Cushing syndrome adlina tugas Dr Irwin

Cushing syndromeOsteoarthritis

Upper gastrointestinal bleeding e.c gastritis erosif

Adlina Sharfi030.08.008

Anamnese

• Patient was auto-anamnesed on Wednesday, October, 17th 2012 at 8.55 am.

Identity

Name : Mr. M Age : 32 years old Sex : Male Address : Cibungur Jaya, Desa Karawang weta

Kec. Karawang Timur, Kab. Karawang Occupation : - Religion : Moeslem Marital Status : Married Race : Sundanese Education : Technician School Admitted : October 16th , 2012 Taken from : Jatisari Dormitory CM number : 465 676

Picture of Patient

History of present illness• Mr. K came to the Emergency Department of Karawang

State Hospital with main complained, hardly to breath and right chest pain which worse since 4 days ago, before he’s admitted to the hospital.

• He’s complained of shortness of breath had been felt since 6 months ago, which felt more severe in last 4 days, arise intermittently, arise when he’s walking or even lying on his bed and disappear when he’s resting sometimes. He’s often awake because of tightness. He had to sit down to relieve the tightness for about 10-15 minutes.

• He also complained of right chest pain since 6 months ago that arise repeatedly and heavier in the last 4 days. It felts like being crushed and intermittently shows up. It arises when he walked roughly after 10 minutes and go away with rest.

• He’s also felt fatigue since 4 days ago.• Since a day ago, he complained of a greenish

defecation, without mucus and blood, 4 times at night and 2 times in a morning after ate the hospital’s food. He’s also felt nauseous and vomited 3 times last night.

• He denied any fever, cought and weight loss.• He’s complained a painful and hot feeling in both of his

knees since 14 years ago, and it’s getting heavier since a day ago, but it wasn’t accompanied by swelling and redness, it's just that he is not able to walk or stand up for long time ( > 10 minutes) because of the pain. The pain is intermittent, arising suddenly and disappear when he took Kalmethasone or Na Diclofenac.

History of present illness

History of present illness

• Pain initially felt in the left knee and then the right knee after a few months, then the pain sometimes move to the pelvis, shoulder, both wrists and fingers. However the pain in pelvis, shoulders, both wrists, and fingers are not accompanied by swelling, redness and trouble of movement. But there is a change at the shape of his fingers that he was not know since when it occurs.

• There’s no decreases of libido nor erectile dysfunction.

History of past illness

• He had no history of cough more than 2 weeks.• He had history of a frequent fever since teenager. But he

does not remember whether he was often had a sore throat.• 1998 painful and hot feeling in both of his knees

accompanied with swelling and redness, he is not able to walk or stand up for long time because of the pain. Pain initially felt in the left knee and then the right knee after a few months, The pain is intermittent, arise suddenly and disappear when he took Kalmethasone or Na Diclofenac.

• 2007 History of hospitalization due to recurrent defecation blackish color, up to his haemoglobin 4 mg/dl and received a transfusion. Previously he consumed

traditional herbs for 1 year.

History of past ilness

• 2008 History of hospitalization due to recurrent defecation blackish color and vomiting blackish liquid and then received a transfusion again, and being hospitalized for 1 week.

• 2009 History of hospitalization due to recurrent defecation blackish color and had diagnosed with osteoporosis by physicians at another hospital.

• September 2012 Injured at the left leg due to erosion by the sandal straps, however it wasn’t recover up to now

History of past illness

Family history

History of habit

• Frequently lift 25 kilograms of rice bags,occasionally transporting rice 2 bags at once 16 years ago for about 10 years.

• He admitted often eating at the less clean places, he also rarely wash his hands.

• He does not often eat sweet foods, fried, sour nor spicy foods.

• He doesn’t smoke anymore in last six years and never drink alcohol.

Employment history

• He used to works as a chef at CFC restaurant, however in 2007 he quits because of the disease is very disturbing in its work.

History of treatment

1998 – 2012 he consumed kalmethasone, however he's taken only if the joint became painful and the dose’s will.

2006-2007 he took traditional herbs to reduce aching joints.

2008-2009 he consumed Na diclofenac and molacort when the joint became painful and the dose’s will.

Physical Examination

General ConditionAppearance : moderately ill

Consciousness: compos mentis

Nutritional status: 160cm, 55kg

BMI : 21. 48 -> normal

Abdominal circumference: 96cm

( n: < 90 cm) central obesity

Vital Sign

Blood pressure: 100/80

mmHg

Heart rate :

60x/min

Respiration rate : 32 x/min

Temperature : 37,6⁰C

MOON FACE

STRIAE IN ABDOMINAL AND EXTREMITY

STRIAE IN ABDOMINAL AND EXTREMITY

Thoracal Examination-Heart

Thoracal Examination-Lung

Abdominal Examination

EXTREMITIY

EXTREMITIY

Localize status (manus and genu)

• Inspection : • Manus : fixed flexion deformity in PIP sinistra, PIP dextra, MCP1

dextra. Redness (–) Swelling (-) Bruise (-)• Genu : Redness (–) Swelling (-) Bruise (-) Deformity (-)• Palpation :• Temperature: manus dextra and sinistra : Both are same. Heat (-)

genu dextra and sinistra : Both are same. Heat (-)

• Pressure pain : manus : all finger• genu : +/+• Ballotement genu : -/-• Undulation genu : -/- • Knees circumference : 39cm/39cm

• MOVEMENT• Active Movement : • Finger unable to grasp +/+• Knees there is limitation of motion ( flexi) due to pain +/+• Pasive Movement : • Knees there is limitation of motion ( flexi) due to pain +/+ crepitation : hardly to assess

LABORATORY EXAMINATION (oct 16, 2012)

Haematology Result Normal Value

Haemoglobin 12,9 gr/dL 12-17 gr / dL

Leukocyte 11.300 5.000 – 10.000

Trombocyte 485.000 150.000 – 450.000

Haematocryte 43% 37-48 %

Basophil 0 % 0-1 %

Eosinophil 0 % 1-3 %

Neutrophyls – Rod 0 % 2-6 %

Neutrophyls – Segment

72 % 40-70 %

Limphocytes 24 % 20-40 %

Monocytes 4 % 2-8 %

Laboratory ExaminationHaematology Result Normal Value

HbsAg - -

Blood Sugar 139 mg/dL 80-140 mg/Dl

Ureum 11.1 mg/dL 10-45 mg/dL

Creatinin 0,59 mg/dL 0,4-1,5 mg/dL

Total Protein 6,5-8,5 mg/dL

Albumin 3,5-5,0 mg/dL

Globulin 2,6-3,6 mg/dL

Total Bilirubin < 1,1 mg/dL

Direct Bilirubin < 0,6 mg/dL

Indirect Bilirubin < 0,5 mg/dL

SGOT < 40 mg/dL

SGPT < 40 mg/dL

Resume A

ADDITIONAL EXAMINATION

Resume B

Resume C

Resume D

Resume E

Differential Diagnosis

Differential Diagnosis

THORAX PHOTO

ECG

Working diagnosis

Suspect Extrapulmonary tuberculose Suspect Suspect Secundary adrenal

insuficiency e.c Cushing’s syndrome e.c exogen steroid

Cushing syndrome e.c exogen steroidUpper GIT Bleeding e.c erosif gastriticOsteoarthritisTinea corporis

Suggested additional Examination

• Liver Function, Kidney Function• Blood electrolyte, LED• Stool culture• X-ray hands,feet, knees and hip• Endoscopy• Serum IgA, plasma ACTH• BTA sputum• ASTO• ECHO• Urinary Free Cortisol test• Dexamethasone suppresion test

Therapy (Medicamentosa)

• NaCl 0.9 % 3 kolf• Loperamid 3x2mg• Omeprazole 1x 20mg• Fibrin 2x1• Meloxin 1x7.5mg• Inhistin 2x1• Ketoconazole 1x1

•

Therapy (Non-medicamentosa)

• Bed rest• Avoid carry heavy loads• Education (avoid using

drugs without a prescription, avoid up and downstairs, avoid jogging and running, avoid kneeling and squatting. Swimming is a good option.)

• Heat and cold therapy• TENS

Prognosis

• Ad Vitam : Dubia Ad Bonam• Ad Functionam : Dubia Ad Malam• Ad Sanationam : Dubia Ad Malam