arissa Anggraeni 030.08.155 Case Report r. Irwin, Sp.PD Arthritis Gout With Hypertension Stage II and Dyspepsia
Oct 30, 2014
Marissa Anggraeni030.08.155
Case Reportdr. Irwin, Sp.PD
Arthritis Gout With Hypertension Stage II and Dyspepsia
Company name2
Identity
Mr. E
Wadas 02/01 karawang
Elementary School
Category Description
Age
Job
Marital Status
57
Security
Maried
Moeslem
Name
Address
Last Education
Religion
Ethnic Sundanese
June 23th, 2012Admitted
Marissa Anggraeni
Company name3
Anamnese
Main Complaint Additional Complaint
Headache
Abdominal pain at upper central abdomen
Stiffness and pain when moving the hands and feet since five days ago
Naussea
Marissa Anggraeni
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Picture of The Patient
Marissa Anggraeni
Company name5
History of Disease
Present
Marissa Anggraeni
Patient came to Emergency Unit of Karawang City hospital with complaint
of stiffness and pain when moving both of th the hands and feet since 5
days before hospitalized. The pain grew increasingly greater and disrupt his daily activities. There is no history
of previous trauma.
The patient also headache, naussea,
intermittent Abdominal pain at
upper central abdomen,. He said
that he had decreased appetite
during illness.
The patient denied cold, coughing, vomitting,
and low back pain.
Defecation was
normal, urination
was normal and colored
clear yellow.
Company name6
History of Disease (cont’d)
Current
Marissa Anggraeni
10 years ago, patient
often experience
stiffness and pain in hands and feet, but he never went
to the doctor, he
just using a herbal balm and drugs to reduce the
pain.
4 years ago the pain and stiffness become more greatly and the
ankle, toe of the patien become swollen. He
also complained headache. He went to doctor, and told that
he had hyperuricemia and hypertension. he takes medicine but he never came to doctor to control the disease
3 months ago. He went to doctor with
severe pain and stiffness, and
headache. The swollen and
redness of the ankle become
large, and there is swollen in finger
and elbow. He went to the doctor and
take never medicine but never
come back to control the disease
2 months ago the swollen doesnt
go away,
it becom
es harder
but there is
no pain.
23th june 2012 the
patient come to the hospital with
that compl
ain
Company name7
History of Disease (cont’d)
Past
Marissa Anggraeni
Same illness
(+)
Hypertension (+)
Diabetes mellitus
(never check)
Asthma (-)
Allergy(+ food alergy)
Magh (-)
Company name8
History of Disease (cont’d)
Habit
Marissa Anggraeni
Alcohol consumption
(-)
Smoking (+)
Routine Excercise
(-)
Injected drugs
(-)
Traditional beverages
(-)
Consumption of foods high in purines (+)
Since elementray school, patient likes to
consume organ meats, chips,
vegetables such as kale, spinach and
beans in large quantities
Company name9
History of Disease (cont’d)
Family
Marissa Anggraeni
Same illnes (-)No history of Hypertension, DM, heart
disease, kidney disease. allergy, or asthma
Company name10
General Conditions
General appearance Moderately ill
Consciousness Compos mentis
Height 175 cm
Weight 65 kg
BMI 21,2kg/m2
Marissa Anggraeni
Company name11
Vital Signs
Marissa Anggraeni
Blood Pressure• 180/90mmHg
Heart Rate• 100x/mins
Respiration Rate• 24x/mins
Temperature• 36.8 ͦC
Company name12
Physical Examinations
Marissa Anggraeni
Head
Normocephali
Eyes
Anemic conjunctiva
-/-
Icteric sclera
-/-
Mouth
Lip: cyanosis
(-)
Pharynx: hyperemic (-), symmetrical,
uvula at midlineNeck
Lymph gland & Thyroid gland is
not palpable
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Heart examination
Inspection: Ictus cordis is availablePalpation: Ictus cordis is palpable
at 5th ICS LMCSPercussion: Right heart border: ICS III-V LSD
Left heart border: ICS V 1cm medial LMCSUpper heart border: ICS III LPSS
Auscultation: Regular I - II heart soundno murmur and gallop
Lung examination
Inspection: SymmetricalPalpation: Equal vocal fremitusPercussion: SonorAuscultation: Vesicular breath soundin both lung, no ronchi and wheezing
Examination
Thorax
Marissa Anggraeni
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Examination (cont’d)
Abdominal
Inspection : Brown skin, Flat, skin abnormality (-)Palpation : Sociable
Tenderness at upper centre abdomen No enlargement of liver and spleen
Percussion : No pain present on abdominal percussion sounds dull• Shifting dullness (-)• CVA (-)
Auscultation :Bowel sound (+), arterial bruit (-), venous hum(-)
Marissa Anggraeni
Company name15
Examination (cont’d)
Extremity
Inspection (look) : thopy +In the left fingers ± 6In the right finger ± 7In the left elbow ± 2In the right elbow ± 2In the left toe ± 10In the right toe ± 10In the left ankle ± 1In the right ankle ± 1
In the left knee ±4In the right knee ±5Diameter : 0,5 – 6 cm redness + in the joints of the handsand feet
Palpation (feel) : Warm acrals (+)
Oedem (-)Thopy palpated
warm and patient complained of pain
during palpation
Move :Range of motion are limited due to
pain
Marissa Anggraeni
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Laboratory Finding
Blood Results Normal
Hemoglobin 12.4 12-14 g/dl
Hematriokit 38 37-43 %
Trombocyte 289.000 150.000-450.000
Leucocyte 8900 5000-10.000
Diifferential counting : Basofil 0 (0-1) %
eosinofil 1 (1-3) %
Batang 3 (2-4)%
Segmen 65 (40-70) %
Limfosit 21 (20-40) %
Monosit 3 (2-8) %
GDS 79 (80-110) mg/dl
Ureum 44 (10-45) mg/dl
Creatinin 1.2 (0.4-1.5) mg/dl
Uric acid 11.0 <6.5 mg/dl
Marissa Anggraeni
June 23th, 2012
Company name17
Resume
Sign & Symptoms
• Stiffness and pain when moving both• Of th the hands and feet since 5 days• Headache• Naussea,• Abdominal pain at upper• Central abdomen
Laboratory
• Uric Acid 11.0 Mg/Dl• Blood Glucose : 79 Mg/Dl
Physical Examination
• Blood Pressure : 180/90mmHg
• Tenderness at upper centre abdomen • Thopi in the hands and feet, palpated warm• Redness in the joints of hands and feet• Range motion of extremity are limited due to the pain
Resume
Marissa Anggraeni
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Differential Diagnosis
Gout arthritis
Hypertension stage II
dispepsia
Rheumatoid arthritis
Osteoarthritis
pseudogout
Marissa Anggraeni
Company name19
Working Diagnosis
Gout arthritis with Hypertensionstage II and dispepsia
Marissa Anggraeni
Company name20
Sugessted Examination
X-Rays Arthrocentesis
The Rheumatoid
Factor
Marissa Anggraeni
Company name21
Therapy
IVFD dextrose 5% 20
drops/minutes
Bed Rest (to rest
the inflamed
joints)
Ketorolac 3 x 1 amp
Captopril 25mg 3x1
Education patient
Ranitidin 2 x 1 amp
Marissa Anggraeni
Company name22
Prognosis
Ad Sanationam : Dubia ad Malam
Ad Fungsionam : Dubia ad Malam
Ad Vitam : Bonam
Marissa Anggraeni
Company name23
THANK YOU