MORNING REPORT

(Right Knee Effusion + OA Genu Bilateral + Hyperuricemia Symptomatik + HHD + CAD)

December 17th 2020

Nurfathanah
PATIENT IDENTITY

 Name : Mrs. JR
 Age : 81 years old
 Address : Makassar
 Religion : Moslem
 Ethnic : Buginese
 Marital Status : Married
 Hospital : Hasanuddin University
 Room : Emergency Room
 Admission : 9/3/2021
HISTORY TAKING

 Patient admitted with complaint pain in the right knee

since 2 months ago, there was swelling in the joint.
The patient has been unable to walk for 2 months.
the patient has had daily activities in bed since 2
months. No history of trauma.
 Fatigue since 2 months ago. Patient difficult to
understand when communicating since 2 months
HISTORY TAKING
 No fever, no history of fever, no headache. Hair
loss since 2 years ago
 No Cough, no shortness of breath. no chest pain
 No nausea, no vomiting, Good appetite. No weight
loss
HISTORY TAKING

 Defecation was normal. Urination yellow color, slight

volume.
 History of coronary artery disease and hypertension
since 2018, the patient does not control medication
regularly
 History of OA Genu since February 2020, The patient
has a history of intraarticular injection in the knee and
taking allopurinol and ibuprofen
PHYSICAL EXAMINATION

 General condition: Moderate illness

Nutrition: normoweight
 Height : 150 cm
 Weight : 40 kg
 BMI : 17,7 kg/m2 (underweight)
 Vital Signs
 Awareness : Composmentis(GCS 15 E4M6V5)
 Blood pressure : 140/90 mmHg
 Heart rate : 62 x/ min, Regular
 Respiratory rate : 18 x/min, Thoracoabdominal
 Temperature : 36,8 °C (Axilla)
 VAS : 3/10
PHYSICAL EXAMINATION

 Head : Normocephal, straight white hair

 Face : Malar rash (-)
 Eyes : Pupils isocor, normal light reflex, pale conjunctiva

no subconjunctival bleeding, no jaundice.

 Ear : No abnormalities, otorrhea (-)
 Nose : No abnormalities, epistaxis (-)
 Lips : No abnormalities, cyanosis (-)
 Oral cavity: oral thrush (-), hypertrophy gingngival
 Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 quiet

 Neck : JVP R + 1 cmH2O, no lymphadenopathy, no enlargement of

thyroid gland, no deviation of the trachea.

PHYSICAL EXAMINATION
 Lung
 Inspection : Symmetrical left and right
 Palpation : No palpable tumor mass, normal tactile fremitus
 Percussion : Sonor
 Auscultation : vesicular breathing sounds, rales (-), wheezing (-)
 Heart
 Inspection : Ictus cordis unseen
 Palpation : Ictus cordis unpalpable
 Percussion : Right heart border in ICS IV linea parasternalis dextra, Left heart border in ICS
V linea medioclavicularis sinistra
 Auscultation : heart sound I / II regular, no murmur ang gallops
 Abdomen
 Inspection : No darm contour and steifung, striae
 Auscultation : Bowel peristalsis (+) normal
 Palpation : Ascites (-), no organomegaly
 Percussion : Timpani
 Extremity
 No edema both of pretibial
PHYSICAL EXAMINATION

 Status Rheumatology
 Gait : Inability to walk
 Arms: Normal
 Legs : Right knee : look swollen, warm, crepitation, effusion, tenderness
 Legs : Unable to evaluate
PATIENT PROFILE
LABORATORY FINDING
Laboratory 2/3/2021
Leukosit 7.840 4000-11.000/µL
Hemoglobin 9,5 13.0 – 16.0 g/dL
MCV 83,1 80-100 fL
MCH 27,1 27-34 pg
Trombosit 649.000 150.000-450.000 / µL
Neutrofil 63,6 50-70%
Limfosit 20,9 20-40%
RBS 82 < 140 mg/dl
Urit Acid 9,6 <6
IgM Anti SARS-CoV-2 Reactive Non Reactive
IgM Anti SARS-CoV-2 Reactive Non Reactive
 ELECTROCARDIOGRAPHY
(8/3/2021)

Interpretation:
Sinus Rhythm, HR 62 bpm, Left Axis Defiation, Complete LBBB, Old Myocard Infarction Inferior
RADIOLOGY FINDING

Chext X-Ray AP Knee X-Ray AP/Lat

RADIOLOGY FINDING
 Chext X-Ray AP
 Interpretation:
 Observe the left
pulmonary nodular lesion,
Cardiomegaly
 Knee X-Ray AP/Lat
 Interpretation:
 Genu joint osteoarthritis
bilateral grade 2, Senile
osteoporosis
RHEUMATOLOGICAL STATUS

Rheumatological status
 Gait : Inability to walk
 Arms: Normal
 Legs : Right knee : look swollen, warm,
crepitation, effusion, tenderness
 Legs : Unable to evaluate
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

1. Right Knee Effusion - Fitajoint Roller Gel 1 app/12

Based on: hours
- pain in the right knee since 2
months ago, there was
swelling in the joint
- Effusion of right knee

2. Osteoarthritis Genu Bilateral - Paracetamol 500 mg/oral if

Based on: pain
- pain in the right knee since 2
months ago, Genu joint
osteoarthritis bilateral grade 2
on Knee X-Ray
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

3. Hyperuricemia Symptomatic Allopurinol 100 mg/24

Based On : hours/oral
• Uric Acid 9,6 mg/dL

4. Coronary Artery Disease Consult Cardiologist

Based On :
• Complete LBBB and Old Myocard
Infarction Inferior on ECG
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

5. Hypetensive Heart Disease Water Retriction

Based On :
• Hypertension (140/90 mmHg)
• Cardiomegaly on Chest X-Ray

6. Anemia Nomocytic - Peripheral Blood Smear

Normochrom et causa suspect
Chronic Disease
Based On :
• Hb 9.5, MCV 83.1, MCH 27.1
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

7. Dementia
Based On :
• Elderly
• Difficult to understand when
communicating since 2 months

8. Suspect Covid-19 Swab RT-PCR Covid-19

Based On :
• IgM and IgG Anti SARS-CoV-2
Reactive
THANK YOU