Morning Report

Dec, 7rd 2014

PHYSICIANS INCHARGE:
IA
: dr. Bayu,dr. Daya,dr. Nando,
dr.Gerry,dr.Eka Maya
IB
: dr. Hesty, dr.Asri,dr. Irene
II
: dr. Lya R
III
: dr. Dewi, SpPD
MODERATOR
: dr. Budi D M,SpPD-KHOM

Summary of Data Base

Mr.S/male/54 y.o/w.25
Chief Complain : Pain at his foot and hand

Patient suffered pain at his foot right and left since 4

weeks ago. Pain didnt only at his joint foot but the pain also
on the muscle. Pain also with swelling at the foot, red and
warm. Some times his felt fever on his body if the foot pain
and swelling. He also suffered pain on his patella and
difficulties for fleksi his patella. Last 3 days ago he felt pain
on his left hand, stiffness, swelling, red and warm. The pain
didnt subsided with paracetamol.

 Past medical history :

Patient was diagnosed with diabetes mellitus since 3 months ago, at

that time his felt decrease of body weight, increase of frequently

passing urine. He consumed metformin every day 2x1 tab.
He was diagnosed hypertension since 2 years ago but Unroutinly

consumed antihypertension.
History of medication: Metformin 2x1 tab
Family History: none of the family members have suffered from the similar
symptoms
Past Medical History : he never got sick before this disease (CKD).
Social history: seller , no Smoker nor alcoholic

Physical examination
BP = 130/80 mmHg

PR = 80 regular

RR = 20 tpm,

Tax : 37 C

General appearance looked moderately ill

looked normoweight, VAS 7

GCS 456

Head

Pale conjunctiva Icterus Sclera -

Pupil isocor 3 mm/3 mm

Neck

JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest

Heart:

Ictus invisible and palpable at ICS VI, MCL Sinistra

LHM ictus,
RHM: SL D
S1, S2 single, murmur (-)

Lung:

Symetric, SF D= S

v v
v v
v v

Rh - ---

Wh

- ---

Abdomen and Genital

Flat, Soefl, liver span 8 cm, traube space tympani,

bowel sound (+) normal,Shifting dullness (-),

Extremities

Oedema -/-, Plantar pedis D/S, warm, edema minimal,hyperemi, pain

-/- , Metacarpal S : warm, edema, stiffness, pain, hyperemi.
Patella : pain, crepitasi +

th
Laboratory
finding
(Dec,
7
2014)
Lab
Value
Lab
Value
Leukocyte

21.780

3.50010.300/L

Natrium

128

136-145 mmol / L

Haemoglobine
MCV

15,3
81,8

11,0-16,5 g/dl
80-97

Kalium

4,09

3,5-5,0 mmol / L

MCH

27,5

26,5-33,5

Chlorida

106

98-106 mmol / L

PCV

45,5

35-50%

RBS

180

<200

Trombocyte

531.000

100.000390.000/L

SGOT

25

0-41U/L

SGPT

33

0-41U/L

3,72

3,5-5,5 mg/dL

Eu/bas/Neu/Ly 0,1/0,2/82,
/Mo
1/12/5,6
Ureum

39,1

10-50 mg/dL

Albumin

Creatinine

1,31

0,7-1,5 mg/dL

Osmolari 272,5
ty

Uric acid

9,1

3,4-7 mg/dL

LED

CRP

11,39

< 0,3 mg/dL

77

285-295
0-20 mm/hour

URINALYSIS
Result

Result

SG

1,020

10 x

PH

5,5

Epithelia

0,3

Leucocyte

Cylinder

Nitrite

Hyaline

Protein

trace

Granular

Glucose

Leukocyte

Erythrocyte

Erythrocyte

40 x
Keton urine

Eritrosit

3,8

Urobilinogen

Eumorfik

Bilirubin

dismorfik

Leukocyte

Bacteria

47,5x 10

jamur

ECG

Sinus Rhythm, Heart rate 88 bpm

Frontal Axis
: normal
Horizontal Axis : normal
PR interval
: 0,32
QRS complex : 0.08
QT interval
: 0.32
Conclusion : sinus Rhythm with HR 88 bpm

CXR
AP position, asymmetric, enough KV, less
inspiration
Soft tissue normal, Bone normal
Trachea in the middlle
Hemidiaphragm D and S are domeshape
Phrenico costalis angle D and S cover by
radioopaque shadow
Pulmo D/S: BVP normal
Cor: site N, size CTR 58%, cardiac waist appear
Conclusion : cardiomegaly

 Metacarp
al normal
Patella
calcificati
on

CUE AND CLUE

PL

IDx

Male/54 yo w.25
A
Pain at his pedis 4
weeks
Pain and stiffness at
his metacarpal 3 days
PE

1. Polyarth
ritis

1.1.
rheumatoi
d Arthritis
1.2 Vira
Arthtritis
1.3 gout
Arthritis
1.4 Septic
arthritis

Plantar pedis D/S, warm,

edema minimal,hyperemi,
pain
Metacarpal S : warm,
edema, stiffness, pain,
hyperemi.
Patella : pain, crepitasi +
VAS : 7

Lab:
Wbc : 21.780 L
LED : 77 mm/hour
CRP : 11,39 mg/dL
Xray metacarpal :
normal
Patella : calcification
Das 28 : 5,87 high
disease activity

Male/54 yo w.25
Uric acid : 9,1
mg/dL

2.
Hyperuri
cemia dt
no 1

PDx

PTx

PMo

Bed rest
IVFD naCl 0,9%
20 dpm
Inj Ceftriaxone
2x1 gram iv
Inj Ketorolac
3x30 mg

VS
Complai
n

Treat underlying
disease

BP,
Target
organ
damage

Ped :
prognosi
s

Ped :
prognosi
s

CUE AND CLUE

Male/54 yo w.25
Diabetes mellitus
since 3 months
ago
Decrease of body
weight
Increase
frequently
passing urine
Consumed
metformin
Lab :
RBS : 202 mg/dL
Creatininyo
: 1,31
Male/54
w.25
mg/dL
Hypertension
since 2 years ago
Unroutinly
consumed
antihypertension
PE
GCS 456
BP 130/80 mmHg

PL

IDx

3. DM T II
on OAD

4. HT Stage
1

4.1
Secondary
4.2 primary

PDx

PTx

PMo

Diet DM 1900
kcal/day
Oral :
Glikuidon 1x 30
mg

S,VS
FBG,
2HFBG

Captopril 2 x12,5
mg

S,VS

Ped :
progno
sis
FBG

Ped :
progno
sis

Problem analysis

Autoimmune

Arthtritis

Risk Factor Analysis

Arthritis :

Family history.
Age.The risk of many types of arthritis including
osteoarthritis, rheumatoid arthritis and gout increases
with age.
Your sex.Women are more likely than are men to
develop rheumatoid arthritis, while most of the people
who have gout, another type of arthritis, are men.
Previous joint injury.People who have injured a joint,
perhaps while playing a sport, are more likely to
eventually develop arthritis in that joint.
Obesity.Carrying excess pounds puts stress on joints,
particularly your knees, hips and spine. Obese people
have a higher risk of developing arthritis.

Management analysis
Bed rest
Diet DM 1900 kcal/day
IVFD naCl 0,9% 20 dpm
Inj Ceftriaxone 2x1 gram iv
Inj Ketorolac 3x30 mg
Oral :
Glikuidon 1x 30 mg
Captopril 2 x12,5 mg

Condition this morning

GCS : 456
BP : 130/80 mmHg
HR : 88 bpm
RR : 20 tpm
Tax 36,5

Thank you

ACR/EULAR (2010) Classification Criteria

ACR/EULAR (2009) Classification Criteria for Rheumatoid Arthritis
Symptom Duration(as reported by patient) Points
<6 weeks 0
> 6 weeks 1
Joint DistributionPoints
1 large joint 0
2-10 large joints 1
1-3 small joints (with or without involvement of large joints) 2
4-10 small joints (with or without involvement of large joints) 4
> 10 joints (at least 1 small joint) 5
Serology Points
RF- and CCP- 0
Low RF+ or CCP+2
High RF+ or CCP+ 3
Acute Phase Reactants Points
Normal ESR or CRP 0
Abnormal ESR or CRP 1
RF: rheumatoid factor. CCP: anti-citrullinated citric peptide. ESR: erythrocyte
sedimentation rate. CRP: C-reactive protein. Low: < 3 x upper limit of normal (ULN).
High: > 3 x ULN
Requirements: patients who haveat least 1 swollen joint,and not better explained by
another diseaseto be applied. A score 6 points is required for classification as definite
RA.