Morning Report

Wednesday, June 2th 2016

CO ASSISTANCE INCHARGE

AGUS HENDRA
RIKA PRATIWI RIJAYANTI

MODERATOR :
dr. IQBAL LAHMADI Sp.PD
 Total Patients

Total patients :
Melati ward : 9 patients

Kenanga ward : 9 patients

Total Patients in ward:

Melati ward : 0 patients

Kenanga ward : 1 patients

Male, 50 y.o., Dx: acute gout arthritis
 Summary of Database

Mr. A /Male /50 y.o

Chief complaint : joint pain

Patient suffered from joint pain in the right hand since 1
weeks ago which was getting worsening since this
morning. The pain type is sudden onset. Patient said that
he was oftenly awake in the night because of the joint
pain. Patient complain that the pain accompanied with
redness, warm, and tenderness. Patient said that he can
not move his finger and wrist. The pain didnt relieved by
the rest. Patient said that he always consumed drug to
relived the pain. Pasient also complain joint pain in
both of knee since 1 weeks ago.
 Patient also complain about loss of his appetite.
patient also like eat organ meats high in purine
content such as liver, kidney, emping melinjo
 Past Medical History

Patient had been hospitalized with diagnosis gout

arthritis since he was 35 years old.
Patient consumed allopurinol as a treatment of gout
disease but for 2 weeks he didnt comsumed
allopurinol
Patient had been hospitalized with diagnosis urinary
tract stones 13 years ago and the patient said uric
acid in urinalysis was + and uric acid serum was
high.
 Physical
BP = 110/80 mmHg
examination
PR : 96 tpm, regular,
in Kenanga
RR = 22 tpm,
Ward
T ax 36,8oC

General appearance looked moderatly ill GCS 456

Head Anemic - Icteric -
Neck JVP 5 cmH2O
Thorax Invisible Palpable at Ictus ICS VI MCL S,
Heart RHM SL D, LHM as ictus,
S1 S2 single, mur mur (-), gallop (-)

lung Simetric, SF D = S SS v v Rh - - Wh - -
SS bv bv - - - -
DS bv bv - - - -

Abdomen Convex, Soefl, Hepar : Liver span 12 cm, splen can not palpable

Extremities Oedema in both lower extremity -/-, a.r palmar D/S there was deformity with
sign of inflamation ( rubor, calor, tumor, dolor, functio laesa); a.r Plantar was
deformity with sign of inflamation ( rubor, calor, tumor, dolor, functio laesa);
Tophi (+) a.r digiti palmar and platar (+). A.r genu there was deformity with sign
of inflamation (+). Thopi (+), limited of ROM.
Clinical picture
ECG in Kenanga Ward
 Interpretation

Sinus Rhythm, HR 93 tpm

Axis :
Frontal axis : normal axis
Horizontal axis : clock wise (V4-V5)
PR interval : 0,12 ms
QRS complex : 0,08 ms
QT interval : 0,32 ms
Poor R Proggresion : V1-V3
Prominant Left Precordial voltage: V4-V6

Conclusion : Normal Sinus Rhythm with HR 93 tpm, LVH

 Lab Value Lab Value

Leukocyte 31.900 3500;10000/L Ureum 160 10-50mg/dL

Haemoglobin 10,1 11,0-16,5g/dl Creatinine 2,3 0,7-1,5mg/dL

MCV 76,5 80-97 AST 96 11-41U/L

MCH 25,6 26,5-33,5 ALT 54 10-41U/L

Thrombocyte 412.000 150000- Uric Acid 11, 38 M: 3,5-7,7,2

F: 2,6-6,0
390000/L
RBS 157 (<200)mg/dL

ESR 120 mm/ 0-10 mm/hour

hour
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNING
LIST DIAGNOSE DIAGNOSE THERAPY MONITORI
NG

male/50 yo 1. Joint 1.1 Arthritis microscop IVFD NS 20 dpm VS

Ax: 1.1.1 Acute y of a Diet low purine Complain
Pain + Metil prednisolone 3
arthralgia(+), rubor(+), Gouty synovial Side Effect
tumor (+), color (+), hyperuri x 31,25 mg 0r 1/4
Arthritis fluid
dolor (+)limited of cemia + amp IV
ROM
1.1.2 aspirate 0r Ranitidine 2 x 50 mg
leuko rheumatoid tophus IV
PE:
sitosis arthritis aspirate oral Colchicine 1,2
BW: 58 kg 1.1.3 CPPD (intracellula mg then 0,6 mg 1
a.r palmar D/S there arthropathy r needle- hour later.
was deformity with sign (pseudogout). shaped Prophylaxis 0,6 mg 1
of inflamation ( rubor, x1 until the gout
crystals ) attack resolves
calor, tumor, dolor,
functio laesa); a.r
-
Plantar was deformity Rhematoid
with sign of inflamation factors
( rubor, calor, tumor,
dolor, functio laesa); a.r
digiti palmar and platar
(+) dan genu sin et dex
(+). Tophi (+)

ECG : SNR with HR 93

tpm.

Lab :
WBC : 31.900 / mm3
Uric acid: 11,38mg/ml
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNI
LIST DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

male/ 50 yo 2. 2.1 due to - Confirm dx Lab

Ax: Azotemia no. 1 finding
-
Pre Renal
PE:
-
Lab:
Ur: 160
Cr: 2,3
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNI
LIST DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

male/ 50 yo 3. 2.1 due to - Confirm dx Lab.

Ax: Transamini no. 1 Avoid drug induce finding
- hepatotoxic
tis
PE:
-
Lab:
AST: 94
ALT: 54
CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING PLANNI
DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

male/ 50yo 3. Normochrom 3.1 - Blood smear Confirm Dx Lab.

Ax: normocytic Chronic + reticulocyte Finding
- Anemia disease count
(Anemia
PE: of
-
Inflamatio
Lab : n)
Hb : 10,1 g/dl
MCV : 76,5
MCH : 25,6
 Present conditions

Joint Pain (+) decrease, tenderness (+) decrease,

redness (-) warm (-)
GA : good GCS E4V5E6
BP : 120/70 mmHg
HR : 84 tpm
RR : 20 tpm
T: 36,30C
Thank you
Terapi
 Mechanism of Anemia in AI

RBC destruction: increased erythrocyte destruction is

caused by the activation of hosts factors such as
macrophages that prematurely remove aging
erythrocytes from the bloodstream. The explanation is
consistent with the predominance of young
erythrocytes in AI.
Suppressive effects of inflammation on erythropoietic
precursors: chiefly tumor necrosis factor (TNF)-, IL-1,
and the interferons, exert a suppressive effect on
erythroid colony formation.
 Inadequate erythropoietin secretion and resistance to
erythropoietin: In support of the EPO suppression
hypothesis are experiments with EPO-producing cell
lines indicate that production of the hormone is inhibited
by inflammatory cytokines including TNF- and IL-1.
The inhibition is mediated by the effects of the
transcription factor GATA-1 on the EPO gene promoter,
and the suppression of EPO production can be reversed
by a GATA inhibitor. Moreover, both baseline and
hypoxia-induced EPO gene expression is suppressed in
rats treated with 551 Chapter 37: Anemia of Chronic
Disease bacterial lipopolysaccharide or IL-1 to mimic a
septic state. However, suppression of EPO production is
not the major mechanism of AI.
Erythropoiesis restriction as a result Of iron
unavailability