MOSCOW MEDlCAL ACADEMY l.M.

SECHENOV


MEDlCAL FACULTY (ENGLlSH MEDlUMI OF PEDlATHlCS DEPAHTMENT

CASE HlSTOHY








PATicNT : GomozovA ALiciA lconcvNA

Sucnvisco aY : STonosTiNA L.S

PncAnco aY : SiTi SAnAH iNTi MoHo SHuKon
(Gnou 6I

MOSCOW 2DD7
Patient`s Profile:

Name: Gomozova Alicia Igorevna
Age : 13 years old
Weight: 31.5 kg
Height : 146 cm
Date of admission : 10 October 2007 (10.50am)
Parent`s occupation : Father Machinist
Mother HousewiIe
Address : Moscow
Clinical diagnosis: Chronic Arthritis
Complaints on admission: Sharp pain and stiIIness in both knee joints aIter coming back Irom
school and headache.


Anamnesis vitae:

1. Antenatal period

She was the 1
st
pregnancy oI her mother. The course oI the pregnancy mother was
complicated with the 1
st
stage toxicosis in the 1
st
and 2
nd
trimesters. Labor was delivered
normally. The labor was on term, born on 24/03/1994.

2. Characteristics of newborn

Full term baby. The weight oI the newborn is 3100g and height is 50cm. Patient cried
immediately aIter bitrh. No asphyxia. Umbilical cord Iall oII aIter 20days. Umbilical wound
heal up within 14days. Regime oI breastIeeding received by the patient until 3 years old.
Patient started to sit at 6 months old, walk at 12 months. Patient entered school like other
normal children.

3. Acute infectious disease and disease during childhood.

1. 1
st
month - ARVI
2. 2
nd
month - Hypothrophy oI limbs muscles and conjunctivitis
3. 3
rd
month - Vulvitis
4. 3 years old - Patient had chronic Chlamydia-Streptococcal inIection


4. Vaccinations

No information in the case history (she has been hospitalized Ior a Iew times and this is not
the 1
st
book oI her medical records. And she was not accompanied by anyone. So no question
can be asked to the parent.)

5. Allergy to food and drugs

No allergic towards anything.

6. Living conditions

The patient lives with her complete Iamily in the apartment. Patient has a dog at home and
the condition oI the apartment is good.

7. Family anamnesis

Patient lives with her mother, Iather and a little sister. All Iamily members are healthy and in
a good condition. Further information is not available in the history.


Anamnesis Morbi

Patient complained oI joint pain since she was 3 years old, 1st investigation done in our clinic on
Sept 2005. Investigation with X-rays conIirmed that she suIIers Irom the Juvenile Chronic
Arthritis.

Throughout the year, patient is Ieeling healthy, increase 6 kg oI body mass, until March 2007
when she started to have some complaints on her knee and ankle joints. StiIIness was very
prominent in the morning and evening. Patient was administered to our clinic again and treated
as inpatient.

Based on her history oI previous admission, the main cause oI her disease was inIection by
Chlamydia and streptococcal when she was 3 years old. Since then, she was treated (Iirstly in
another hospital) then being transIerred to our clinic as a reIerred case.

From March 2007 until 10th October 2007, diagnosis oI the patient are : Juvenile Chronic
Arthritis (Oligoarthritis), associated with Chlamydia-Streptococcal inIection background.

Treatment received : Firstly was administered Ior bed regime; Antibiotic (SulIasalazine); Vit. A
and C.

Pain in large joints oI hands and legs were diminished and no stiIIness was reported until a week
ago when she suddenly complaining oI sharp pain in the knee joints oI both legs. Now she is
tread with SulIasalazine only.







Objective examinations

General status oI patient is satisIactory
(36.6`C body temperature)


1. Nervous system:

Patient is conscious, responsive to stimuli and well-orientated to time and space.
Calm mood. Attention and memory is good.
Intellectual development corresponding to her age. Speech is clear and proper.
Sleep is not disturbed.
No abnormalities oI cranial nerves.
Skin (abdominal) and tendon (knee and Achilles) reIlexes are preserved.
Meningeal symptoms, Kernig sign and Brudinski signs are absent.
From inspection, the pathological changes in eyes and ears are absent.



2. Physical development


eight : 31.5kg (N-58kg) (F (n.6) 20kg)
Height : 146cm (N-155)
Head circumIerence 52cm (N-52 cm)

Physical development is almost normal and corresponding to her age (slightly below the
normal range oI physical growth and development in relative with normal range)
Normosthenic type oI constitution.



3. Skin

Normal skin colour and mucous membrane. Slightly moist in the place oI physiological
moisture-palm and armpit and dry in the physiological dryness place-elbow and knee. The skin
temperature is warm. The hair is in normal distribution and the skin cleanliness is good. The skin
was in normal humidity. The skin is elastic.







4. Subcutaneous fat

Subcutaneous Iat is develop and distributed normally and equally.
No edema
Normal turgor
Subcutaneous Iat: abdomen 1.5 cm
: subscapular region 1 cm



5. Lymph nodes

Palpable submandibular, axillar and inguinal lymph nodes. Single , mobile and painless, slight
elasticity in consistency, size is oI 0.3cm.
Other groups oI lymph nodes are not palpable. Normal.



6. Muscles

Muscles development is good, atrophy and hypertrophy is not seen.
Painless in palpation during active and passive movement
Muscle strength 5
Muscle tones 5
Normal volume oI movement
No pathological changes



7. Skeletal system

Normal Iorm oI head (oval)
Cylindrical chest Iorm
Condition oI upper spine is normal
Normal condition oI joint. No deIormation oI joint during the inspection)
Normal arch oI Ieet
Teeth are in normal development and number.
Teeth bite is in straight Iorm








. Cranial nerves examination

Did not perform during the inspection because she had to go to the X-rays room. As a
whole, she responds well to the surrounding with good vision, hearing, smelling and touching
sensations. Normal phonation, no slurred speech, normal swallowing and the Iace is
symmetrical.


. Motor system

The gait is normal. No atrophies, Iasciculations and Iibrillar twitching. Tones muscle is normal.


10.Conditions of movements

Patient able to walk normally
Normal Ilank gait
Romberg test is negative Performed)
No tremor on extremities
No ataxia


11.Reflexes

No changing oI reIlex. Deep and superIicial reIlex is normal. No pathological reIlex

Tendon reIlex DS Normal)


12.Vegetatives-trophics functions

No erythema, hyperpigmentations, depigmentations, local hypertrichosis, Iragility or thickening
oI the nails, trophic ulces, leukoplakia, ulcer. Moderately sweating.


13.Respiratory system

Free nasal breathing. Respiratory rate is 20 per minute (N 18-20). No coughing and dyspnea
seen. Thoracic respiration.

Palpation: No changes oI chest resistance. The chest is elastic. Normal vocal Iremitus and
symmetrical on both sides Performed)

Percussion: Pulmonary sound in all segments. No box-like percussion sound.
Comparative percussion: both lungs are symmetric. No changes.

%OPOGRAPHIC PERCUSSION

Not performed because the patient had to go to the radiographic room immediately.
Auscultation: vesicular breathing and no crepitations. No wheezing or rales at time oI
examination.


14.lood circulatory system

No visible protrusion and pulsation is visualized during inspection.
Pulsation: carotid, Iemoral, tibialis posterior, dorsalis pedis, cubital, and temporal artery
palpable.

Radial pulse: 84/min, equal on both hands, medium tension, normal, Iullness good, pulse was
uniIorm pulsus equalis).

Auscultation:
short; systolic murmur at apex point, rhythmic heart beat, clear tones, accents sound on
pulmonary artery

Palpation:
Heart apex is palpable at the lateral to leIt medioclavicular line in 5
th
intercostal space. Apex beat
is not intensiIied, apex region is 2 cm in wideness.

Percussion:
Not performed because the patient had to go to the radiographic room immediately.



15.Digestive system

Good appetite.
No nausea and vomiting.
No belching or heartburn.
Formed stool with normal color

Mouth

Lips- rosy colour, moist. No cracks or ulcers.
Oral cavity and gums are clean.
Mucous membrane is pinkish-rosy colour and a little white dotes in mucus mambrane ,
moist, no pathological changes. No gum bleeding.
Tongue is pale, moist with no white coating.
Papillae oI tongue is well developed, no cracks and ulcers, no imprints oI teeth and
deviation oI tongue.

Pharynx

Lined with rosy mucous membrane
No thin coating.



Salivary gland

not enlarged and painless.
No changes oI skin around the gland.
Painless during mastication and opening oI mouth.


Stomach

Deep palpation: Normal Iorm, soIt in palpation. Painless.
Protrusion, retraction and visible pulsation not seen.
Percussion around the stomach surIace tympanic sound.


16.Liver and gall bladder

Liver
Not enlarged.

Palpation oI liver is painless, normal in size, the edge is soIt and slightly elastic in consistency.
The liver is at the same level oI costal arch on the right side. It is normal Performed)

Percussion
Not performed because the patient had to go to the radiographic room immediately.


Gall bladder
Not performed because the patient had to go to the radiographic room immediately.


Spleen

Palpation: Not palpable Performed)
Percussion (size) length : within normal range Performed)






17.Genitourinary system

Base oI urinary bladder is at the suprapubic level, Iemale sexual characteristics, no
tension oI muscles in lumbar area
Kidneys are not palpated.
Urination is at normal Irequency, no signs oI retention. No incontinence. Normal colour
oI urine (yellow)




1.Endocrine system

Inspection was normal and the thyroid gland is in normal size Not enough information in the
history as well)


1.Diary

The patients was examined on 15 October 2007. No sign oI pathology and she was active. The
physical development is good. No problem in conducting the activity. No restriction in
movement and no complaints on stiIIness oI the joints. The pulse is 84 beats per min, 36.6`C. All
other systems are normal.

The patient is now receiving:

1. Sulphasalazine 2g/d to control progression of disease)
- 10am of pill
- pm of pill

2. Vit. A and C as supplement of growth.

My second visit was on 24 October 2007 and she has been discharged. No further information
were collected from the history nor the patient herself.










Preliminary Diagnosis:

Juvenile Chronic Arthritis (Juvenile Rheumatoid Arthritis) (JRA)

The presentation oI clinical maniIestation showed by the patient is the sign oI Juvenile
Rheumatoid Arthritis with such background oI streptococcal inIection during her childhood. The
suggestive symptoms are limitation in joint movements (in previous episodes), joint stiIIness,
sharp pain in large joints especially knee and ankle joints and subIebrile Iever. The patient
already has the history oI JRA since she was 3 years old and her current condition is possibly due
to the aggravation oI previous disease. She has Polyarticular Iorm oI JRA since no systemic
maniIestation is observed, yet.




Plans of investigations:

1) Blood analysis to look for any blood abnormalities)
2) Blood biochemistry to control metabolic changes)
3) Urine analysis to control metabolic changes and to evaluate kidney function in
general)
4) Test Ior Rheumatoid Iactor to check for activity of the disease and for confirmation)
5) Serologic reaction Ior antibody to check for seropositivity against foriegn DNA)
6) HBsAg, HcV, HIV, Syphillis test for differential diagnosis)
7) CG to evaluate cardiac functions for any abnormalities systemic 1RA
8) Complication))
9) chocardiography to evaluate any cardiac malformation systemic 1RA
complication))
10)Regional Joint X-Ray to evaluate degree and progression of the disease)
Investigations

O lood analysis 11.10.2007)

RBC 3.8 x 10 `6/mm3 (Normal)
Hb 10.9 g/dl (Decreased)
HCT 31.9 (Decreased)
MCV 84m3
MCH 29.7 pg
MCHC 34.3 g/dl
PLT 346 x 10`3/mm3 (Normal)

*BC 4.5 x 10`3 /mm3 (Decreased)
Colour index 0.86 (Normal)
Neutrophils - Band 1 (Normal)
- Segmental 42 (Normal)
Basophils 0 (Normal)
osinophils 0 (Normal)
Lymphocytes 52 (Increased)
Monocytes 5 (Normal)
SR 10 mm/hour (Normal)

Conclusion: She has mild anemia and leucopenia


O iochemical analysis : 11.10.2007)
Total proteins 77 g/dl (65-85)
Glucose 4.4 mmol/l (3.9-6.4)
ALT 8 U/l (0-40)
AST 24 U/l (0-40)
Total bilirubin 7.6 mkmol/l (5.0-21.0)
Creatinin 47 mkmol/l (max-88)
Cholesterin 4.3 mmol/l (2.6-5.2)

Conclusion: All parameters are within normal range.


O General urine analysis: 12.10.2007)
Colour Clear
Reaction 6.0
SpeciIic Gravity 1021
Transparency Complete
Glucose Absent
Protein Absent
pithelial-Ilat 6 in vision
Leucocytes 1-2 in 1 vision
rythrocytes Absent

Conclusion : All parameters are normal



O Rheumatoid %est
Rheumatoid Iactor Neg M/ml (Negative)
C-reactive Protien Neg mg/dl (Negative)
Antistreptolysin-O 0 M/ml (0-125)

Conclusion: All parameters are normal


O Serologic Reaction
Antibody against DNA Neg (Negative)

Conclusion: Normal


O HsAg, HcV, HIV and Syphillis test

Conclusion: Result oI tests Ior HBsAg, HcV, HIV and syphilis are negative.


O ECG

No latest ECG for current admission.
Suggestion: Have to do ECG to evaluate cardiac functions for any abnormalities systemic
1RA complication)


O Echocardiography

No latest ECG for current admission.
Suggestion: Have to do immediately to evaluate any cardiac malformation systemic 1RA
complication)


O Regional 1oint X-ray findings:

Patient went for radiographic investigation on that day.
















CLINICAL DIAGNOSIS

1uvenile Chronic Arthritis 1uvenile Rheumatoid Arthritis) 1RA)

The presentation oI clinical maniIestation showed by the patient is the sign oI Juvenile
Rheumatoid Arthritis with such background oI streptococcal inIection during her childhood. The
suggestive symptoms are limitation in joint movements (in previous episodes), joint stiIIness,
sharp pain in large joints especially knee and ankle joints and subIebrile Iever. The patient
already has the history oI JRA since she was 3 years old and her current condition is possibly
due to the aggravation oI previous disease. She has Polyarticular Iorm oI JRA since no systemic
maniIestation is observed, yet.

Juvenile Rheumatoid Arthritis (JRA) is a general term Ior the most common types oI arthritis in
children. It is a long-term (chronic) disease resulting in joint pain and inIlammation, which may
lead to joint damage.

Three major subsets are described:-
1). Pauciarticular onset - with 4 or less than 4 joints involved.
2). Polyarticular onset - with more than 4 joints involved.
3). Systemic onset - with Iever, rash and arthritis.

As Ior this patient, she has Polyarticular Iorm oI JRA. This occurs in 20 oI children with JCA.
Some oI these are Rheumatoid Factor IgM positive and they can be similar in pattern to the adult
onset arthritis. Those patient`s are usually Iemale and present between 12 and 16 years oI age
with a symmetrical small joint involvement, Ilexor tenosynovitis and Irequently nodules and
erosions. Systemic features are less common in this group. It is this patient who Irequently
develop into active disease in adulthood. Systemic involvement with extraarticular
maniIestations may occur - including lung, cardiac, aortic and vascular disease.
In those patients oI polyarticular JRA, who are Sero-negative for Rheumatoid Factor - there is
also an association with Iever, hepatosplenomegaly, as well as a symmetrical arthritis. However,
the long-term prognosis is more Iavourable. Hip, neck, hand and Ieet joints are commonly
aIIected, as well as the knee, wrists and ankles.

Clinical examination in JCA children, oIten Iinds an undersized inIant or child with generalised
growth abnormality, compared to those children without arthritis. Growth hormone
supplementation to these children can increase growth patterns. The clinic picture is oIten a child
with a limp and who has swelling.

X-rays changes usually show soIt tissue swelling, but erosions can occur especially in the
Polyarticular Iorm.











Management

The main purposes oI therapy is to:
-Relieve pain
-Preserve Iunction oI the joint
-Maintain normal growth and psycho-social development

Chosen %reatment

1. Sulphasalazine 2g/d to control progression of disease)
- 10am of pill
- pm of pill

2. Vit. A and C as supplement for growth


%he Differential Diagnosis
1) InIection - Viral, bacterial, tuberculosis or Lyme disease.
2) Post-inIectious - Post Streptococcal / Rheumatic Fever or Post Dysenteric Fever.
3) Non-inIlammatory causes such as trauma, congenital disorders, slipped epiphysis,
osteochondrosis and hypermobility syndrome.
4) Haematological disorders - including malignancy such as leukaemia or haemophilia with
recurrent intraarticular bleeds. Other bleeding disorders can also produce bleeding into the joints
with joint damage.
5) Collagen Vascular Disorders - including Dermatomyositis, SL, Mixed Connective Tissue
Disorder, Scleroderma, Psoriasis, Behchet`s Vasculitis or Ankylosing Spondylitis.
6) Miscellaneous conditions such as Sarcoid and Familial Mediterranean Fever.
7) Malignancy including Leukaemia, Bone Tumours or Neuroblastoma.


Prognosis
In those patient`s with Polyarticular Sero-negative Rheumatoid Factor - only 10 - 15 have
severe limitation at 15 years and oIten go into remission with little erosive disease.
However, the Polyarticular Group which are Rheumatoid Factor positive run a more severe
course with only 33 independent at 15 years with erosions and 20 require total hip
replacements and approximately 10 require total knee replacements.