CRIMEAN STATE MEDICAL UNIVERSITY NAMED AFTER S.I. GEORGIEVSKY DEPARTMENT OF INTERNAL DISEASES HEAD OF DEPARTMENT: PROFESSOR S.N. KRUTIKOV TEACHER: ABRAMOVA TATYANA GRIGORIEVNA CASE REPORT PATIENT: MAYA ALEXANDROVNA KOVOLOVA CLINICAL DIAGNOSIS MAIN DISEASE : SEVERE IRON DEFICIENCY ANEMIA COMPLICATION : ABSENT ACCOMPANYING DISEASES : 1) RHEUMATID POLYARTHRITIS (REMISSION) 2) CHRONIC PYELONEPHRITIS ACUTE STAGE RENAL FAILURE-0 NAME COURSE GROUP FACULTY : RASTOGI AYUSH : 4RD : 192-2 :INTERNATIONAL MEDICAL FACULTY PASPORT DATA Patient’s full name Age Sex Nationality Marital status Occupation Home Address Time of admission : Maya Alexandrovna Kovolova : 74 years : Female : Russian : Widow : Pensioner (formerly worked as cashier in railways) : Gavenna 3, Kvartira 68, Simferopol. : 16th January 2023 (12.50pm) COMPLAINTS Patient complaining about pain at joints mainly in elbow, knee and hand joints. Pain is not constant, it increases or sometimes worsen during walk. Patient is not able to stand because of joint pain in knees. The pain is localized and it does not irradiate to other parts of body. Patient prefers lying on the back while sleeping. Patient also complains of difficulty in breathing which develop during slow walking. She complains of expressed general weakness and fatigue. Patient has poor appetite. HISTORY OF PRESENT DISEASE (ANAMNESIS MORBI) It all started in 1997,when the patient fell and was hurt at joints. She has been treating herself without doctor’s consultation. However, her condition did not improve. In 1999, patient came to hospital because the pain never reduced, instead kept on intensifying and was diagnosed with rheumatoid arthritis. She was under medication. After 7 years, patient had severe pain at knee joints and had difficulties in walking. Expressed general weakness appeared. Dyspnoea during walk arised. Patient came to the hospital on 16th April 2007. On examination of patient, it was observed deviation of the hand in the ulnar direction (seal’s fin deformity). Patient was asked to take blood analysis and then admitted at 12.50pm. LIFE HISTORY (ANAMNESIS VITAE) Patient was born in Simferopol. She was married and has 2 daughters aged 53 and 47 years old. She is pensioner and formerly worked as cashier in railways. Her condition at work was satisfactory. Work conflicts were rare. Patient mentioned that she will have all her meals regularly (2-4 times a day) mainly at home. Patient prefers eating meat and drinking juice. She does not have habit of smoking and consuming alcohol. Past illness: Patient had cataract operation a month ago (March 2007). She never suffered from any infectious diseases such Tuberculosis, Hepatitis, AIDS, Syphilis and other venereal diseases. Patient bears medical preparation well without any allergic reaction. Allergic reactions to various food and chemical substances are absent as well. She has underwent blood transfusion (only erythrocytes) 3 times previously. She never underwent dialysis before. DATA OF PHYSICAL EXAMINATION (STATUS PRAESENS) General condition of patient is satisfactory. Consciousness is clear. Patient is in passive posture, gait is not changed. Facial expression is satisfactory. Body build is hypersthenic. Color of conjunctiva is pale. Skin is warm, pale and dry. Lips are normal. Subcutaneous fat is poorly developed. There is no visible rashes on patients body. Submandibular, posterior cervical, axillary, and inguinal lymph nodes are determined with size from 0.5-1.0 cm in diameter, rounded form with smooth surface, elastic consistence, and mobile, not changed. The muscle are moderately developed, tone and muscle force are identical on both sides. Palpation and tapping of the bones are painless. Joints are of irregular shapes, painful. Active movements in joints are limited and passive movements in joints are painful. Temperature and skin over them are not changed. Pathologic deformation of spinal column is absent. Its function is normal. Height Weight Temperature of body Blood pressure Pulse : 156cm : 49kg : 36.7ºC (normal) : 140/70 mmHg : 76/min (regular) 1)Skin: The skin colour of the patient is not usual, pallor of skin. The patient’s skin is dry. Patient’s hair is proper corresponding to her age. There are no visible rashes on the patient’s body. 2)Fatty tissue: Subcutaneous fat is poorly developed. The colour of the mucous membrane is pale color. The mucous membrane was examined at the conjunctiva, nasal and oral mucosa. The skin fold under the scapula is measured to be 1.0 cm. The shape of the patient’s head is proportional, and symmetrical. The patient’s facial expression is healthy. The shape of her eyes and nose is normal. The shape of the neck is usual. 3)Muscle and joints The muscles are developed moderately, tone and muscle force are identical on both sides. Palpation and tapping of the bones are painless. Joints are irregular in shape, painlful during palpation and movements. Joints are deformated at particular areas,knees and hands. Crackles are felt. 4) Lymph nodes The palpation of the lymph nodes was done in the following order. Occipital group Not Palpable Preauricular group Not Palpable Ant. Sternocleidomastoid group Not Palpable Post. Sternocleidomastoid group Not Palpable Submandibular group Palpable Submental group Palpable Supraclavicular group Not Palpable Cubital group Not Palpable Axillary group Not Palpable Inguinal group Not Palpable Popliteal group Not Palpable RESPIRATORY SYSTEM Inspection Respiration : nasal breathing Chest shape : normal – hypersthenic Epigastric angle : dull Chest is symmetry, position of clavicle is symmetry, supra & sub-clavicular fossae are expressed. Direction of horizontal,width of the intercostal space is narrow. Position of shoulder blades fit to the chest Type of respiration : thoracic Deep and rhythm of respiration : normal Respiration rate : 14/min Palpation Tenderness along the ribs, intercostal spaces, trapezoid muscles, intercostal nerves points are absent. Chest is slightly rigid. Vocal fremitus is of equal intensity in the symmetrical parts of the chest (anterior, lateral and posterior). Pleural friction sounds are absent. Percussion On comparative percussion of the lungs, clear lung sound is heard over symmetrical points. Traube’s space is determined, it is located in the inferiolateral part of chest, in has semilunar form. On topographic percussion, the height of lung apexes is 3 cm above the clavicles anteriorly and posteriorly, it is located on the level of the spinous process of the 7th cervical vertebra. Lower border of the lung on different lines are showed in the following table. Line Right lung Left lung Parasternal 5-th costal interspace - Midclavicular 6-th costal interspace - Anterior axillary 7-th costal interspace 7-th costal interspace Midaxillary 8-th costal interspace 8-th costal interspace Posterior axillary 9-th costal interspace 9-th costal interspace Scapular 10-th costal interspace 10-th costal interspace Paraspinal 11-th spinous process 11-th spinous process Mobility of the lower lung borders along midclavicular, medial axillary and scapular lines are as following :- Topographic line Right lung Left lung Midclavicular 5cm - Midaxillary 6cm 6cm Scapular 5cm 5cm Auscultation On lungs auscultation, vesicular breathing is heard over symmetrical points of the lungs. Adventituous sounds are absent. In bronchophony, illegible whisper sound is heard over symmetrical points of the lungs. CARDIOVASCULAR SYSTEM Visible pulsation of arteries is absent. Venous pulse is negative. Cardiac hump back and visible pulsation in the heart region is absent. Apex beat is palpated in the 5th intercostals space 0.5cm laterally from the left midclavicular line. Cat’s murmur was not determined. Systolic murmur at the apex beat is heard and nun’s murmur is present over jugular vein. Pulse is equal on both arms. Pulse rate is 76 beats per minute. Pulse is rhythmic, moderate filling and diameter about 2mm. Relative cardiac dullness: Right border - 2cm lateral from right border of sternum in the 4th intercostal space. Upper border - at the level of 3rd rid on parasternal line Left border - 1,0cm laterally from the left midclavicular line at the level of 5th inter costal space. Absolute cardiac dullness: Right border - along the left edge of the sternum Upper border - on the inferior border of 4th rib on the level of mid clavicle Left border - 1 cm medially from relative cardiac dullness Borders of vascular bundle: Right border - on the right sternal line Left border - on the left sternal line On auscultation of the heart the 1st tone is louder than the 2nd tone in apex and below the sternum. The 2nd tone is louder than the 1st tone on pulmonary and aorta trunk points. On Botkin-Erb’s point both the tones are equal. No murmurs. The tone is rhythmic and can be heard clearly. Pulse of the temporal and carotid arteries are felt well, pulsation on the both the sides are equal. BP - 140/70 mm Hg. Pulse pressure is 70mm hg. Digestive System Surface palpation of the patient’s entire abdominal region reveals a soft, symmetrical and painless abdomen. Auscultation of the abdomen reveals normal peristaltic sounds of the gastro-intestinal tract. There is also no diastasis of the abdominal muscles though tonus of the muscle is lowered due to old age. Tympanic sound is heard over all parts of the abdomen. Hernias and superficial tumours are not palpable. Sklyarov’s, Mendel’s and Shchetkin-Blumberg’s symptoms are negative. The patient does not have any difficulty in swallowing or passing food through the esophagus. There are no incidences of hypersalivation as well. The mouth is in a generally clean condition, without any unpleasant smells. The size of the patient’s tongue is usual. The tongue is in a generally normal state. However, her most of her teeth has already been removed and patient feels pain in her gums. Mucous membrane of the mouth is pale. Caecum Diameter 3cm approximately. Painless, mobile, elastic, smooth surface. No rumbling sound. Ascending Colon Diameter 2cm approximately. Painless, mobile, elastic, smooth surface. No rumbling sound. Descending Colon Diameter 2cm approximately. Painless, mobile, elastic, smooth surface. No rumbling sound. Transverse Colon Diameter 2cm approximately. Painless, mobile, elastic, smooth surface. No rumbling sound. Sigmoid Colon Diameter 2cm approximately. Painless, mobile, elastic, smooth surface. No rumbling sound. Sign of liver enlargement is absent and it was palpable as soft, elastic and painless. On the right midclavicular line, the upper border is located at level 6th rib and lower border is located at the edge of costal arch. Gall bladder is not palpable. Symptoms of pressing and tapping of gall bladder are negative and all tenderness point of gall bladder is negative. (Kera’s symptom, Murphy’s symptom, Ortner’s symptom, Lepene’s symptom and Vasilenko’s symptom are negative.) Pancreas is not palpable. Kacha’s point and choledochopancreatic point are negative. Spleen is not palpable. On left side of costal arch, percussion of splenic dullness is situated 9th-11th rib in transverse size, 5cm, and its length is 7cm. Urino-genital system Visible pathology of the lumbar region is absent. Kidneys are not palpable. Palpation of the kidney’s region is slightly painful. Palpation along the course of ureters is painless. Pasternatsky’s symptom is weakly positive on the both sides. The urinary bladder is not palpable. Palpation of the uterus and appendages region is painless. Volume of the excreted urine is about 1450ml per day, colour is straw-yellow, clarity is transparent and odor smells ammonia. Mammary glands are symmetric, nipples are not changed. Consolidations and swellings on palpation are not determined. Endocrine system There is no sign of gigantism, dwarfism, cachexia, obesity and habitus. Expression of the patient’s face is normal. Secondary sexual signs of eunuchoidism and hirsutism are absent. Changes of the eyes (exophthalmus or enophthalmus) and chair are not determined. Ocular symptoms (Graefe, Kocher Moebius, Stellwag, Dalrymple) are negative. Thyroid gland is not enlarged. Its isthmus is palpated as soft, painless band 1 cm in diameter. In accordance with decision of the WOPH 3 degrees of the thyroid gland enlargement are distinguish: O - The thyroid gland is not visible. Its size is less than phalanx of thumb finger of the patient. I - The thyroid gland is visible during swallowing and its size is more than thumb finger of patient. II - The neck is deformed due to significant enlargement of thyroid gland. Blood system Haemorrhagia on skin and mucosa are absent. Spleen is impalpable. The borders of the spleen dullness are determined between 9th and 11th ribs. Skin colour is pale and dry. Nervous system and psychic state The patient is fully competent in place and time, quiet. Sleep is normal. Speech is correct, elocution. Thinking is logical. Gait is regular. The patient in Romberg’s pose is steady. Paralyses and paresis absent. Pupils is identical size, react on light. Nystagmus is absent. INITIAL DIAGNOSIS Analysis of the symptoms, received during inquiry, inspection, palpation and auscultation of the patient: Pain at joints, deviation of the hand in the ulnar direction (seal’s fin deformity). Difficulties in walking, Dyspnea during walk arised. Decrease appetite, decrease work capacity, weakness, fatigue Paleness of conjunctiva Skin is dry, rough CONCLUSION : Rheumatoid Polyarthritis with anemia RESULTS OF THE ADDITIONAL METHODS OF INVESTIGATION 01. COMMON BLOOD ANALYSIS 1st result Hemoglobin Erythrocytes Leucocytes -Basophil -Eosinophil -Neutrophil -Young -Stab -Segmented -Lymphocytes -Monocytes -Color index -Hematocrit : 30.7 g/L : 1.8 X 10l2 per litre : 13.2 X 109 per litre : 0% :0% :0% : 15% : 70 % : 12 % :3% : 0.78 : 10% 2nd result Hemoglobin Erythrocytes Leucocytes -Basophil -Eosinophil -Neutrophil -Young -Stab -Segmented -Lymphocytes -Monocytes -Color index : 65.37 g/L : 2.23 X 10l2 per litre : 8.4 X 109 per litre : 0% :2% :0% : 4% : 64 % : 25 % :7% : 0.87 CONCLUSION: decreased hemoglobin and erythrocytes count indicates anemia. Decrease of colour index indicates hypochromic iron deficiency anemia. Blood Glucose level : 5.1 mmol/l Coagulagram Test Recalcification of serum Prothrombin Fibrin A Fibrin B Ethanol : 82s : 100 : 3.55 :: negative 02. URINE TEST : 1st result Color Transparency Reaction Specific gravity Glucose Bilirubin Urobilin Protein : light yellow : cloudiness : slightly acidic : 1008 :::: 0.132g/l Microscopy of urine sediment Leucocytes : in all vision field Erythrocytes : 1-2 in f.v. Cast Hyaline :Granular :Salt :Mucus :Bacteria :Epithelium : moderate Oxalate : moderate 2nd result Color Transparency Reaction Specific gravity Glucose Bilirubin Urobilin Protein : light yellow : cloudiness : slightly acidic : 1008 :::: 0.003g/l Microscopy of urine sediment Leucocytes : 30 – 40 f.v Erythrocytes : 4-6 in f.v. Cast Hyaline :Granular :Salt :Epithelium : moderate Oxalate : moderate CONCLUSION: leukocyturia, presence of non significant proteinuria indicates pyelonephritis. X-ray examination - no pathology present. ECG - Depression of ST segment indicates signs of ischemia - apex of heart - anterior side of left ventricle. - has sinus rhythm - electrical axis normal - hypertrophy of left ventricle - insufficiency of Hb leads to coronary insufficiency. FINAL DIAGNOSIS The findings of the tests of the patient confirmed the main diagnosis suspected in the patient: MAIN DISEASE COMPLICATION ACCOMPANYING DISEASES : SEVERE IRON DEFICIENCY ANEMIA : ABSENT : 1) RHEUMATID POLYARTHRITIS (REMISSION) 2) CHRONIC PYELONEPHRITIS ACUTE STAGE RENAL FAILURE-0 TREATMENT The patient is advised to adhere to free regime with limiting walking Patient should follow Diet No. Drug recommended for anemia Rp: Dr. Ferri sulfatis 0,325 D.t.d.No 30 S. 1 dr. PO 3t/d after meals. Drug recommended for rheumatoid polyartheritis Rp: Tab. Ac. Acetylsalicyclic 0.5 No30 D.S. 1-2 tab. PO 3 times a day after meal. Drug recommended for pyelonephritis Rp: Tab. Furazolidoni 0.05 D.t.d No 20 S. 2 tab PO 4 t/d after meal.
