Summary of Data Base

Mrs. S/46 y.o/W28 Chief complaint: Right knee pain

Patient suffered from pain in the right knee since 1 year ago, especially when she walked and walked up stair. It worsened since 2 months ago and makes limitation of activity. It was accompanied with swelling on the right knee, inflammed but no pain when pressed, leg edema was negative. History of trauma was denied. There were no cracking sensation on morning stiffness. She didnt take any analgetic. She didnt complained about fever and cough. Urination normal, defecation normal. Nausea, vomit, and headache was denied.

SUMMARY OF DATA BASE

History of past illness : 1 year ago she underwent joint fluid aspiration in RSSA because of same complain Hypertension since 15 years ago, no routine control, and blood pressure is around 150/ History of DM was denied History of social living : She had 3 children, worked as factory labour. Her husband passed away 1 year ago because renal failure, drunk traditional potion, analgetic and alcohol was denied

Physical examination
Ward BP: 170/100mmHg Ward PR: 90 bpm regular strong Ward RR: 20 tpm Ward Tax: 36,8C General appearance looked ly moderately ill Head Neck Chest Heart: Within normal limit Within normal limit Ictus invisible and palpable at ICS V 2 cm lat MCL S LHM ictus RHM: SL D S1, S2 single, murmur ( - ) Ward GCS: 456 Looked overweight BW: 70 BMI: 28.4 Within normal limit

Lung:
Abdomen Extremities

Within normal limit

Within normal limit Acral warm, leg edema -/Genu D swelling (+), pain (+), crepitation (-), mass (-)

Laboratory findings
LAB VALUE (NORMAL) LAB VALUE (NORMAL)

Hb MCV MCH Leucocyte

12.2 78.60 24.90 9.610

11,0-16,5 g/dL 80-96 fl 26,5-33,5 pg 3.500-10.000/L

Ureum Creatinine Kolesterol Total Trigliserida

23.80 0.95 111 87

10-50 mg/dL 0,7-1,5 mg/dL <200 mg/dL < 150mg/dl

Eos / Bas / Neu / Limf / Mon

3.1 / 0.1 / 78.6/13.6 / 4.6 %

Kolesterol HDL
Kolestrol LDL

52
98

>50mg/dL
<100

PCV
Plt

38.50
349.000 150.000390.000/L

BUN/Cr

20.06

ECG
Sinus rhythm, heart rate 88 bpm Frontal Axis :N Horizontal Axis : CWR PR interval : 0,12 QRS complex : 0,08 QT interval : 0,36 Conclusion : Sinus rhythm HR 88 bpm

Genu R AP/Lateral
Alignment: Good Bone: fracture (-) Joint: dislocation (-) Soft tissue: Looks swelling, radiolusent appearence Conclusion: Soft tissue swelling, gangrene gas

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Female / 46 yo A Genu D pain since 1 years ago limitation of activity History sinovial fluid aspiration PE: BW:76 BMI: 28.4 Swelling at genu D Warm pain (+) Genu AP/Lat : Soft tissue swelling

1. Chronic monoarthrit is genu dextra

1.1 Tuberculosis arthritis 1.2 Septic arthritis

synovial fluid culture analysis , AFB

IV Plug Inj. Ceftriaxon 2x1 PO: Parasetamol 3x500 mg

S, VS

Female / 46 yo A History of HT for 15 years PE BP 170/100

2. Hypertensio n st II

3.1 secondary 3.1.1 3.1.2 3.2

Funduscopy

PO: captopril 3x25 mg

S, VS

CUE AND CLUE Female / 46 yo A limitation of activity History sinovial fluid aspiration PE: BW:76 BMI: 28.4 Swelling at genu D Crepitation bilateral genu (+)

PL 3. OA genu bilateral

IDx

PDx

PTx

PMo

PROBLEM ANALYSIS

Tuberculosa arthritis

Septic Arthritis

OA

Hypertension

Risk Factors
Artificial joint implants Existing joint problems (osteoarthritis, gout, rheumatoid arthritis,or lupus) Bacterial infection somewhere in your body Cronic illness or disease (DM, RA, Sickle cell disease) Intravenous or injection drug use Medication that suppresed imune system Recent joint injury Recent joint arthroscopy or other surgery Skin fragility

Management analysis
Emergency: Urgency: Non Urgency: Septic arthritis Inj. Ceftriaxon 2x1 PO: Parasetamol 3x500 mg

 Condition this morning BP: 160/100 PR: 88 RR: 18 Tax: 36.8

Thank you