧烈疼痛、中度侵犯脊柱活动能力、短暂晨僵、轻度抑郁、重度疲劳;腰椎、膝关节、踝关节及足部关节结构轻微违例;白天维持活动有中度困难,表现出功能障碍,表现出行走困难,从事有偿工作有轻微困难,与家人和朋友共度时光有轻微困难,娱乐和休闲有中度困难,驾驶有中度困难。结论。该临床病例证明了在as患者模型上使用ICF在临床实践中的可能性,它可以全面了解患者并量化患者的病情,从而形成多学科团队工作的共同语言,以确定患者的下一步康复阶段。
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АНКИЛОЗИРУЮЩИЙ СПОНДИЛИТ: ОПИСАНИЕ КЛИНИЧЕСКОГО СЛУЧАЯ С ПОЗИЦИИ МЕЖДУНАРОДНОЙ КЛАССИФИКАЦИИ ФУНКЦИОНИРОВАНИЯ, ОГРАНИЧЕНИЙ ЖИЗНЕДЕЯТЕЛЬНОСТИ И ЗДОРОВЬЯ
Objective : to describe the clinical case of a patient with ankylosing spondylitis (AS) with an assessment of the functioning of his body taking into account the clinical situation, environmental factors and personal factors from the standpoint of the international classification of functioning, life and health limitations. Materials and methods . The patient, 26 years old, was hospitalized in the Department of therapy with complaints of periodic aching pain in the lumbar and cervical spine at rest; aching pain in the ankle and knee joints when moving; heel pain when walking; morning stiffness in the spine lasting 30 minutes; weight loss to 11 kg. over the past year. The patient was evaluated laboratory parameters, electrocardiography, echocardiographic examination, ultrasound examination of hepatobiliary zone and kidneys, radiography of pelvic bones, lumbar spine, ankle, knee, foot joints, magnetic resonance imaging of sacroiliac joints. Results . During the examination, a clinical diagnosis was established: as. Formed rehabilitation diagnosis: b280.3, b710.2, b780.1, b130.1, b134.0, b455.3, s760.1, s740.0, s750.1, d230.2, d410.3, d450.3, d850.1, d760.1, d920.2, d475.2, which fixed the patient has intense pain, moderate violations of mobility in the spine, a short morning stiffness, mild depression, severe fatigue; minor violations in the structure of the lumbar spine, knee and ankle joints and joints of the foot; moderate difficulties in maintaining activity during the day, expressed functional disorders, expressed difficulties in walking, minor difficulties in performing paid work, minor difficulties in spending time with family and friends, moderate difficulties in recreation and leisure, moderate difficulties in driving. Conclusion . This clinical case demonstrates the possibility of using ICF in clinical practice on the model of a patient with as, which allows a comprehensive look at the patient and quantify the condition of the patient, to form a common language for the work of a multidisciplinary team to determine the further stage of rehabilitation of patients.
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