MEDICAL ACADEMY NAMED AFTER 

S.I. GEORGIEVSKY
OF VERNADSKY CRIMEA FEDERAL
UNIVERSITY.

DEPARTMENT OF SURGERY

TEACHER: ANDREY DREVETNYAK

CASE REPORT

Clinical diagnosis:-

(1) Main disease: Rheumatoid Arthritis

(2) Complication: Left ankle joint deformation

(3) Accompanied disease: Palpitations (tachycardia) and Myopia.

Name : Hansana Fernando

Course : 3rd
Group : 171 A-LA-1
PASSPORT DATA

NAME : Nastya Beloshiskaya

AGE : 24
STATUS : Single
DATE OF BIRTH : 30th July 1990
SEX : Female
NATIONALITY : Russian
OCCUPATION : Vendor
HOME : Podivoskogo 36
DATE OF ADMISSION : 1st March 2015

INQUIRY

COMPLAINTS

1. Main Complains:
Patient complains of pain in the joints with increased intensity mostly in the morning until 1pm
(phalanges, wrist, elbow, shoulder and left ankle). She also feels pain in the neck (spine). There is also
morning stiffness (which is the inability to extend joints mostly carpals and metacarpals). Discomfort in
throat due to weather changes. She also complains of deformation of her ankle joint which has been
progressing with time. When the weather is warmer, she feels bad but in cold weather, she feels better.

2. Additional Complains:
Additionally, patient complains of weakness, headache and dizziness.

ANAMNESIS MORBI

The patient first experienced rheumatic arthritis in 2012. The patient had severe pain in the large joints.
The pain was of migratory character. She was put on a few medication such as, methotrexate, with
hormonal therapy with glucocorticoids and prophylactic treatment for tuberculosis, also, she received
“biological therapy”. Due to complications of rheumatic arthritis, she had mild mitral stenosis and
palpitations. Now she is admitted in Semashko hospital because needs the follow up of her rheumatoid
arthritis and her “biological therapy” followup.

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ANAMNESIS VITAE
Patient was born in Yalta on 30th of July 1990. She has her parents and her sister living with her. The
condition of patient’s childhood was satisfactory, even though she had many episodes of sore throat
(angina of the throat). She says that she had a low level of immunity and thus suffered a lot from
infections. Patient sells in a shop for a living. Nutrition of patient is regular (3-4 times). She was not on a
diet. She neither smokes but drinks alcohol occasionally. She also had a fall and fracture of her elbow
joint.
She is single. She is the first in her immediate family with such a disease but her cousins from the
mother’s side are also sick with rheumatoid arthritis. She takes medical preparation without allergic
reactions. Allergic reactions to various food and chemical substances are absent.

PHYSICAL EXAMINATION
Temperature : 36.9ºC
Pulse rate : 80 per minute
Respiratory rate : 18 per minute
Blood pressure : 130/85 mmHg
Height : 164cm
Weight : 59kg

GENERAL EXAMINATION
The general condition of the patient is satisfactory. Her consciousness is clear and can answer to all given
questions. Her position is active.
Patient has normostenic body composition. The patient has got normal skin. It is elastic and with
normal temperature. Absent of skin hyperemia. Tugor of the skin is normal. The patient has short hair of
normal strength. Subcutaneous fat is moderately developed and skin fold is 1.5 cm symmetrically.
Submandibular and axillary’s lymph nodes are sized from 0.5- to 0.8 mm in diameter, round in
shape and smooth surfaced, elastic consistency, mobile, not adhered to skin and surrounded subcutaneous
fat. It is painless when palpated and skin over it is not changed.
She got a normal hair growth, absence of alopecia. Face is symmetric. Eyes are also symmetric.
Her nose bridge is visible, with dry pale lips revealing fissures at the angle of the mouth.
The muscle development is normal and identical. Tenderness of the extremities muscle during
palpation is marked. Palpation and tapping of the bones are painless. Joints are regular shape and painless
during palpation. Except for her left elbow joint, it is deformed and cannot do a complete literal to medial
active rotation. Active and passive movements of joints are full, except for her left elbow joint.

SYSTEMS REVIEW

EXAMINATION OF BODY PARTS

Her head is round, proportion to her body constitution, symmetrical and her facial and cerebral part is
corresponding. Her face is symmetrical, expression is usual and shape is regular. Her hair covering is of a
female type and corresponds to her age. The widths of her eyes slits are moderate. Patient bad vision,

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myopia of -7.5. Her pupils are in normal shape and size. Her nasolabial folds are normal, size and shape of
nose is normal. Colour of the skin of ears is normal. No carotid or jugular pulsation noted.

SKIN & FATTY TISSUE

The skin colour of the patient is usual, not pale and corresponds to a Caucasian like skin colour. The
patient’s skin humidity is usual. The patient’s skin has normal turgor and elasticity. There are no visible
rashes on the patient’s body. External tumours are absent. There is no pigmentation, desquamation in any
areas of skin in the body. There are no skin elements on his skin. There is an operative scar in her left
elbow joint because of her operation on bone fracture. Subepidermal adipose tissue accumulates
moderately in the abdomen. During investigation, no edema was noted. Patient’s hair corresponds to her
age. Mucus membrane of conjunctiva, nasal and oral cavity appears to be pale - pink. Nail’s shape is also
normal with brittleness or breakages. Longitudinal and transverse lines appear normal. The fatty tissue of
the patient appears to be normal.

LYMPH NODES
The lymph nodes are not palpable in the area of occipital , auricle , cervical area of anterior , lateral and
posterior, area of supra and intraclavicular, cubital and inguinal areas. It was not palpable in axilarry fossa
and also in popliteal area. The lymph nodes are palpable slightly in the area of submandibular. The sizes
are norm about 2mm. Skin over lymph nodes are also norm.

LOCOMOTOR SYSTEM
All active and passive movements of the joints are full. Except the left elbow joint which hasn’t a free
rotation of pronation and supination .No pathologic deformation is seen in the spinal column. Its function
is full.

The muscles are developed moderately, tone and muscle force are identical on both sides. Palpation and
tapping of the bones are painless. Joints are regular in shape, painless during palpation and movements.
The muscles, bone and joints are in a generally good condition.

THE RESPIRATORY SYSTEM.

INSPECTION
At sitting position, patient breathes through her nose.
Her chest shape is normal without pathological signs. Chest is symmetrical with supra and subclavicular
spaces. The patient has a normosthenic and regular chest, the epigastric angle is about 90 º. The chest is
symmetric, supraclavicular fossae are pronounced. Ribs are moderately inclined when viewed from the
side, scapular are closely fit to the chest and are at the same level. The chest is same longer than the
abdominal part of the trunk.
Respiratory rate is 18 per minute and it is regular.
Movement of the chest is symmetrical during respiration.

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PALPATION
There is no tenderness noted along the ribs, intercostal spaces, trapezoid muscles and intercostal nerves
points.
Resistance of chest at longitudinal and transverse direction is moderate. Vocal fremitus at the anterior,
lateral and posterior is symmetrical and normal. Pleural friction is absent.

PERCUSSION
At comparative percussion, symmetrical normal tympanic sound is heard over both sides of the lungs.
Traube’s space is present.
At topographic percussion, lung borders as the following is determined.
Lower Borders.
Lines Right lung Left lung
Parasternal 5th rib --
th
Mid-clavicular 6 rib --
th
Anterior axillary 7 rib 7th rib
Middle axillary 8th rib 8th rib
Posterior axillary 9th rib 9th rib
th
Scapular 10 rib 10th rib
Paraspinal 11th thoracic vertebra 11th thoracic vertebra

Upper Border
Anterior Side 4cm above clavicle
Posterior Side At spinal processes of 7th cervical
vertebra

AUSCULTATION
Over auscultation, vesicular breathing sound is heard over all symmetrical points of the chest. In the
vesicular breathing, during entire inspiration a soft blowing noise is heard but during expiration vesicular
breathing is heard in 1/3 of entire phase. No pathological sounds are heard.
No adventitious sounds or rales were present.
Patient has inspiratory dyspnoe during physical exertion.

CARDIOVASCULAR SYSTEM
Patient feels pressing in behind her sternum and the pain radiates to left shoulder and arm. Patient
doesn’t have paleness of skin, cold sweat and normal arterial blood pressure.

In percussion, relative cardiac dullness:

 Right border – 1cm laterally of the right edge of the sternum
 Left border – on the left midclavicular line
 Upper border –on the 3rd intercostals space on the left side of chest

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 Absolute cardiac dullness:
 Right border – on the left edge of the sternum
 Upper border – on the lower edge of the 4th rib
 Left border – 1cm medially of the border of relative cardiac dullness

Vascular dullness
 Both borders are found on both edges of the sternum on 2nd intercostals space

On auscultation of the lung, the following are found out:

 Apex - there is a presence of diastolic murmur which spreads to the Botkin –Erb
point.

 Pulmonary- the second sound is louder then the first and there are
no presence of murmurs.
 Tricuspid- the first sound is louder then the second sound. There are
no presence of murmurs.
Pulse rate is 80 per minute. Pulse is arrhythmic. Its diameter and tension are satisfactory.

Arterial pressure: systolic – 130 mm Hg, diastolic – 85 mm Hg.

The patient’s heart rate is 80 beats per minute.

DIGESTIVE SYSTEM
The tongue is of usual size, moist, coated with white layer. Mucous of mouth is light pink color. Abdomen
is of a regular form, symmetric .Abdominal wall participates in breathing. Tympanic sound is heard over
all parts of the abdomen during percussion. In superficial palpation, abdomen is soft, painless. Hernias and
superficial tumors are absent. Shchetkin-Blumberg’s symptom is negative.
Deep palpation: sigmoid is palpable in the left iliac region as a smooth firm cylinder 2cm in diameter ,it is
painless, does not produce rumbling sounds, caecum is palpable in the right iliac region as a smooth soft
cylinder with diameter 3cm. Other parts of the intestine are not palpable due to presents of fats.
In auscultation: of the abdomen, peristalsis of the intestine is of moderate sound and frequency is heard.
Vessel murmurs are absent.

Greater curvature of the stomach is determined as soft smooth ridge 3cm above the navel, it is
painless. Other parts of the stomach are not palpable.
Visible enlargement of the liver is absent. Upper border of absolute hepatic dullness on the right
mid-clavicular line is on the 6th rib, lower – on the edge of costal arch. Gall bladder is not palpable .The
symptoms of pressing and concussion of gall bladder is negative. Tenderness in the points of gall bladder
is not determined. Pancreas is not palpable. Tenderness in the points of conforming to the head, to the
body and to the tail of pancreas and in points of phrenic nerve and costo-vertebral to the left is not
determined. Spleen is not palpable. Its percussion is between IX – XI rib ( 5 cm ) and length is 7 cm.
The sizes of liver according to Obraztrov and Kurlov are as follows:

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UPPER BORDER:
L. Axillaris Anterior Dextra
L. Midclavicularis Dextra
L. Parasternalis Dextra
L. Mediana Anterior
L. Parasternalis Sinistra
- on the level of X rib
- on the lower edge of rib arch
- 2cm below edge of rib arch
- 3-6 cm below xiphoid process
- on lower edge of left rib arch

LOWER BORDER: (cm from upper border) according to Obraztrov

L. Axillaris Anterior Dextra – 10 cm
L. Midclavicularis Dextra - 9 cm
L. Parasternalis Dextra - 8 cm

LOWER BORDER: (cm from upper border) according to Kurlov

L.Midclavicularis Dextra - 9 cm
L.Mediana Anterior - 8 cm
L. Mediana Anterior till the point of costal arch – 7 cm
(till the change of sound of dull to tympanic)

Patient has no complaint regarding digestive system. She has good and normal appetite

URINARY SYSTEM
INSPECTION
Visible pathology of the lumbar region is absent. Patient has no complaint over disturbance in urination of
rhythm of urination. Color of urine of patient is straw color. No edema in face and loins are noted.

PALPATION
Kidneys are not palpated.

PERCUSSION
Pasternatsky’s symptom is negative.

BLOOD SYSTEM
INSPECTION
Color of the skin is pinkish. There was no hemorrhagic reddening on skin of left arm up to elbow. Hair is
normal consistency. No regional swelling in the neck.

PALPATION
There is no pain upon tapping on flat tubular bones.

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NERVOUS SYSTEM
INSPECTION
Patient responded actively throughout the interview and answered all the questions consciously. Patient
has no trouble going to sleep at night. Her gait is regular. Paresis and paralysis is absent. Pupils are
identical in size and respond to light. Nystagmus is absent.

ENDOCRINE SYSTEM
During inspection, changes of the eyes (exophthalmus or enophthalmus) are not visible.
Ocular symptoms like Grafe’s, Kocher’s, Moebius’, Stelwag’s are negative.

During palpation, the thyroid gland is not enlarged. Its isthmus is palpated as soft, and painless .

Organs of Internal Secretion (Endocrine Organs)

Thyroid Gland
Absent of tumors in the neck region. No pain in the neck region. No complaints of compressing of internal
organs of the neck. No difficulty in breathing, stridor breathing, husky voice, aphonia, dysphagia, oedema
on face and swelling of veins. No eye pain , bitting and compression feeling or diplopia.

Parathyroid Glands
Absent attacks of convulsions, no parathesia, pain in leg muscles or bones, no fragility of nails or falling
of hairs, no fracture of bones.

Islet of Langerhans of Pancreas

There are normal functions of pancreatic gland.

Adrenal Gland
Progressing weakness was absent. There is no change of shape, moon face or scarlet colour of skin.
Redistribution of fat tissue is absent. She has not lost hair.

Genital Glands

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She has not experienced any physical changes characteristic to genital development. She has regular
development of secondary sexual manifestations. She doesn’t experience loss of hair. Her menstrual cycle
is regular and slightly painful.

Hypophysis : Hypothalamus
Patient is normal weight. Changes in body proportion equal.

PLAN of ADDITIONAL INVESTIGATIONS

1. General blood analysis

2. ECG
3. CXR ( Chest X-Ray)
5. Radioimmunology test

RESULTS of ADDITIONAL INVESTIGATIONS

General blood analysis

Hemoglobin : 104 g/L N: 120-140 g/L
Erythrocytes : 4.1 x 1012/L N: 4.0-5.0 x 1012/L
Colour index : 0.8 N : 0.85 -1.15
Thrombocytes : 532x109/L N : 180.0 - 320.0x109/L
Leukocytes : 11.2x109/L N : 4.0 – 9.0x109/L
Stab : 7% N : 1-6%
Neutrophils : 62 %
Eosinophils :1% N: 0,5-5%
Lymphocytes : 27% N: 19-37%
Monocytes : 3% N: 3-11%
ESR : 26 mm/hr N: 2-10mm/h
Basophils : 0% N: 0-1%

Conclusion: Blood test shows signs of inflammation, and a low level of hemoglobin and
thrombocytes count is very high. ESR is also high signifying the presence of an inflammatory process.

Liver functional test

ALT : 18 E/l. N to 41 E/L
AST : 22 E/l. N to 40 E/L

Conclusion : nothing abnormality detected.

Rheumotest:
Rhematologic factor: 150 mE/L [upto 14 mE/l]

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C- Reactive protein: 60 [N : 5]
DAS28 Rheumatic activity:- 6.89

Coagulogramm
Protrombin index 59.4% N: 90 - 120%
Protrombin time 22.5 secs N: 11.5-16.5secs
MNO 1.86 N: 0.9-1.4
Fibrinogen A 10.52g/l N: 2.22-4.44g/l
Conclusion: Abnormal coagulation process revealed. Bleeding tendencies are increased as showed by the
results.

 ECG
Regular cardiac rhythm: fibrillation of atrium, arthymia of ventricles is absent. The heart beat rate
76 beats/min. There is a deviation of electrical axis to the left showing left ventricular hypertrophy.
 X-ray
It shows deformation of the right ankle joint. And it also shows an erosion of the tibio-calcaneous
joint and other patchy erosions around the joint!

DIFFERENTIAL DIAGNOSIS:-

Septic Endocarditis Myocarditis Rheumatoid Arthritis

Definition A type of An inflammation of Rheumatoid arthritis (RA) is a

inflammation of the the heart muscle. chronic systemic inflammatory
heart valves. It can disease of unknown cause. An
affect the heart external trigger (eg, cigarette
muscle (myocarditis) smoking, infection, or trauma) that
or the lining of the triggers an autoimmune reaction,
heart (pericarditis). leading to synovial hypertrophy
and chronic joint inflammation
along with the potential for extra-
articular manifestations, is
theorized to occur in genetically
susceptible individuals

Etiology Candida Lymphocytic  Genetic predisposition

 Diphtheroids  Autoimmune reaction to Group
 Enterococcus Acute infectious: A Stretococcal Infection
 Gram Negative  Streptococcal Pharyngitis
Rods a) Viral illness  Scarlet Fever

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  Group A  Coxsackie Virus  Impetigo never results in
Streptococcus B (most rheumatic fever
 Staphylococcus common)
aureus  Influenza
 Staphylococcus  Hepatitis
epidermidis  Adenovirus
 HIV Infection
 Cytomegalovirus
(CMV)

b) Tropical
Disease
Trypanosoma cruzi
(Chagas' Disease)

Symptoms  Petechiae on  History of 1. MORNING STIFFNESS FOR

and Signs mucus membranes preceding viral AT LEAST ONE HOUR AND
(mouth, illness PRESENT FOR AT LEAST SIX
Conjunctiva)  Fever WEEKS. 
 Splinter  Chest pain that 2. SWELLING OF THREE OR
Hemorrhages may resemble a MORE JOINTS FOR AT
beneath nails heart attack LEAST SIX WEEKS. 
 Painless  Joint 3. SWELLING OF WRIST,MCP
hemorrhage pain/swelling OR PIP FOR SIX OR MORE
Nodules on palms  Abnormal heart WEEKS. 
or soles beats 4. SYMMETRICAL JOINT
 Retinal  Fatigue SWELLING. 
hemorrhages with 5. HAND XRAY CHANGES
 Shortness of
central pallor TYPICAL OF RA THAT MUST
breath
 Cerebral emboli INCLUDE EROSIONS OR
 Leg edema
 Systolic Murmur UNEQUIVOCAL BONY
 INADility to lie DECALCIFICATION. 
from heart valve flat 6. RHEUMATOID NODULES. 
 Finger Clubbing  Syncope 7. SERUM RHEUMATOID
 Decreased urine FACTOR BY A METHOD
output POSITIVE IN LESS THAN 5%
OF NORMALS.

REQUIRE AT LEAST FOUR

CRITERIA.

SUBSTANTIAL DIAGNOSIS

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 The patient complaints of morning stiffness for at least one hour, and this has been present since 2
years ago. There is also swelling and deforming of her ankle joint and the fracture of her left elbow joint
led to its deformation too.  On anamnesis vitae, patient reports of repeated episodes of tonsillitis and other
infection in her childhood. This exposure to a probable streptococcal infection might have been the start
leading to her disease. Another characteristic of her symptoms is that of a symmetrical joint swelling and
pain. On X-ray of her ankle joint, there is erosion and deformation found.

On serological analysis, we got can see the following results of Rheumotest: Rhematologic factor of
150 mE/L [upto 14 mE/l], C-reactive protein of 60 [N: 5], DAS28 Rheumatic activity of 6.89. These
results are evidence of autoimmune reaction going on in the body, and especially the result of rheumatic
factor test, which has a specificity of 99% and a sensitivity of 98%, giving our diagnosis more grounds.
Serum analysis gives a powerful reason to think of this disease because in the CBC (complete
blood count), we have the following; Hemoglobin: 104 g/L [120-140 g/L], Thrombocytes of 532x109/L
[180.0 - 320.0x109/L], Leukocytes: 11.2x109/L [4.0 – 9.0x109/L], ESR: 26 mm/hr [2-10mm/hr]. These
results give evidence of an ongoing inflammatory reaction or process in this patient.
From the ongoing signs, symptoms of the patient, coupled with the objective laboratory analysis, it is
evident that our patient is suffering from chronic rheumatoid arthritis.

FINAL DIAGNOSIS

1) Main disease : Chronic Rheumatoid Arthritis (Remission phase)

2) Complication : Deformaton of the ankle joint (1st degree)
3) Accompanied disease : None

Treatment

 Free bed regime

 Diet no 10 ( decrease salt and water )

MEDICATION:

For rheumatic arthritis

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DMARD Therapy
Rp.: Tab. Sulfasalazine 500mg
D.S.: 2-4 tab. PO 4 times daily, gradually decreasing dose as condition improves.
or
Rp.: Tab. Leflunomidi 100mg
D.S.: 1 tab. PO 1 time daily during 3 days (saturating dose).
or
Rp.: Tab. Methotrexate 0.0025
D.S.: 1 tab. PO 2-3 times daily
or
Rp.: Tab. Phenoxymethyl pennicilini 250mg
D.S.: 2 tablets 3 times daily

Corticosteroids
Rp.: Tab. Prednisolone 0.005
D.S. PO 4 tabs. after meal in the morning, and 2 tabs. after lunch.

Antiarrhythmic drug

Rp.: Tab.Amiodaroni 0.2 no 30

D.S.: 1 tablet PO 3 t/d during or after meals.

Rp.: Tab.Anapirilini 0.01 no 30

DS: 2 tablets PO 3 t/d before meal.

Mild physical exercise is advised to this patients coupled with a good diet. This can enhance their immune
system to fight against the disease!

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