May 29th 2015

Name : IDPR
Sex
: Male
Age
: 47 yo
Nationality : Indonesia
Status : married
Occupation : Religion
: Hindu
Address
: Br. Pelaga Petang
Badung
TC: 13.30 Wita

Chief complain : pain in left knee

Patient came with complain pain in left knee since 2
weeks BATH. He felt pain continously and became
progresively worse, so was admitted to hospital. He
felt this pain like sharp pain. Since 2 week he felt his
knee swelling and followed by redness on his knee
and then he felt pain so he cant move his leg
properly. He had examine his complain to GP and
was given pain reliever. The pain was relieve for a
while but appear again. When he tried to move his
leg, he felt more painfull. And when he rest his leg,
he felt less painfull.

There is no other simptoms from the patient.

Past illness history

No history of having the same complaint before.
Patient has felt this pain since 10 years ago and
has diagnosed with gouty artritis. He regularly
took alpopurinol if he felt the pain of his gouty.
History of trauma, osteoartritis, and heart
disease was denied by the patient.
Family history
None of his
symptoms.

family

members

have

similar

Social history
Patient was a civil servant before he had this
complain. Since 1 month he didnt work anymore
because his complain. No neighbours have
similar symptoms.
Smoking (-), alcohol (-)

Appearance
Level of conciousness
Blood pressure
Temperatur axilla
Pulse rate
Respiratory rate
VAS
Weight
Height
BMI

:
:
:
:
:
:
:

: Moderately ill
: E4V5M6
130/90 mmHg
36,5 OC
100 x/min, reguler
24 x/min
6
70 kg
: 160 cm
27,3 kg/m2

Physical examination
Status Present
Eyes
: Anemia -/-, ict -/- PR +/+
Isokor
ENT
: WNL
Neck
: Glands enlargement (-) JVP PR 0
cm H2O
Chest examination
HEART
Insp
: ictus cordis not visible
Palp
: ictus cordis not palpable
Perc
: UB: ICS II, RB: PSL D, LB: MCL S
Ausc
: S1S2 single regular murmur (-)
LUNG
Insp
Palp
Perc

: symmetrical
: vocal fremitus N/N
: sonor/sonor

 Abdomen
inspection
auscultation
palpation
: spleen
percussion

:
:
:
:
:

distention (-)
normal bowel sounds
liver
: unpalpable
unpalpable
tymphani

Extremities
warm

edema

Knee : look : red, swelling

right and left
elbow
feel : warm, pain look : swelling (tofus)
move : ROM limited by pain feel : pain (-), warm
(+)
move : WNL

Parameter
WBC
-Ne

-Ly
RBC
HGB
HCT
MCV

Result

Unit

Remarks

Reference
range

27,4

103/L

4,1 10,9

103/L

2,5 7,5

26,3

96 %

Abdomen: Insp : distensi (-) 3

0,7
3%
10 /L
L
Ausc : Bowel sound 6(+) normal
4,85
10 /L
N
Palp
: H/L not palpable
14,7
N
tenderness(-)g/dL
42,6
H
Ballotment (-) %
Perc:
87,8 Tympani (+) fL
N

MCH

MCHC Extremity:

30,3

pitting
34,5 edema

RDW

15,8

PLT

342

- - -

Pg

g/dL,

warm

%
103/L

1,0 4,0
4,00 5,20
12,00 16,00
36,0 46,0
80,0 100,0

26,0 34,0

31,0 36,0

11,0 14,8

150 440

+ +
+ +

Paramater

Hasil

Satuan

Nilai Rujukan

Creatinin

0,93

Mg/dl

0,70-1,20

GDS

224

Mg/dl

70,00-140,00

Uric Acid

6,4

mg/dl

2 5,7

BUN

30

Mg/dl

15 - 40

Paramater

Hasil

Warna

Kuning

Kekeruhan

Jernih

Nilai Rujukan

Satuan

Kimia
Berat jenis

1.020

1.000 1.030

PH

6.0

5.0 8.0

Leukosit

Negatif

Negatif

Nitrit

Negatif

Negatif

Protein

Negatif

Glukosa

Negatif

Negatif

Keton

Negatif

Negatif

Urobilinogen

0.2

0.2

Bilirubin

Negatif

Negatif

Eritrosit

Negatif

Negatif

Mg/dl

Paramater

Hasil

Nilai Rujukan

Eritrosit

Negatif

02

Leukosit

Negatif

Sel epitel bulat

Negatif

Mikroskopis

Sel epitel squamos Negatif

Kristal

Negatif

Bakteri

Negatif

Lain-lain

Negatif

Negatif
0-5

Satuan

 Alignment

baik
Trabekulasi tulang normal
Celah dan permukaan sendi
menyempit
Tak tampak erosi/destruksi tulang
Tampak jelas soft tissue swelling
KESAN
artritis

Cor : bentuk dan ukuran normal

Pulmo : tak tampak infiltrat/nodul
corakan bronkovaskular normal
Sinus pleura kanan dan kiri tajam
Diafragma kanan kiri normal
Tulang-tulang : tak tampak kelainan

Kesan:
Saat ini secara radiologis cor dan pulmo tak
kelainan

 Susp septic artritis

Acute on chronic gouty artritis

Hospitalized
IVFD RL 20 drips/min
Diet high calori high protein,
Paracetamol 3x750mg
Cefoperazone 2x1gr iv
Colchicin 3x0,5mg

low purin

PLANNING
Pdx:
USG joint
Sinovial joint culture

Monitoring
VS
Complaints
Fluid Balance