Morning Report

October 11th 2019

 Patient Identity
• Name : Miss. SG
• Age : 16 years old
• Hospital : RSWS
• Room : Emergency Room Bed 5
• MR : 897226
• Admission : October 10th, 2019
 History Taking

• Chief complaint : Fatigue

• fatigue has been experienced since onet month ago.
Worsening since the last 2 weeks, so patients tend to lie
down.
• Reddish spots on the face since 3 months, but felt increased
since the last 1 month, also began to appear on the arms
since 2 weeks. History of treatment at the Elim hospital and
given prednisone before refered to Makassar
• Pain in all joints experienced since 1 months, worsening since
the last weeks.
• No Fever at this time, history of fever since 1 months ago,
Sometimes accompanied by chills. there’s no history of
nosebleeds and gum bleeding.
• No Cough No chest pain.
• There’s Nausea and no history of vomiting.
• No History of recurrent mouth ulcers
• No family history of the same complaint
 Physical Examination
General Description
General condition : Moderate illness
Nutritional status : Well nourished
Consciousness : Compos mentis (GCS 15 E4M6V5)

• Vital Signs
• Blood pressure : 100/60 mmHg
• Heart rate : 88 x/ min regular
• Respiratory rate : 20 x/min
• Temperature : 36,7°C (axilla)
• IMT : 22,22 kg/m2
 PHYSICAL EXAMINATION
• Head : Normocephal, hair is difficult to remove
• Face : Malar rash (+)
• Eyes : Isocor pupils, normal light reflex, pale conjungtiva (-), no
icteric sclerae
• Ear : No abnormalities, otorrhea (-)
• Nose : No abnormalities, epistaxis (-)
• Lips : sore(-)
• Oral cavity : Gingival hypertrophy (-), oral thrush (-),
• Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 normal

• Neck : JVP R -1 cmH2O, no lymphadenopathy

• Skin : Vasculitis (+),

 PHYSICAL EXAMINATION
• Thorax :
• I : Symmetrical left and right,
• P : No tumor mass , No tenderness
• P : Sonor in both lung fields
• A : The sound of breathing: Vesicular
Additional sound: Rhonki - / -, Wheezing -/-

• Heart :
• I : Ictus cordis not visible
• P : Ictus cordis are not palpable
• P : Right heart border in ICS IV linea parasternalis dextra;
Left heart border in ICS V linea medioclavicularis sinistra
• A : Heart sound I / II pure, regular. No Gallop

• Abdomen :
• I : Flat, follow the motion of breath,
• A : Peristaltic (+) normal
• P : Liver and spleen are not palpable
• P : Tympani (+)
 Rheumatological Status

G (Gait) : unable to walk

A (Arms) : normal, no sign of joint inflammation

L (Legs) : normal, no sign of joint inflammation

S (Spine) : Normal
PATIENT PROFILE
 LABORATORY FINDING
Laboratory 11/10/19
Leukosit 5800 / uL 4000-11.000/µL
Eritrosit 4,34 x 106 / uL 4.5-5.5 x 106 / µL
Hemoglobin 12,9 g/dL 13.0 – 16.0 g/dL
Hematokrit 38 % 40-50 %
Trombosit 191000 / µL 150.000-450.000 / µL
MCV 87 fL 80-100 fL
MCH 30 pg 27-34 pg
Neutrofil 80,8 % 50-70%
Limfosit 10,1 % 20-40%
Monosit 7,0 % 2-8%
Eosinofil 1,4 % 2-3 %
Ureum 16 0-53 mg/dL
Creatinin 0,62 0.6-1.3 mg / dL
GOT 37 < 38 U/L
GPT 50 < 41 U/L
Na 132 136 – 145
K 4,3 3,5 – 5,1
lab 3/10/19
LED ½ 41/62 L < 10, P < 20
ANA IF > 1/1000
 Urinalisa (3/10/19)
• Protein : Negative
• Blood : Negative
• Erythrocyte Sediment : 1
 SLE/ACR Score 1997
1. Malar Rash: +
2. Diskoid: -
3. Photosensitivity: +
4. Oral ulcers: -
5. Arthritis: +
6. Serositis: -
7. kidney disorders: -
8. Neurolgi disorders: -
9. Hematologic disorders: -
10. Immunological disorders: -
11. ANA: +

 ACR score of 4/11

 MEX- SLEDAI
• Vasculitis :4
• Mucocutan disorder : 2
• Arthritis :2
• Fatigue :1
• Lymphopenia :1

Score of 10 (Moderate activity)

Assessment Planning Diagnostic Planning Therapy
1. Sistemic Lupus Erytematosus
Moderate Activity
Based on
Problem List
• Suggestion
ANA PROFILE
• Pulse Methylprednisolone
500 mg in Normal saline
• SLE (ACR 97) Score 4/11 • C3, C4 0,9% 100 cc in 1 hour
• MEX SLEDAI 10
complement • Omeprazole 40
• Blood Routine mg/24h/intravena (empty)
• Ur/cr •Hydroxycloroquin 200
• GOT/GPT mg/12h/oral
• Urinalysis • Calgae tab/24h/oral
• electrolite
THANK YOU