USMF

State University Of Medicine and Pharmacy

“Nicolae Testimitanu”
Of the Republic of Moldova

Clinical Case Report

Name: Daniela Lisnic

Group: m1442
Chishinău 2019

General data
1.Name: Nikita
2.Family name: Ursu
3.Gender: male
4.Age: 4 years old
5.Date Of Birth:
6.Home address:
7.Occupation: child
8.Date and time of beginning the disease:

9.Date and time of admitting:

10.Clinical Diagnosis: Periodic fever syndrome

11.Operation: no history of surgeries

Complain :
Fever especially in the evening.The character of fever is
undulating.The etiology of fever is unkown ,no trigger factors are
observed.The fever fluctuate between 37.8-38.5 for the period of
2 weeks.

History of life
Second child.
Was born at 40 weeks by natural delivery .
Weight at birth-4,300 ,Height -53 cm
Mom was breastfeeding for 1 year.The child was introduced to
food since 6 months first with cereals then pureed vegetables
,fruits, and then meet.
No history of allergy or skin eruptions during that period.
The child was developing normally ,gaining weight according to
age.
Vaccination status are all up to date ,without
complications

History of the disease:

In January 2019 the mother addressed to local hospital.Blood tests
,urinalisys and ultrasound didn’t show any pathological changes but the
fever was persisting.
The mom complained that the child lost appetite, aversion to meet
products.Refuses to eat them in any prepared form.

General Clinical examination:

General state: the child is active and interacts with other children in the
room.
Conciseness: clear conciseness.
facial expression: look optimistic and calm
type of body: normostenic.
skin: moist
edema: absent
fat: normal
mucosa: normal ,absence of any lesions.
hair: no alopecia, no hirsutism, no fragile.
nails : fragile nail.

lymph:
Occipital Normal dimension(<1cm) and painless palpation
Mastoid Normal dimension(<1cm) and painless palpation
Submandibular Normal dimension(<1cm) and painless palpation
Mental Normal dimension(<1cm) and painless palpation
Anterior cervical and tonsillar Normal dimension(<1cm) and painless palpation
Posterior cervical Normal dimension(<1cm) and painless palpation
Supraclavicular Normal dimension(<1cm) and painless palpation
Subclavicular Normal dimension(<1cm) and painless palpation
Axillary Normal dimension(<1cm) and painless palpation
Thoracic Normal dimension(<1cm) and painless palpation
Cubital Normal dimension(<1cm) and painless palpation
Inguinal Normal dimension(<1cm) and painless palpation
Poplitial Normal dimension(<1cm) and painless palpation

Proportion of head and painful spots in head: head is proportional with

the body, symmetric ,facial bones all are symmetrical. Abcense of pain
while pressing on the supraorbital, suborbital areas, above maxillary
sinuses and mastoid process.

Musculo-skeletal system:
Inspection : the patient presents with thick dry skin in the hands and
palms and had desquamation of the skin in her finger and black spot in
her nails .
Palpation : painfull , stiffness , tenderness .
Osteo - articular system :
Sacroiliac joint : no
ankle (tibia-fibula and talus) joint : no
intermetatarsals : n pain
metatarsophalangeal : pain
tarsometatarsal : no pain
subtalar :no pain
talus and calcaneus : no pain
talus and navicular : no pain
Knee joint : pain.

no pain on palpation in the following joints :

Acromioclavicular ,atlantoaxial, atlantooccipital, calcaneocuboid,
carpometacarpal, elbow (humerus, radius, and ulna) ,intercarpal (proximal
carpal, distal carpal, and the two rows of carpal bones with each other),
intermetacarpal , interphalangeal,shoulder (humerus and scapula),
sternoclavicular, sternocostal, symphysis pubis, temporomandibular,
tibiofibular, ulnohumeral ,wrist , femur, tibia, and patella, manubristernal,
radioulnar joints.

Respiratory system:
1)Complains : no complains
2)Inspection:
Nose: participates in breathing, breathing through the nose is free. No
discharge from it..
Constitutional type: during inspection there is absence of any deformation
in thoracic cavity or the vertebral column ,no barrel chest, no
scoliosis\kyphosis\ lordosis
*Absence of abnormal displacement of trachea . Trachea is not shift to
the left or right.

3)palpation:
chest is cylindrical
elasticity in chest
vocal fremitus: normal

no painful points:

Suborbital No pain detected during palpation

Supraorbital No pain detected during palpation

Mandibular No pain detected during palpation

Auricular No pain detected during palpation

Chest No pain detected during palpation

4)percussion:
Resonant
5)Topographic percussion

1. Upper border of the lungs:

I.Superior anterior borders:

Right lung:3 cm above clavicle
Left lung: 3 cm above clavicle

II.Superior posterior borders:

Right lung- at the 7 cervical vertebral level.
Left lung- at the 7، cervical vertebral level.

Kroenig area= 4 cm

2. Lower borders of the lungs:

Right Lung:

-Parasternal line: 9thintercostals space

-Midclavicular line: 6thintercostals space
-Anterior Axillary line: 7 intercostals space
- mid axillary: 8 intercostal space
-Posterior Axillarry line: 9 intercostals space
-Scapular line: 10 I.C.
-Paravertebral line: 11th rib
Left lung:

-Anterior Axillary line: 7 intercostal space

-Midaxillary line: 8th intercostal space
-Posterior Axillary line: 9th intercostal space
-Scapular line: 10 intercostal space
-Paravertebral line: 11th rib

Respiratory motitity of pulmonary border:

1. On Axillary line:
Right lung: 4cm
Left lung: 4cm

2.Lungroot:
Right lung: 3cm
Left lung: 3cm

4.auscultation:
pleural friction normal (no pleurisy)
normal vesicular breathing over the area of both lungs

cardio-vascular system
No complains , regular sinus rhythm .
Inspection:
There is no pathological pulsation of the carotid arteries and no dilated
neck veins. Inspection in the region of the pericardium is satisfying,
visible pulsation of apex, visible pulsation near the sternum, no visible
pulsation in epigastric region. cyanosis, acrocyanosis, clubbing of fingers,
no splinters.
Palpation:
Pulse: 130/min
1.Apex beat: present in the fifth intercostal space, with the area of 1
left midclavicular line.
Location: 1.5 cm
Height: moderate
Resistance: none
Force: none forceful
2.Pulsation to the left of the sterna line: no cardiac beat
3.Epigastric pulsation: no pulsation were present
4.Cat’s purr symptoms-Heart murmur: were absent

Percussion:
1.True borders of the heart relative dullness:
a) Right border: 4th right intercostal space 1 cm right to the
sternum.
b) Left border: corresponds with apex of beat of 5 intercostal
space; 1.5 cm medially to the left midclavicula line.
c)Upper border: 3 left rib on parasternal line

2.Absolute dullness of heart-Uncovered heart:

a) Right border: left border of the sternum; 4thintercostal space.
b) Left border: 2 cm medially from apex beat.
c) Upper order: 3 intercostal space.

3.Configuration of the heart: Mitral configuration of the heart.

4.Width of the vascular bundle in the 2ndintercostals space: 6cm

Auscultation:
Mitral valve: Is sound is heard.
Aortic valve: 2nd sound is heard.
Pulmonary valve: 2nd sound is heard and has the same intensity as that
heard in the aortic valve point.
Tricuspid valve: 1st sound is heard better and has the same intensity as
that heard in mitral valve point.

Erb’s point: no pathological sound heard

Examination of vessels:
 No changes in the major arteries during palpation.
 Same pulse on radial arteries in filling, Strength, rate and rhythm.
 No varicose dilation of veins in the legs.
 No hyperemia.
 No pain in palpation.

Digestive system
Inspection:
-Asymmetrical size of abdomen
-No signs of hernia
-No abdominal breathing
Auscultation:peristaltic sound herd above all auscultation points.
Percussion:
-Above stomach and intestine was performed; no painful points.
-No presence of ascites
-No gases in abdominal cavity

Palpation:
Superficial: negative Blumberg sign, no presence of tumors or
 abnormal masses, no herniation or any protrusions.

Deep palpation:

 Sigmoid colon: is painless and elastic.

 Cecum: is painless and elastic.
 Terminal end of ileum: is painless and elastic.
 Ascending colon: is painless and elastic
 Descending colon: is painless and elastic.
 Transverse colon: is painless and elastic.
 Stomach: no pathologies where detected and no reactive pain.
 Pyloric part of the stomach: is painless and elastic.
 Liver: enlargement of lower border.

Liver and gallbladder examination

a) Complaints: none.

b) Examination: no protrusions and pulsations.

c) Percussion:
 Between 1st and 2nd points: 15cm
 Between 3st and 4nd points: 12cm
 Between 3st and 5nd points: 10cm

d) Palpation:
 Liver edge is soft,painless,regular surface.
 Courvoisier-tierrer sympoms are not present.
 Merphy symptoms are not present.
 Frencus symptoms are not present

e) Gallbladder: is not enlarged or painful upon palpation

f) Pancreas: is not accessible

Spleen:
-examination: not protruded
-palpation: not palpable- normal
 -examination of fluid wave- absent
-percussion: longitudinal:6cm

Uro-genital system:
Kidneys are not palpable
Absence of any pathological condition
Negative Giordani sign on percussion.
Diuresis:normal 4-5 times a day

Endocrine system :
Absence of any pathology on inspection
Appetite: decreased.
Weight: weight loss , around 2 kg by mother’s words
Muscles: slight fatigue with hyperactivity
Thyroid gland is normal; not painful/not enlarged/no nodular formation.

Nervous system:
Response to deep sensation: yes normal response
Response to superficial sensation: yes normal response
Tendon reflexes: symmetrical Normal response (+2)
Gate: Normal gate /normal balance.
Tremors: absent
Eye: no ptosis, the pupils are horizontal ,at the midline, no nystagmus, no
anisocoria.
Facial expressions: present.
Vomiting reflex/gag reflex: present.
Babinski sign : negative.
No insomnia, no depression, no somnolence.
Preliminary diagnosis:
Based on the clinical picture, history of life & physical
examination the patient has : periodic fever syndrome
,additional investigations need to be done.

Differential diagnosis :
Juvenile idiopathic arthritis
CMV
EBV
TB
SLE
Malignancies ,including leukemia/lymphoma
Second part: plan of examination
**clinical and para-clinical investigations planning:
CBC :

Hb 117 g/dl
RBC 3,50x10*6/l
Non segmented 6%
segmented 58%

monocytes 6.00
WBC 9.90x10*9/ul
lymphocytes 39.00
eosinophils 5.00

Biochemical analysis:
ALT 416mmol/l
Lactate dehydrogenase 1914.00 u/l
Creatine kinase 16350.00 u/l

Coagulation:

Fibrinogen 5.33 gr/l

INR 0.97
Prothrombin 104.60%

Serological
Anti-jo1 antibody
Anti-nuclear antibody
Anti-Ro 52 antibody

Diagnosis :

Treatment :
• medications, such as glucocorticosteroids and methotrexate,
which treat the inflammatory disorder, and hydroxychloroquine,
which treats the skin-related aspect of the condition
(dermatomyositis)
• intravenous therapy
• physical and occupational therapy to improve muscle
function and strength
• liberal use of sunscreens to prevent further irritation or
damage to the skin
• nutritional support to ensure an adequate diet
• alternative therapy , such as reiki, acupuncture and massage
in order to make your child more comfortable.

Conclusion :

Juvenile dermatomyositis ,myalgia, muscle weakness,

Gotron papules,
hepatosplenomegaly,
mouth ulceration,
increase in muscle breakdown enzymes,
positive autoimmune markers
Retard stature. Iatrogenic hyperacortism.
Investigation plan and treatment according to national clinical
protocol, "Juvenile dermatomyositis".