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Name : Ny.

SR
Date of Birth : 31-12-1962 (55 y.o)
Adress : Majene, West Sulawesi
Medical Record : 851515
Date of Admission : 4 August 2018
 Chief Complaint: Swelling in both legs

 Swelling in both legs were felt 2 weeks before admitted to the


hospital, and worsening since last 5 days. Swelling initially develops
in the legs, then spreads to the calves and thighs. The right leg is
more swollen than the left leg. Both legs felt pain, and the patient has
difficulty moving his legs due to pain. Fever is present 2 days before
admitted to the hospital. No shortness of breath, no cough, no chest
pain. Nausea and vomiting are present.
 Trauma (-), Hypertension (-), DM (-). There were history of gout
arthritis since the last 2 years, and often taking herbal medicines
(Montalin), and there were history of bedrest for the last 1.5 months
with chronic ulcer disease & hepatitis
 BP: 100/70 mmHg, HR : 109x/m regular, RR : 20 tpm, T: 37,0°C, O2 saturation 100%
 Conjunctiva anemic, sclera not icteric
 JVP R+2 cmH2O
 Vesicular breath sound, no ronchi and wheezing
 S1/ S2 Regular, murmur (-)
 Normal Peristaltic, hepar and lien unpalpable
 Extremity:
Edema dorsalis pedis et pretibial inferior extremity sinistra et dextra,
Pitting edema (+), tenderness (+), CRT> 2 seconds. Posterior tibial artery
pulses (+). Warm. Dextra MTP-1 swelling (podagra), tenderness (+).
EXAMINATION RESULT REFERRENCE UNIT

WBC 20,6 4,00-10,00 103/ul

RBC 3,24 4,00-6,00 106/ul

PLT 282 150-400 103/ul

HGB 9,3 12,0-16,0 gr/dl

PT 12,3 10-14 Detik

APTT 35,4 22,0-30,0 Detik

INR 1,18 -

GDS 112 140 Mg/dl

Ureum 23 10-50 Mg/dl

Kreatinin 0,76 P (<1,1) Mg/dl

SGOT 15 < 38 U/L

SGPT 20 < 41 U/L

Albumin 2,5 3,5-5,0 Gr/dl

D-Dimer > 5,0 < 0,5 ug/ml

Asam Urat 8,9 P (2,4-5,7) Mg/dl


Sinus Rhytm, HR 101 bpm, normoaxis, P wave 0,12 s, QRS 0,08s,

Conclusion: Sinus rhythm, heart rate 101 times / minute, regular


(tachycardia)
 Deep Vein Thrombosis

 Gout Arthritis

 Anemia

 Hipoalbuminemia
1. Non-Pharmacology
- Bedrest
- Compression Stocking
- Low-Purin Diet

2. Pharmacology
- Heparin 5000 IU bolus intravena
- Heparin 1000 IU/hour/syringe pump
- Lansoprazole 30mg/12h/intravena
- Domperidone 10 mg/8h/oral
- Furosemide 40 mg/12h/intravena
- Human albumin 25% 100 ml/24h
- Ceftriaxone 2 gram/24h/intravena
USG Doppler (Venous Ultrasonography)
Echocardiography
Peripheral blood smear