All things about arthritis is present

1. Medical Academy named after S.I. Georgievsky
Department Propaedeutics of Internl Medicine
HEAD OF DEPARTMENT : PROFESSOR USHAKOV A.V
TEACHER : Assistant pro. IVANCHENKO .V.S
Case Report
CLINICAL DIAGNOSIS
MAIN DISEASES :- Rheumatoid arthritis
ACCOMPANIED DISEASES :- Felty syndrome(neutropenia with splenomegaly)

2. STUDENT : MEET DAVDA
COURSE :- 4th COURSE
GROUP : LA1 -CO-173 B

3. PASSPORT DATA
• Full name :- LATADEVI
• Age :- 40
• Date of Birth:- 22nd February 1980
• Nationality :- Indian
• Family status :- married
• Education :- Economic
• Occupation :- Employee
• Work place :- -
• Home address :- india
COMPLAINTS
The patient complains of intermittent pain.He complains of stiffness In his wrists,
hands, knees, and feet. The stiffness seems to last anywhere from 30 minutes to 2
hours In the morning.when his Joints are sore he Is ere unstable and feels as though
he has no balance. The Joint pain does not occur on a regular basis but when it does,
he tends to lose his appetite.
NOTE: The patient also compains of pain in the left hypochondric region
CASE HISTORY ( Anamnesis Morbi )

4. He just took pain killer to eliminate the pain. he also complaint of nausea and
weakness. Moreover the pain will increase when he does heavy work and disappear
after rest . Pain during this period just temporary and disappear after some time.
Under the prescription of his regular doctor he has taken some painkillers which
were effective only in temporary pain relief.After few hours the pain started to
reappear and is unbearable which made him visit the doctor.
LIFE HISTORY ( Anamnesis vitae)
Family History: Grandmother and mother have rheumatoid arthritis and have
had surgery. Grandma had a hip replacement and his mother had a knee
replacement. Most of his family is overweight but there is no history of diabetes
or heart disease. Social Lifestyle: Married with 2 children and wife is pregnant
with their third.
Lives in markapur where he is the manager at a bank. He walks with a cane when
his flare ups’ are bad. Lifestyle History: Enjoys playing with the kids. He is as
active as he can be without being in pain. He helps coach the hockey team his oldest
son plays on. Wife is a dietician and so he eats healthy meals on a regular basis.
Risk Factors He has no drug use, sick contacts, recent travel, exposure to
tuberculosis and unprotected sexual exposure. He does not smoke. He drinks beer
occasionally on weekends but denies illicit drug use. He works in a food store with
no direct raw food contact. He has no history of sexually transmitted diseases.
Status localis
There is pain in the joints while moving and inflammation in the area of joints such
as metacarpo phalyngeal joints etc. There are also some visible nodules on the
extensor side of the arm. The patient also has sveare pain in the left hypochondric
region

5. 1.0 GENERAL EXAMINATION
( status praesens )
He denied chest pain, shortness of breath, palpitations, cough, headache, dizziness,
nausea, vomiting, abdominal pain, bowel or urinary symptoms, weight or appetite
changes.General condition of the patient is satisfactory. Consciousness is clear,
posture is active, gait is not changed and facial expression is unhealthy. Body
structure is normosthenic. Patient position are normal while nourishment
satisfactory
Temperature of body :- 37.5 ºC ( oral ) , 37.9 (axillary)
Height :- 158cm
Weight :- 61kg
1.1.1 Examination of body part
(a) Head - Her head is proportion, symmetry and correspondent to facial and
cerebral parts
(b) Face- Her face is symmetry apathic and regular shape
(c) Hair-
(e) Eye- Width of eye slit is moderate and normal shape but she far sighted
wearing polarized glasses. pupils are blue color
(f) Nose- Shape of nose is normal

6. (g) Ear- Color of skin is usual and node not palpated.
(i) Neck- Usual shape and absent of carotid and jugular pulsation.
RESPIRATORY SYSTEM
Respiratory type is thoracic ( costal ) respiration. The chest markedly broadens and
slightly lowers. Breathing is rhythmic. Respiration rate is 21 per minute.
Vocal fremitus: is louder in the upper parts of the chest and softer in its lower part.
Comparative Percussion: character of percussion sound having clear lung &
symmetric parts of the chest
AUSCULTATION
During auscultation of the lung, vesicular breathing is heard. No pathological
sounds are heard.
CVS
Cardiovascular: No carotid bruits, no Jugular venous distension, clear lungs,
normal point of impulse, regular rate and rhythm, no extra heart sounds, no
edema, normal peripheral vascular exam.
Skin: no rashes, a bit red, swollen and warm around knuckles on hands and feet.
Musculoskeletal: walks slow due to pain, Joints on the hands and feet are a bit
swollen, does not have a full range of motion In his Joints.
Neurological: Normal cranial nerves, loss of fine motor skills In and, normal
sensory exam.
Lymphnodes:cellulitis at right inguinal area and left inguinal lymphadenopahy.

7. DIGESTIVE SYSTEM
The tongue is of usual size, moist, coated and clean. Mucous of mouth is
light pink color. Tonsils are absent. Most of teeth still present with absent of each
one molar teeth upper right and lower left jaw.
Abdomen is of a regular form, symmetric. A scar after appendectomy is determined
in Right Inguinal Region. Abdominal wall participates in breathing. Presence of
post-operative scar in the epigastrium region. 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 are negative. Reveal thick deposition of fat over abdominal cavity with
fold thickness 5cm.
Intestine
Surface palpation: on surface palpation the abdomen is soft and pain reveal on right
lumbar region especially Djardan (choledochopancreatic point).
Deep palpation :
• sigmoid is palpable in the left inguinal region as a smooth firm
cylinder 2cm in diameter, it is painless, does not produce rumbling sounds,
tight-elastic consistency and mobile.,
• caecum is palpable in the right iliac region as a smooth, soft ,
painless cylinder with diameter 3cm and mobile.
• descending colon is palpable in left lumbar region with elastic
cylinder, diameter 3-4cm, painless and with limited motility.
• ascending colon is palpable in right lumbar region with elastic
cylinder, diameter 3-4cm , painless and with limited motility.
• transverse colon is palpated as soft painless, cylinder with
diameter 2-3 cm without rumbled.
On auscultation of the abdomen, peristalsis of the intestine is of moderate
sound and frequency is heard. Vessel murmurs are absent.

8. Stomach
Greater curvature of the stomach is determined as soft smooth ridge 3cm above the
navel, it is painless, ,produces slightly rumbling sound. Other parts of the stomach
are not palpable.
Liver
Visible enlargement of the liver is absent.
• Upper border of absolute hepatic dullness on the right mid-
clavicular line is on the VI rib,.
• lower border on the edge of costal arch
• Kurlov size = 8 – 7 – 7
• Obraztov size = 9- 7- 6
Liver is palpable on 1cm below of rib of arch along linea midclavicularis,
edge is soft-elastic, equal, painless and easily tucked.
Gall bladder
Gall bladder is impalpable
Spleen
Spleen is not palpable. Borders of the splenic dullness are situated
• Upper- at level of the IX rib
• Lower- at level of the XI rib
Sizes of the splenic dullness are
• Transverse- 6cm
• Vertical – 7cm

9. ADDITIVE TESTS
• RBC 4.0 X10*12
• Hemoglobin was 10.6 g/dL,
• hematocrit was 30% with MCV of 86.4,
• white blood cell count was 1.2 × 109/L with absolute neutrophil
count of 450 (0.45 × 109/L) and
• platelet was 221 × 109/L.
• Peripheral blood smear showed no significant abnormality with
normal appearing white blood cells with few toxic granulations.
• Bone marrow biopsy showed normocellular and maturing
trilineage hematopoiesis.
• Flow cytometry showed no evidence of lymphoproliferative
disorder. He had negative tests for Syphilis, HIV, hepatitis B and hepatitis
C.
• Monospot test, PPD skin test, ANA panel and Parvovirus B19
also were negative.
• Erythrocyte sedimentation rate was 50 mm/hr.
• reactive protein was 60.2 mg/l. Lymph node biopsy from left
inguinal node revealed benign reactive lymph node.
• Rheumatoid factor (RF) was positive with titer of 1:640.
• Antibodies to cyclic citrullinated peptides (anti-CCP) were
positive >250.
• creatinine levels -1.5mg/dl
• Ferritin levels-900 ngm/ml

10. RADIOLOGY TESTS
Joint x-rays including wrists, hands, knees, ankles, feet showed evidence of
erosions.
Deformity
- muscle wasting
- humeral medialisation 2° bone loss in glenoid cavity with humeral protrusion
- effusion with swelling
Abdominal computed tomography and ultra sound showeleend splenomegaly
( a ) Ultrasound examination
ENLARGED SPLEEN IN US
US SHOWING THE ENLARGMENT OF SPLEEN

11. Final diagnosis & its substantiation:
Based on the lab reports and the radiographic imaging we can conclude that
elevated erythrocyte sedimentation rate, elevated C-reactive protein and anemia
of chronic disease pointed toward connective tissue disorder. The clues that lead
to the diagnosis of RA were high-titer RF and positive anti-CCP. Anti-CCP has
very high specificity for RA-96% . Combination of RF and anti-CCP has
specificity of 99.5% for RA and highly predictive for development of erosions at
5 years of disease . This case is an atypical presentation of FS because the lack of
severe long lasting course of erosive RA. There is no specific diagnostic test for
FS.
It is a clinical diagnosis in RA with unexplained neutropenia and
splenomegaly.
Management
As Felty's syndrome is rare, information about management relies on small
studies and case reports. This condition is difficult to treat and associated with a
poor prognosis due to the substantial risk of infections.
Treatment to improve neutropenia
• Immune-modulating drugs: some of these may be the same drugs
used to treat the underlying RA.
• Methotrexate is usually first choice, as there is most experience
with this drug.
• Various disease-modifying antirheumatic drugs (DMARDs)
have been used with mixed success and few data are available on the use of
biological agents that might even increase the infection risk.

12. • Other DMARDs, including hydroxychloroquine, ciclosporin A,
sulfasalazine, leflunomide, azathioprine and cyclophosphamide, have also
been used in the treatment of Felty's syndrome.
• Rituximab has been used with encouraging results.It is usually
reserved for use as a second-line treatment in those patients with refractory
Felty's syndrome.
• Other biological agents include the anti-tumour necrosis factor
alpha agents, etanercept, infliximab and adalimumab.
• Treatment with granulocyte colony-stimulating factor is a safe
and effective treatment in the management of neutropenia associated with
Felty's syndrome.
• The dose and frequency of the recombinant human granulocyte
colony-stimulating factor should be adjusted at the lowest effective dose.
• Splenectomy is generally reserved for those not responding to
medical treatment. Splenectomy is also the treatment of choice for
complications of portal hypertension in patients with Felty's syndrome.
• Prevention of infection:
• Immunisation against influenza and pneumococcus.
• Patient awareness to seek immediate treatment for
symptoms of infection.
• Splenectomy patients require additional measures for
prevention of infection
• Rp: Tab. Methotrexati 0.0025 no. 10
D.S 1 Tab. PO 2t/d
• Rp: Tab. Ibuprofen 0.2 No. 30
D.S. 1 tab po 2-3 t/d
3) Rp: Tab. Ac. Folici 0.001 No. 10

13. D.S. 1 tab po 2-3 t/d
4) Rp: Sol. Dexamethasoni 0.4%-1 ml
D.t.d No. 10 in ampull
S. 1-3 ml IV 1 t/d
5) Rp: Hydrocotisoni hemisuccinatis 0.025
D.t.d no. 10 in ampull
S. 0.025 dissolve in 5 ml of water for injection IV
6.Rp: Sol. Adalimumabi 40 mg / 0.8 ml
D.td No. 2
S. Subcutaneously, once a day
Mangement of splenomegaly
Advise patients about activities, depending on their infection risk and spleen
size. For example, advise patients to avoid any activity that could result in blunt
trauma to the left upper quadrant (re the risk of splenic rupture).
Prognosis
• Overall, patients with Felty's syndrome have a poorer prognosis
than those with uncomplicated RA. They have increased morbidity and
mortality from infections and malignancy.
• Serious infection is the main cause of death.
• As with all patients with RA, patients with Felty's syndrome also
have an increased risk of cardiovascular disease.
• The degree of neutropenia in Felty's syndrome varies with time,
and spontaneous remission of neutropenia can occur in up to 40% of
patients without specific treatment. However, these patients remain at
increased risk of infection despite normal neutrophil counts.