Arthritis Gout With Hypertension Stage II and Dyspepsia

Marissa Anggraeni 030.08.155

Case Report dr. Irwin, Sp.PD

Identity
Category Name Age Address Job Last Education Marital Status Mr. E 57 Wadas 02/01 karawang Security Elementary School Maried Description

Religion
Ethnic Admitted

Moeslem
Sundanese June 23th, 2012

Company name Marissa Anggraeni

Anamnese

Main Complaint

Additional Complaint

Headache

Stiffness and pain when moving the hands and feet since five days ago

Naussea Abdominal pain at upper central abdomen

Company name Marissa Anggraeni

Picture of The Patient

Company name Marissa Anggraeni

History of Disease
Present

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 complaint 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, morning stiffness.

Defecation was normal, urination was normal and colored clear yellow.

Company name Marissa Anggraeni

History of Disease (contd)

Current

since 7 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 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 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 hospit al with that compl ain

Company name Marissa Anggraeni

History of Disease (contd)

Past

Same illness (+)

Hypertension (+)

Diabetes mellitus (never check)

Asthma (-)

Allergy (+ food alergy)

Magh (-)

Company name Marissa Anggraeni

History of Disease (contd)

Habit

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. The patien stating to reduce the comsumsion since 4 yearsago

Company name Marissa Anggraeni

History of Disease (contd)

Family

Same illnes (-)

No history of Hypertension, DM, heart disease, kidney disease. allergy, or asthma

Company name Marissa Anggraeni

General Conditions
General appearance Consciousness Height Weight BMI
10

Moderately ill
Compos mentis 175 cm 65 kg 21,2kg/m2
Company name Marissa Anggraeni

Vital Signs
Blood Pressure
180/90mmHg

Heart Rate
100x/mins

Respiration Rate
24x/mins

Temperature
36.8 C
11

Company name Marissa Anggraeni

Physical Examinations

Head Normocephal i Eyes Anemic Icteric conjuncti sclera -/va -/Lip: cyanosis (-)

Mouth
Pharynx: hyperemic (-), symmetrical, uvula at midline

ear

No thopi

Neck
Lymph gland & Thyroid gland is not palpable

12

Company name Marissa Anggraeni

Examination
Thorax

Lung examination Inspection: Symmetrical Palpation: Equal vocal fremitus Percussion: Sonor Auscultation: Vesicular breath sound in both lung, no ronchi and wheezing

Heart examination Inspection: Ictus cordis is available Palpation: Ictus cordis is palpable at 5th ICS LMCS Percussion: Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS Auscultation: Regular I - II heart sound no murmur and gallop

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Company name Marissa Anggraeni

Examination (contd)
Abdominal

Inspection Palpation

: Brown skin, Flat, skin abnormality (-) : 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(-)
Company name Marissa Anggraeni

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Examination (contd)
Extremity

Inspection (look) : thopy + In the left fingers 6 In the right finger 7 In the left elbow 2 In the right elbow 2 In the left toe 10 In the right toe 10 In the left ankle 1 In the right ankle 1

In the left knee 4 In the right knee 5 Diameter : 0,5 6 cm redness + in the joints of the hands and 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

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Company name Marissa Anggraeni

Laboratory Finding
June 23th, 2012
Blood Results Normal

Hemoglobin
Hematriokit Trombocyte Leucocyte

12.4
38 289.000 8900

12-14 g/dl
37-43 % 150.000-450.000 5000-10.000

Diifferential counting : Basofil

eosinofil Batang Segmen Limfosit Monosit

0
1 3 65 21 3

(0-1) %
(1-3) % (2-4)% (40-70) % (20-40) % (2-8) %

GDS Ureum Creatinin

Uric acid
16

79 44 1.2
11.0

(80-110) mg/dl (10-45) mg/dl (0.4-1.5) mg/dl

<6.5 mg/dl Company name Marissa Anggraeni

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

Resume
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
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Company name Marissa Anggraeni

Differential Diagnosis
Gout arthritis Hypertension stage II dispepsia Rheumatoid arthritis Osteoarthritis pseudogout
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Company name Marissa Anggraeni

Working Diagnosis

Gout arthritis with Hypertension stage II and dispepsia

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Company name Marissa Anggraeni

Sugessted Examination

X-Rays

Arthrocentesis

The Rheumatoid Factor

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Company name Marissa Anggraeni

Therapy
Bed Rest (to rest the inflame d joints) Ranitidi n2x1 amp IVFD dextrose 5% 20 drops/mi nutes

Ketorol ac 3 x 1 amp

education

therapy

Captopr il 25mg 3x1

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Company name Marissa Anggraeni

Prognosis
Ad Vitam : Bonam

Ad Fungsionam : Dubia ad Malam

Ad Sanationam : Dubia ad Malam

Company name Marissa Anggraeni

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