CASE REPORT

May 24th 2017

 PATIENT IDENTITY
• Name : Ms. A
• Age : 21 years old
• Address : Makassar
• Occupation : Student
• Religion : Moeslem
• Ethnic : Bugisnese
• Marital Status : Single
• Hospital : Wahidin Hosp.
• Room : Emergency Ward
• MR : 79845
 HISTORY TAKING
• Chief complaint : Pain at all joints
Pain in all body joints felt by patient since 3 months ago, and
worsening since 3 days ago, pain felt from waist, knee, wrist
and leg, until fingers. Patient felt morning stiffnes in all joints
lasting for > 30 minutes every day, patient felt weak and no
eager to walk. Patients no history of hair easily fall out, no
appear rashes on the face and redness when exposed to
sunlight, patient no decrease of apetite, no weight lost, no
shortness of breath, but had history of fever since a couple
mounth which appeared alternating with normal body
temperature eventhough patient not taking any medicine.
 PHYSICAL EXAMINATION
General Description
General condition : Moderate illness
Nutritional status : normoweight
(BW: 50 Kg, BH: 166 cm, IMT: 19.53 Kg/m 2 )
• Vital Signs
• Consciousness : Compos mentis (GCS 15 E4M6V5)
• Blood pressure : 120/70 mmHg
• Heart rate : 80 x/ min regular
• Respiratory rate : 20 x/min
• Temperature : 36,5°C (axilla)
 PHYSICAL EXAMINATION
• Head : Normocephal

• Face : Malar rash (+)

• Eyes : Isocor pupils, normal light reflex, normal conjungtiva, no icteric

sclerae

• Ear : No abnormalities, otorrhea (-)

• Nose : No abnormalities, epistaxis (-)

• Lips : No abnormalities, cyanosis (-)

• Oral cavity : Gingival hypertrophy (-), oral trush (-),

• Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 normal

• Neck : JVP R -1 cmH2O, no lymphadenopathy

 PHYSICAL EXAMINATION
• Lung
• Inspection : Symmetrical left and right
• Palpation : No mass, normal tactile fremitus
• Percussion : Sonor
• Auscultation : Vesicular breathing sounds, no ronchi,
no wheezing
• Heart
• Inspection : Ictus cordis unseen
• Palpation : Ictus cordis unpalpable
• Percussion : Dull, left heart border 2 finger laterally from left
linea midclavicularis
• Auscultation : heart sound I / II regular, no murmur

• Abdomen
• Inspection : Convex
• Auscultation : Bowel peristaltic (+) normal
• Palpation : No ascites, no organomegaly
• Percussion : Tympani
 RHEUMATOLOGICAL STATUS
• Gait : antalgic
• Arm :
• Manus (D/S) : kalor (-), dolor (-), rubor (-), bony enlargement (-)
tenderness (+)
• Leg :
• Genu (D/S): kalor (-), dolor (-), rubor (-), bony enlargement (-),
crepitation (-) buldge sign (+), effusion (+),
limited ROM (+)
• Pedis (D/S) : kalor (-), dolor (-), rubor (-), tenderness (+)
• Spine : Normal
 Laboratory Finding
• WBC : 9000 • ESR : 75
• HGB : 12.0 gr/dL • CRP : 6,95 mg/dl (positive)
• MCV : 82 • ASTO : positive
• MCH : 28
• Ur : 14
• MCHC : 35
• Cr : 0.55
• PLT : 473.000
• RBG : 78
• GOT : 22
• GPT : 22
• Albumin : 3.7
• Na/K/Cl : 138/4.1/102
THANK YOU