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Case Report :
: MEYLISA/C11112156
/C11112
dr.
: dr. ABDUL RAHMAN, SP.Pd
ARTHRITIS
GOUT
Name
: Mr. T
Age
: 60 years old
Occupation
: Retirement
Religion
: Moeslim
Marital Status
: Married
Address
: Pare-Pare
Hospital
: RS Wahidin Sudirohusodo
Room
: HCU bed 4
RM
: 780074
Date of admission : 23 November 2016
ANAMNESIS
CHIEF COMPLAINT
HISTORY TAKING
ANAMNESIS
HISTORY TAKING
Physical
Examination
General Description
Impression
: moderate illness
Physical
Vital Sign Examination
Blood Pressure
: 120/90 mmHg
Heart Rate
: 76x/minutes
Respiration Rate
: 26x/minutes
Temperature
: 36,6C
VAS
: 4/10 on Paracetamol 1 g
Weight
Height
BMI
: 50 Kg
: 160 cm
: 19,5 kg/m2
Physical
Examination
:
Thorax
Inspection
Palpation
Percution
:
:
Auscultation :
Heart
Inspection
Physical
Examination
Abdomen
Inspection
Physical
Examination
Abdomen
Inspection
Physical
Examination
INTERN
DEPARTMENT
RHEUMATOLOGY
STATUS
-
G (Gait)
A (Arms)
L (Legs)
S (Spine)` :
LABORATORY FINDING
Type
WBC
LYMP
MON
RBC
HGB
PLT
Result
9,1x 103 /uL
19.8 %
10.1 X 103 /Ul
3.82
11.6
360
Normal Range
4 - 12 x 103 /uL
20.0 - 40.0%
2.00 8.00 x 103 /uL
4-6x106 L
12-16 g/dL
150-400 x 103 l
HCT
MCV
MCH
MCHC
RDW
34
89
30
34
13.8
37-48 %
80-97m3
26.5-33.5 pg
31.5-35.0 g/dL
10-15%
ESR I/II
79/85
LABORATORY FINDING
Ureum
25
Creatinin
1,2
Uric Acid
11
Glucose
92
10 50 mg/dL
P(<1.1);
L(<1,3) mg/dL
P(2.4-5.7);
L(3.4-7) mg/dL
140 mg/dL
LABORATORY FINDING
Color Yellow (pale)
Clarity/turbidity Clear or cloudy
pH 6.0
Specific gravity 1.010
Protein - trace
Glucose Negative
Bilirubin Negative
Urobilirubinogen Normal
PROBLEM LIST
Problem List
P:
1. Control of serum uric acid
2. Arthrocentesis
3. X-ray genu dextra et sinistra (AP/lateral)
T:
a. Pharmacologic treatment :
4. Colchicine 0,5mg/24 hour/oral
5. Paracetamol 1 g/ 8 hours/oral
6. Allopurinol 100mg/24 hour/oral
b. Physical Exam :
L
:Effusion,
rubor,
calor, 7. Corticosteroid injection intrarticular
crepitation, tenderness, and
limited ROM in genu sinistra b. Non-pharmacologic treatment :
8. Low-diet purin
and dextra (1)
9. Rest the pain joint
c. Laboratory Exam : serum uric
(1)
(3)
(2)
(4)
TOTAL SCORE
10
DISCUSSIO
N
DEFINITION
An excess of uric acid (Monosodium urate
monohydrate crystals) in the blood and tissues of
the body which if present long enough may form
into a needle like crystals which can inflame your
joints and cause severe pain and swelling (UK
GOUT Society, 2016)
EPIDEMIOLOGY
ETIOLOGY
Too much uric acid in the blood ( hyperuricemia)
High purine diet ( too much meat and seafood) or drinking too
much alcohol.
Drugs that increase uric acid concentration (aspirin or niacin) or
drugs that reduce the amount of salt and water in the body
( diuretics)
Genetic conditions ( Kelley seegmiller syndrome or Lesch Nyhan
syndrome)
PATHOMECHANISM
PATHOMECHANISM
STAGES OF GOUT
CRITERIA
DIAGNOSTIC
CLINICAL
CLINICAL
MANIFESTATION
MANIFESTATION
DIFFERENTIAL
DIAGNOSIS
PHARMACOLOGICAL
TREATMENT
NON PHARMACOLOGICAL
TREATMENT
NON PHARMACOLOGICAL
TREATMENT
Thank you