Cushing syndrome Osteoarthritis Upper gastrointestinal bleeding e.

c gastritis erosif
Adlina Sharfi 030.08.008

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

Identity
Name Age Sex Address : : : : Mr. M 32 years old Male Cibungur Jaya, Desa Karawang weta Kec. Karawang Timur, Kab. Karawang :: Moeslem : Married : Sundanese : Technician School : October 16th , 2012 : Jatisari Dormitory : 465 676

Occupation Religion Marital Status Race Education Admitted Taken from CM number

Picture of Patient

 Shortness of breath Main complaint Chest pain

Nausea Green stool and watery

Additional

complaints

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 hes admitted to the hospital. Hes complained of shortness of breath had been felt since 6 months ago, which felt more severe in last 4 days, arise intermittently, arise when hes walking or even lying on his bed and disappear when hes resting sometimes. Hes 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.

History of present illness

Hes 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 hospitals food. Hes also felt nauseous and vomited 3 times last night. He denied any fever, cought and weight loss. Hes complained a painful and hot feeling in both of his knees since 14 years ago, and its getting heavier since a day ago, but it wasnt 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

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. Theres 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 wasnt recover up to now

History of past illness

Same Symptoms (+)
Hypertension

(-)

Diabetes

Heart disease
(-)

(-)

Liver disease (-)

Food and drug allergy (-)

Malignancy

Dispepsia

(-)

(+)

Family history
Same symptoms (-) Hypertension (+) Diabetes (+) Food and drug allergy (-) Arthritis (+)

Liver disease (-)

Heart disease (-)

Malignancy (-)

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 doesnt 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 doses 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 doses will.

Physical Examination
General Condition
Appearance : 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 : 37,6C

Black hair and evenly distributed. Moon Face +

Anemic conjuctiva +/+ icteric sclera -/- Direct and indirect light reflexes +/+
Normotia, ear secretion -/- hyperemic -/- tragus pain -/auricula pain -/- intact tymphani membrane +/+

Septum, deviation -, hyperemic concha -/- nasal discharge -/-

Red lip +, dry +, oral higiene +. Pharyngeal arc symetrical , tonsil T1-T1 in normal measure

Unbpalpable lymph node and thyroid, JVP 5-2 cm H2O, supraclavicular pads -/-

STRIAE IN ABDOMINAL AND EXTREMITY

MOON FACE

Thoracal Examination-Heart
Inspection
Ictus cordis is invisible

PALPATION
Ictus cordis is palpable at 5th ICS Left Midsternal

PERCUSSION
AUSCULTATION Ireguler I-II sounds absence of murmurs gallop in hearts sound -

Thoracal Examination-Lung
INSPECTION
Symmetrical in shape, spider navi -

PALPATION
Equal vocal fremitus

PERCUSSION
AUSCULTATION
Vesicular breathing sound in both lungs ronchi -/- wheezing -/-

Abdominal Examination
INSPECTION
Brown skin, striae (+), abdominal circumference 96cm , caput medusae -

PALPATION
pain +, undulation -, liver and lien not palpable

PERCUSSION
pain on percution -, shifting dullness AUSCULTATION
Bowel sound , arterial bruit -, Venous hum -

EXTREMITIY
+ +
-

Warm acrals
+ +
-

Oedem
-

EXTREMITIY

+
Striae in proximal extremity +

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 Haemoglobin Leukocyte Trombocyte Haematocryte Basophil Eosinophil Neutrophyls Rod Neutrophyls Segment Result 12,9 gr/dL 11.300 485.000 43% 0% 0% 0% 72 % Normal Value

12-17 gr / dL

5.000 10.000
150.000 450.000 37-48 % 0-1 % 1-3 % 2-6 % 40-70 %

Limphocytes
Monocytes

24 %
4%

20-40 %
2-8 %

Laboratory Examination
Haematology HbsAg Blood Sugar Ureum Creatinin Total Protein Albumin Globulin Total Bilirubin Direct Bilirubin Indirect Bilirubin Result 139 mg/dL 11.1 mg/dL 0,59 mg/dL Normal Value 80-140 mg/Dl 10-45 mg/dL 0,4-1,5 mg/dL 6,5-8,5 mg/dL 3,5-5,0 mg/dL 2,6-3,6 mg/dL < 1,1 mg/dL < 0,6 mg/dL < 0,5 mg/dL

SGOT
SGPT

< 40 mg/dL
< 40 mg/dL

Resume A
ANAMNESE
PHYSICAL EXAMINATION ADDITIONAL EXAMINATION
shortness of breath , orthopnoe right chest pain felt like being crushed, intermittent,arises when he walked and go away with rest.

Irregular heart sound

Leukositosis P wave (-) in lead II suspek AF Thorax X-RAY : Atelektasis Lung Dextra , Ellis dummosiaeus line + in Lung Dextra, traction effect on trachea and heart to the injury lung

Resume B
Fatigue Diarrhea in greenish defecation

ANAMNESE

Nauseous and vomited Abdominal pain History of consumed KS and NSAID in along period History of stop using kortikosteroid suddenly

PHYSICAL EXAMINATION ADDITIONAL EXAMINATION

Bowel sound increase Abdominal Pain (+)

Resume C
ANAMNESE
Using kortikosteroid in a long period in an unregular dose Muscle weak progresively Fatigue Thin skin which is easily to bruise and slowly recovered

PHYSICAL EXAMINATION ADDITIONAL EXAMINATON

Moon face Central obesity ( 96 cm) Striae +

Resume D
ANAMNESE
History of hospitalization due to recurrent defecation blackish color and vomiting blackish liquid History of using kortikosteroid and Na diclofenac in a long period and in an unregular dose Nauseous and vomited Abdominal pain

PHYSICAL EXAMINATION ADDITIONAL EXAMINATION

CA +/+ Abdominal pain

Resume E
Painful in both of his knees, it wasnt accompanied by swelling and redness, it's just that he is not able to walk or stand up for long time because of the pain. Slowly progresive History of frequenly carried heavy sacks of rice The pain wasnt gone with rest Typical predilection site ( DIP, PIP,knees, hip) not at the same time Finger irregularity Fixed flexion deformity in fingers typical predilection site ( DIP,PIP, knees, hip, finger)

ANAMNESE

PHYSICAL EXAMINATION

ADDITIONAL EXAMINATION

Differential Diagnosis
A
Suspect Extrapulmonary tuberculose Suspect MCI Suspect RHD Suspect Crohn

B
Suspect Secundary adrenal insuficiency e.c Cushings syndrome e.c exogen steroid Suspect Crohn disease e.c prolonged use of NSAID Suspect Colitis ulcerative Suspect acute gastro enteritic e.c Bacterial diarrhea Suspect acute gastro enteritic e.c Viral diarrhea

C
Cushings Syndrome etcausa exogen steroid Obesity Cushings disease Pseudo cushing

disease
Suspect CHF e.c RHD

Deppression

Differential Diagnosis D
Upper GIT bleeding e.c gastritis erosiv Upper GIT bleeding e.c chronic gastritis Upper GIT bleeding e.c stress induced gastritis Upper GIT bleeding e.c peptic ulcer disease Cirrhosis hepatic

E
Osteoarthritis Reumatoid arthritis Psoriatic arthritis Gouty arthritis Reactive arthritis

THORAX PHOTO

ECG

Working diagnosis
Suspect Extrapulmonary tuberculose
Suspect Suspect Secundary adrenal insuficiency e.c Cushings syndrome e.c exogen steroid

Cushing syndrome e.c exogen steroid Upper GIT Bleeding e.c erosif gastritic Osteoarthritis Tinea 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 Ad Functionam Ad Sanationam : Dubia Ad Bonam : Dubia Ad Malam : Dubia Ad Malam