Académique Documents
Professionnel Documents
Culture Documents
(070100364)
Maal Abrar
(070100374)
Supervisor:
dr. Yazid Dimyati, Sp. A (K)
DEPARTMENT OF PEDIATRIC
HAJI ADAM MALIK GENERAL HOSPITAL
UNIVERSITY OF SUMATERA UTARA FACULTY OF
MEDICINE
MEDAN
2012
PREFACE
Sp.A(K)
for
her
valuable
advices
and
guidance
Writers
CONTENTS
PREFACE ..
ii
CONTENTS
iii
CHAPTER I INTRODUCTION
1.1.
Background
1
1
................
1.2.
Objective ..
.................
CHAPTER II LITERATURE REVIEW
2.1. Definition ......
3
3
2.2.
Epidemiology...
..............
2.3.
Etiology....
...............
2.4.
Pathogenesis.
..
2.5.
Classification
2.6.
Clinical
Presentation..
2.7.
.
2.8.
Diagnosis..
15
Laboratory
16
Test.
2.9.
Treatments.
21
2.10.
23
Prognosis..
CHAPTER III MEDICAL REPORT
3.1. Case
25
25
...
3.2.
27
Discussion..
3.3. Summary..
28
..
REFERENCES...................................................................
29
.....................
ATTACHMENTS
CHAPTER I
INTRODUCTION
1 . 1.
Background
Juvenile rheumatoid arthritis (JRA) is a generic term for arthritis that has an onset
before the age of 16 and persists for more than 6 weeks. The JRA nomenclature
represents an exclusion diagnosis that includes all forms of chronic childhood
arthritis of unknown origin1.
Currently, 3 separate classification systems are used to categorize
individuals under 16 years of age with chronic arthritis. These include the
American College of Rheumatology (ACR), the European League Against
Rheumatism (EULAR), and the International League of Associations for
Rheumatology (ILAR) criteria. Because none of these systems are perfect models,
some JRA patients fulfill criteria for more than one subtype, whereas others are
difficult to classify into any of the specific subgroups. Both the ACR and EULAR
criteria are based solely on the onset type as it is manifested during the first 6
months of disease, whereas the ILAR criteria also include the course type over an
unknown period of time thereafter, in order to further distinguish the group of
patients with oligoarticular disease1.
1 . 2.
Objective
The objective of this case report is to familiarize ourselves with Juvenile
CHAPTER II
LITERATURE REVIEW
2 . 1.
Definition
Epidemiology
The exact incidence and prevalence of JRA is not known. A recent meta-analysis
of 34 epidemiological studies showed wide variability in both the reported
incidence and prevalence of JRA. Incidence numbers varied considerably from
0,008 to 0,226/1000 children per year. Prevalence numbers varied even more
widely and ranged from 0,,07 to 4,01/1000 children4.
2 . 3.
Etiology
JRA is an autoimmune disease. This means it is the body's own immune system
that causes the damage. The immune system problems may be caused by genetics
and/or environment 3, 5.
Various studies seeking epidemiological evidences for etiology of arthritic
manifestation thaw infectious connection to RA. For obvious reason, triggering
immune response against antigenic determinant is a preparative cascaded reaction
in order to eliminate invaders. There are two principal difficulties with the
hypothesis that infection triggers rheumatoid arthritis: first proving a causal
relation and second the limitation of the methods of detection of recent or past
infection. Past or recent infection develops onset of polyarthritis persistently
associated with the development of antibody response, giving satisfactory
explanation for infection triggering immune response in rheumatoid phenomena6.
No particular studies documented persistence of infectious agents in joint
inflammatory site, even though availability of bacterial products at the site of
inflammation and triggered immune response to earlier infection and its related
antibody activities and particularly of crossreactivity might be given attention in
order to facilitate hypothesis to etiology of rheumatic diseases. And also from
clinical concern, patients with earlier infection before develops rheumatological
criteria may be no longer infectious giving opportunity to understand its
connection and involvement of such infectious connection to etiopathology. Hence
it could be strengthening the suggestion that rheumatoid arthritic etiology has
satisfactory explanation for infection, and joint inflammation might have develops
soon after or during an infection elsewhere in the body6.
2 . 4.
Pathogenesis
and
chondrocytes,
to
release
tissue-destroying
matrix
10
11
Classification
The 3 major subtypes of JRA are based on the symptoms at disease onset and are
designated systemic onset, pauciarticular onset, and polyarticular onset.
Pauciarticular-onset and polyarticular-onset JRA are further divided into 2 subsets.
Although the major JRA classifications are based on onset type, the course of the
disease is also critical to patient prognosis. For instance, systemic-onset JRA can
eventually become indistinguishable from polyarticular JRA. Patients with this
pattern of onset and disease course may be particularly difficult to treat. JRA that
begins as pauciarticular-onset disease, with more extensive joint involvement over
time, is frequently referred to as extended pauciarticular or extended
oligoarticular disease2.
2 . 6.
Clinical Presentation
Arthritis
An arthritic joint exhibits a number of cardinal signs of inflammation, such as
swelling, erythema, heat, pain, and loss of function. Involved joints are often
12
warm, but are not typically erythematous. Children with arthritis may not
complain of pain while at rest, but active or passive motion typically elicits pain.
Joint tenderness is usually maximal at the joint line or just over the hypertrophied,
inflamed synovium. Of note, bone pain or tenderness is not characteristic of JRA
and may instead indicate the possibility of a malignancy involving bone. Morning
stiffness and gelling following inactivity are common manifestations of joint
inflammation, but young children infrequently describe these symptoms. Often,
young children do not complain of pain and instead refuse to use the affected joint
entirely1, 3.
Figure 2. Swelling and flexion contracture of the right knee of a representative patient with
oligoarticular disease1.
Any joint can be affected by JRA, but large joint are more frequently
involved than smaller joints. However, small joints of the hands and feet are also
affected, particularly in polyarticular onset disease. Of note, cricoarytenoid
arthritis is unusual but may be responsible for acute airway obstruction.
Inflammation of the synovial joints in the middle ear has also been detected by
tympanometric studies. The temporomandibular joint and the cervical, thoracic,
and lumbar spine should also be examined in the case of JRA. JRA often affects
the cervical spine, and the most common changes in the upper cervical spine are
anterior atlantoaxial subluxation and impaction. Subluxation of the atlantoaxial
13
joints may also occur, rendering the affected child at risk of injury in an accident
or upon attempted intubation prior to receiving general anesthesia. Scoliosis,
which possibly reflects asymmetric thoracolumbar apophyseal joint inflammation,
may also occur in children with JRA. Small outpouchings of symovium are not
uncommon in individuals with JRA and are particularly evident at the extensor
hood of the proximal interphalangeal joint and around the wrist or ankle. A
synovial cyst in the antecubital area or anterior to the shoulder may be the initial
or sole presentation of JRA1.
Oligoarticular disease develops in at least 50% of children with JRA
during the first 6 months of disease. This subtype is the only form of JRA without
an adult equivalent. Oligoarticular disease affects up to 4 joints at presentation,
with the knee joints mostly affected, followed by the ankles. In contrast, this
subtype almost never affects the hips, and rarely the smaller joints of the hands
and feet. Oligoarticular disease is characterized by asymmetric arthritis, early
onset (before 6 years of age), female predilection, high frequency of positive
ANAs, and a high risk of iridocyclitis1.
Polyarticular disease is defined as the presence of arthritis in 5 or more
joints during the first 6 months of disease. The arthritis may be symmetrical and
usually involves the large and small joints of the hands and feet, although the axial
skeleton, including the cervicalspine and the temporomandibular joints, may also
be affected. This subtype includes children with both RF-negative and RF-positive
diseases. Both types affect girls more frequently than boys. RFnegative patients
often develop polyarthritis in early childhood, whereas RF-positive patients
instead develop arthritis during late childhood and adolescence1.
14
Figure 3. Polyarticular disease affects the joints of the wrist and hand. The proximal and
distal interphalangeal joints are erythematous. There are flexion contractures of the fingers 1.
15
Figure 4. High intermittent fever in a representative patient with systemic onset disease 1.
16
17
most prominent within the first years after onset of systemic onset disease. The
degree of splenomegaly may be extreme, but it is uncommonly associated with
Feltys syndrome (splenic neutropenia). Hepatomegaly is less common than
splenomegaly. Furthermore, moderate to severe enlargement of the liver is often
associated with only mild derangement of function and relatively nonspecific
histopathologic changes. However, massive enlargement of the liver is usually
accompanied by abdominal distention and pain1.
Uveitis
Chronic, anterior, nongranulomatous uveitis (iridocyclitis) develops in up to 21%
of patients with oligoarticular disease and 10% of patients with polyarticular
disease. However, no patients with systemic onset disease have been diagnosed as
having uveitis to date. The only known independent risk factor for developing
uveitis is a positive ANA test. The onset of chronic uveitis is typically insidious
and often entirely asymptomatic, although up to one half of affected children have
some symptoms attributable to uveitis (e.g., pain, redness, headache, photophobia,
change in vision) later in the course of their disease. Uveitis may be present at the
time of diagnosis, may develop during the course of JRA, or may be an initial
manifestation of JRA that is usually detected in the course of routine
ophthalmologic examination. JRA patients should be screened routinely to prevent
delay in diagnosis of uveitis. The earliest signs of uveitis on slit-lamp examination
are the presence of inflammatory cells and increased protein concentration in the
aqueous humor of the anterior chamber of the eye. In addition, deposition of
inflammatory cells on the inner surface of the cornea (keratopunctate deposits)
may develop later during the course of disease. Complications of uveitis include
posterior synechiae, cataracts, band keratopathy, glaucoma, and visual
impairment1, 3.
2 . 7.
Diagnosis
History
18
Arthritis must be present for 6 weeks before the diagnosis of juvenile rheumatoid
arthritis (JRA) can be made. Disease onset is either insidious or abrupt, with
morning stiffness or gelling phenomenon (ie, stiffness after long periods of sitting
or inactivity) being a frequent complaint and arthralgia occurring during the day.
A morning limp that improves with time may be noted, and a toddler may no
longer stand in the crib in the morning or after naps3,8.
Complaints of joint pain may not be predominant in the patients history,
however; children often stop using joints normally (eg, develop contractures of
joints, decreased wrist range, limp) rather than complain of pain. Up to a quarter
of children with oligoarticular JRA have no pain3,8.
Individuals with JRA may have a history of school absences, and their
ability to participate in physical education classes reflects the severity of the
disease or acute flares3,8.
Systemic-onset JRA is characterized by spiking fevers, typically occurring
once or twice each day, at about the same time of day, with temperature returning
to normal or below normal. The fever pattern is very useful because infections,
Kawasaki disease, and malignancy usually do not have such a predictable pattern.
Systemic-onset JRA is usually accompanied by an evanescent rash (lasting a few
hours), which is typically nonpruritic, macular, and salmon colored on the trunk
and extremities. Occasionally, the rash is extremely pruritic and resistant to
antihistamine treatment3,8.
Physical Examination
JRA is a clinical diagnosis. A complete physical examination is critical for the
diagnosis. Physical findings are important to provide criteria for diagnosis and to
detect abnormalities suggestive of alternative etiologies. The diagnosis of JRA is
based on the physical finding of arthritis in at least 1 joint that has persisted for at
least 6 weeks, with other causes excluded, in an individual younger than 16
years3,8.
Arthritis is defined as either intra-articular swelling on examination or as
limitation of joint motion in association with pain, warmth, or erythema of the
19
joint. The hips, temporomandibular joint, and small joints in the spine do not
demonstrate swelling when affected by synovitis but demonstrate the combination
of loss of motion and pain. The physical findings in JRA are a reflection of the
extent of joint involvement3,8.
In synovitis, in which there is synovial proliferation and an increase in
joint volume, the joint is held in a position of maximum comfort. Limbs with
synovitis are generally held in flexion. Range of motion often is limited only at
the extremes. In synovitis, the fingers may appear swollen, and the range of
motion becomes painful. The wrist goes into flexion. In the knee, the parapatellar
fossae often are obliterated, and a doughy synovium may be palpable. A soft,
boggy swelling is appreciated in the popliteal fossa3,8.
The hip is held in an attitude of flexion, abduction, and external rotation.
Attempted range of motion will be painful to a varying degree. Guarding is an
early sign of synovitis8.
2 . 8.
Laboratory Test
The diagnosis of juvenile rheumatoid arthritis (JRA) is based on the history and
physical examination findings. No laboratory studies are diagnostic for JRA, and
indeed, all laboratory study findings may be normal in children with this disorder.
However, laboratory studies help to exclude other underlying disorders, classify
the type of arthritis, and evaluate for extra-articular manifestations of JRA.
Imaging of affected joints is usually indicated8.
Inflammatory Markers
The erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level is
usually elevated in children with systemic-onset JRA (with a disproportionate
increase in the CRP) and may be elevated in those with polyarticular disease;
however, it is often within the reference range in those with oligoarticular disease.
When elevated, inflammatory markers can be used to monitor disease activity8.
20
21
patients with systemic-onset JRA, the following test results are indicative of the
development of macrophage-activating syndrome (MAS)8:
Falling ESR
Low platelets
Increased ferritin
Increased triglycerides
Low fibrinogen
Erratic fevers
Radiography
When only a single joint is affected, radiography is important to exclude other
diseases, such as osteomyelitis. Basic radiographic changes in JRA (see the
images below) include the following8, 9:
Joint-space narrowing
Bony erosions
Periosteitis
Growth disturbances
Joint subluxation
Synovial cysts
22
Figure 6. Ankylosis in the cervical spine at several levels due to long-standing juvenile
rheumatoid arthritis (also known as juvenile idiopathic arthritis) 8.
Figure 7. Widespread osteopenia, carpal crowding (due to cartilage loss), and several
erosions affecting the carpal bones and metacarpal heads in particular in a child with
advanced juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis) 8.
Ultrasonography
On ultrasonograms, inflamed synovium can appear as an area of mixed
echogenicity lining the articular cartilage; the vascularity of the synovium can be
assessed with Doppler flow studies. Serial measurements of synovial thickness
and effusion volumes have been used to monitor disease progression. It can be
helpful to evaluate joints that are difficult to palpate, such as the hip and shoulder.
Some researchers claim that ultrasonography is more sensitive than plain
radiography in the detection of cartilage erosions and effusions. Ultrasound has
the advantages of no exposure to ionizing radiation; it can be done in the clinic is
an awake, moving child; and it can help guide injections8, 9.
23
Figure 8. (A) T2-weighted MRI shows high signal in both hips, which may be due to hip
effusions or synovitis. High signal intensity in the left femoral head indicates avascular
necrosis. (B) Coronal fat-saturated gadolinium-enhanced T1-weighted MRI shows bilateral
enhancement in the hips. This indicated bilateral active synovitis, which is most pronounced
on the right. Because the image was obtained with fat saturation, the hyperintensity in both
hips is pathologic, reflecting an inflamed pannus8.
24
2 . 9.
Treatments
For all patients, the goals of therapy are to decrease chronic joint pain and
suppress the inflammatory process. Accomplishing these goals will lead not only
to improved short-term and long-term function but also to normal growth and
development2.
First-line
therapy
includes
nonsteroidal
anti-inflammatory
drugs
25
26
2 . 10. Prognosis
The course of the disease is highly variable. Only approximately one quarter of
patients with polyarticular onset are in remission at 5 years after disease onset, and
more than two thirds develop erosions within the first 5 years of the disease. The
extended oligoarthritis phenotype has a similar prognosis2.
As might be expected from the high frequency of erosions in patients with
polyarticular disease, polyarticular onset and polyarticular disease course both
have been identified as significant risk factors for disability. Other factors that
determine disability include female gender and the presence of rheumatoid factor.
Lower remission rates have been observed in patients with polyarticular onset,
rheumatoid factor, persistent morning stiffness, tenosynovitis, subcutaneous
nodules, or antinuclear antibody. Poor outcomes are also associated with early
involvement of the small joints of the hands and feet and rapid appearance of
erosions2.
The most challenging patients to treat are those with poor prognostic
indicators. These patients are likely to require more aggressive therapy, as well as
early initiation of treatment. A recent study of predictive factors that influence the
outcome of patients with JRA or juvenile spondyloarthropathy found that patients
who developed erosions and disability tended to have received treatment later than
those who did not2.
Table 2. Poor Prognostic Indicators for Patients With JRA2
27
CHAPTER III
MEDICAL REPORT
3. 1.
Case
DP, a 15 years and 10 months old boy, with a body weight of 25 kg, was
28
PERSONAL ANAMNESIS
Name
: DP
Age
Sex
: Male
: 25 kilogram
Body Height
Religion
: Christiani
Race
: Batak
Address
Admission Date
: 04 May 2012
Medical Record
: 51.37.45
cm
ANAMNESIS OF DISEASE:
Chief complaint: swelling of the joints
Resume:
Swelling was felt by the patient since 4 month ago. Sweeling felt on the
knee joints. The knee joint could not be moved by the patient. Pain and burning
sensation was felt and become worsen in 4 months. The patient could not walk
since 4 months ago. The knee could not be straightened. History of recurrent fever
since 9 months ago, but now the patients did not have a fever. Defecation and
urination was normal. Nausea and vomiting were not found.
The patient was referred from regional hospital with the diagnosis of
Rheumatoid Arthritis. The patient was transfused with 1 bag blood in that hospital.
PHYSICAL DIAGNOSTIC:
Status Presence:
General Condition
Sensorium: Alert,
Temperature: 37 C
Disease Condition
Anemic (+), icteric (-), edema (-), dyspnea (-), cyanosis (-), edema (+)
29
Nutrition Status
Age
Differential Diagnosis:
Therapy:
Treatment/Diagnosis Plan:
3. 2.
DP, a 15 years and 10 months old boy, with a body weight of 25 kg, was admitted
to to the non-infection ward of H Adam Malik General Hospitals Pediatric
Division on 4 May 2012 at 09.30 AM with a chief complaint of swelling on the
joints Swelling was felt by the patient since 4 month ago. Sweeling felt on the
knee joints. The knee joint could not be moved by the patient. Pain and burning
sensation was felt and become worsen in 4 months. The patient could not walk
since 4 months ago. The knee could not be straightened. History of recurrent fever
since 9 months ago, but now the patients did not have a fever. Defecation and
urination was normal. Nausea and vomiting were not found.
On further questioning, The patient was referred from regional hospital
with the diagnosis of Rheumatoid Arthritis. The patient was transfused with 1 bag
blood in that hospital.
Juvenile Rheumatoid Arthritis, persistent arthritis in 1 or more joints for at
least 6 weeks if certain exclusionary conditions have been eliminated 2. JRA is the
most common chronic rheumatic illness1. Patients with JRA often have symptoms
including arthritis, fever, rash, arthritis, enlargement of lymph nodes and spleen,
and uveitis 1. In this patient, DP, experienced swelling, pain, and burning sensation
of the joints which realized 4 month ago. He also has history of fever since 9
months ago.
The diagnosis of juvenile rheumatoid arthritis (JRA) is based on the history
and physical examination findings. No laboratory studies are diagnostic for JRA,
31
and indeed, all laboratory study findings may be normal in children with this
disorder8. From anamnesis, DP experienced symptoms of arthritis and had history
of fever since 9 months ago. From physical examination, there was a swelling of
the joints (knee joint). When the joint was moved, the patient complained of pain
and burning sensation. From the laboratory results, the hemoglobin was 9,1 g%,
LED 27 mm/h, qualitative CRP was positive, rheumatoid factor was negative,
ANA was 8, and Anti ds-DNA was 15,3.
For all patients, the goals of therapy are to decrease chronic joint pain and
suppress the inflammatory process. Accomplishing these goals will lead not only
to improved short-term and long-term function but also to normal growth and
development2. First-line therapy includes nonsteroidal anti-inflammatory drugs
(NSAIDs). The patient was given ibuprofen as a first line therapy. Ibuprofen
inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
The pediatric dosage is 30-50 mg/kg/d PO divided qid, not to exceed 2.4 g/d.
3. 3.
Summary
from
history
taking,
physical
examination,
and
laboratory
examination. The goals of therapy are to decrease chronic joint pain and suppress
the inflammatory process. The patient still being treated in the non-infection ward
of H Adam Malik General Hospitals Pediatric Division.
32
REFERENCES
1. Hahn YS, Kim JG. 2010. Pathogenesis and Clinical Manifestations of Juvenile
Rheumatoid Arthritis. Korean J Pediatr 2010;53(11):921-930
2. Ilowite NT. 2002. Current Treatment of Juvenile Rheumatoid Artrhitis.
Pediatrics 2002;109;109
3. Abraham, Rudolph. 2006. Buku Ajar Ilmu Pediatri Rudolph.Jakarta: EGC
4. Olson JC. 2003. Juvenile Idiopathic Arthritis: An Update. Winconsin Medical
Journal. Vol. 102(7): 45-50
5. Rudis J. 2012. Juvenile
Rheumatoid
Arthritis.
Available
from:
http://pediatrics.med.nyu.edu/conditions-we-treat/conditions/juvenilerheumatoid-arthritis
33
EKG
34
ECHO
35
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =116x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 116 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 100/70 mmHg, edema
pretibial (+/+), edema on the poplitea (+/+)
Anogenital
: male, within normal range.
Hemoglobin: 9,1 g%
57,8%
Erithrocyte: 4,27x106/mm3
Neutrofil:
Lymphocyte:
36
24 %
Leucocyte: 10,6x103/mm3
7,9 %
Hematocrit: 29,9 %
9,9 %
Trombosit: 488x103/mm3
MCV: 70 fL
MCH 21,3 pg
MCHC: 30,4 g%
LED: 27 mm/jam
LE cell : negative
Monocyte:
Eosinofil:
Basofil: 0,4%
Clinical Chemistry:
Liver
ASTO: <200
Rheumatoid Factor (RF) : negative
Autoimmune
ANA Test : 8
Anti ds-DNA : 15,3
37
38
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =120x/i, regular, murmur (-)
RR = 26x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 120 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 100/70 mmHg, edema
pretibial (+/+), edema on the poplitea (+/+)
Anogenital
: male, within normal range.
39
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =114x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 114 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 100/70 mmHg, edema
pretibial (+/+), edema on the poplitea (+/+)
Anogenital
: male, within normal range.
40
O: General Status: Sensorium: Alert, Temp: 36,8 C, BB: 25 kg, PB: 104 cm,
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =110x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 110 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 100/60 mmHg, edema
pretibial (+/+), edema on the poplitea (+/+)
Anogenital
: male, within normal range.
Trough swab
Bone surgery referral
Medic rehabilitation referral
41
O: General Status: Sensorium: Alert, Temp: 36,8 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =120x/i, regular, murmur (-)
RR = 20x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 120 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 120/50 mmHg, edema
pretibial (+/+), edema on the poplitea (+/+)
Anogenital
: male, within normal range.
Trough swab
Bone surgery referral
42
O: General Status: Sensorium: Alert, Temp: 36,8 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%
Anemic (+), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : +/+
Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =112x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 112 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
pretibial (+/+)
Anogenital
: male, within normal range.
Physiotherapy
43
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =110x/i, regular, murmur (-)
RR = 26x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 110 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 120/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
44
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =114x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 114 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
45
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =114x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 114 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
46
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =110x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 110 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
47
O: General Status: Sensorium: Alert, Temp: 37,2 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =100x/i, regular, murmur (-)
RR = 20x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 100 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
48
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =110x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 110 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
49
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =100x/i, regular, murmur (-)
RR = 22x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 100 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
50
O: General Status: Sensorium: Alert, Temp: 36,8 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =110x/i, regular, murmur (-)
RR = 28x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 110 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
51
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =88x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 88 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
52
O: General Status: Sensorium: Alert, Temp: 37 C, BB: 25 kg, PB: 104 cm,
BW/Age=66%, BH/Age=60%, BW/BH=69,4%,
Anemic (-), Dyspnea (-), Cyanosis (-), Edema(+), Icteric (-)
Localized Status :
Head
: Eye: light reflex: +/+ , isochoric pupil,
Pale Inferior conjunctiva palpebra : -/Ear/Nose/Mouth : in normal range
Neck: Lymph nodes enlargement (-),
Thorax
: Simetris Fusiformis, Retraction (-)
HR =114x/i, regular, murmur (-)
RR = 24x/i, regular, wheezing (-/-), ronchi (-/-)
Abdomen
: Soft, peristaltic (+) N
Liver: not palpable
Spleen: not palpable
Extremities: Pulse: 114 x/i regular, pressure/volume: adequate, warm acral,
Capillary refill time < 3, blood pressure: 110/60 mmHg, edema
Anogenital
pretibial
: male, within normal range.
Photo Patient
53
54
55