May 29th 2015

Name: IDPRSex: MaleAge: 47 yoNationality: IndonesiaStatus: marriedOccupation: -Religion: HinduAddress: Br. Pelaga Petang BadungTC: 13.30 Wita

Chief complain : pain in left kneePatient 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 historyNo 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 historyNone of his family members have similar symptoms.

Social historyPatient 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: Moderately illLevel of conciousness: E4V5M6Blood pressure : 130/90 mmHgTemperatur axilla: 36,5 OCPulse rate : 100 x/min, regulerRespiratory rate : 24 x/min VAS: 6Weight : 70 kgHeight: 160 cmBMI: 27,3 kg/m2

Status Present

Eyes: Anemia -/-, ict -/- PR +/+ Isokor ENT: WNLNeck: Glands enlargement (-) JVP PR 0 cm H2OChest examinationHEARTInsp: ictus cordis not visiblePalp: ictus cordis not palpable Perc: UB: ICS II, RB: PSL D, LB: MCL SAusc: S1S2 single regular murmur (-)

LUNGInsp: symmetricalPalp: vocal fremitus N/NPerc: sonor/sonorAusc: Vesicular +/+; ronchi -/-; wheezing -/-

Physical examination

Abdomen inspection: distention (-)auscultation: normal bowel soundspalpation: liver : unpalpable : spleen : unpalpablepercussion : tymphani

Extremitieswarm + + edema - - + +- -

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

Abdomen: Insp : distensi (-) Ausc : Bowel sound (+) normal Palp : H/L not palpable tenderness(-) Ballotment (-) Perc: Tympani (+)

Extremity: pitting edema , warm

----

++++

ParameterResultUnitRemarksReference rangeWBC27,4103/LL4,1 10,9 Ne26,396 %103/LL2,5 7,5Ly0,73 %103/LL1,0 4,0RBC4,85106/LN4,00 5,20HGB14,7g/dLN12,00 16,00HCT42,6%H36,0 46,0MCV87,8fLN80,0 100,0MCH30,3PgN26,0 34,0MCHC34,5g/dLN31,0 36,0RDW15,8%N11,0 14,8PLT342103/LL150 440

ParamaterHasilSatuanNilai RujukanCreatinin0,93Mg/dl0,70-1,20GDS224Mg/dl70,00-140,00Uric Acid6,4 mg/dl2 5,7BUN30Mg/dl15 - 40

ParamaterHasilNilai RujukanSatuanWarna KuningKekeruhanJernihKimiaBerat jenis1.0201.000 1.030PH6.05.0 8.0LeukositNegatif Negatif NitritNegatif Negatif ProteinNegatifGlukosaNegatifNegatifKetonNegatifNegatifUrobilinogen0.20.2Mg/dlBilirubinNegatifNegatifEritrositNegatifNegatif

ParamaterHasilNilai RujukanSatuanMikroskopisEritrositNegatif0 2LeukositNegatifSel epitel bulatNegatifNegatifSel epitel squamosNegatif0-5KristalNegatifBakteriNegatifLain-lainNegatif

Alignment baikTrabekulasi tulang normalCelah dan permukaan sendi menyempitTak tampak erosi/destruksi tulangTampak jelas soft tissue swellingKESANartritis

Cor : bentuk dan ukuran normalPulmo : tak tampak infiltrat/nodul corakan bronkovaskular normalSinus pleura kanan dan kiri tajamDiafragma kanan kiri normalTulang-tulang : tak tampak kelainan

Kesan:Saat ini secara radiologis cor dan pulmo tak tampak kelainan

Susp septic artritisAcute on chronic gouty artritis

HospitalizedIVFD RL 20 drips/minDiet high calori high protein, low purinParacetamol 3x750mgCefoperazone 2x1gr ivColchicin 3x0,5mg

Pdx:USG jointSinovial joint culture

MonitoringVSComplaintsFluid Balance PLANNING

**********