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

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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

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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.

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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

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History of Disease (cont’d)

Past

Marissa Anggraeni

Same illness

(+)

Hypertension (+)

Diabetes mellitus

(never check)

Asthma (-)

Allergy(+ food alergy)

Magh (-)

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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

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History of Disease (cont’d)

Family

Marissa Anggraeni

Same illnes (-)No history of Hypertension, DM, heart

disease, kidney disease. allergy, or asthma

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General Conditions

General appearance Moderately ill

Consciousness Compos mentis

Height 175 cm

Weight 65 kg

BMI 21,2kg/m2

Marissa Anggraeni

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Vital Signs

Marissa Anggraeni

Blood Pressure• 180/90mmHg

Heart Rate• 100x/mins

Respiration Rate• 24x/mins

Temperature• 36.8 ͦC

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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

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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

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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

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Working Diagnosis

Gout arthritis with Hypertensionstage II and dispepsia

Marissa Anggraeni

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Sugessted Examination

X-Rays Arthrocentesis

The Rheumatoid

Factor

Marissa Anggraeni

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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

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Prognosis

Ad Sanationam : Dubia ad Malam

Ad Fungsionam : Dubia ad Malam

Ad Vitam : Bonam

Marissa Anggraeni

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THANK YOU