MORNING REPORT

Systemic Lupus Erytematosus

Trombositopenia
Hipoalbuminemia
Hepatitis C Infection
Hipertensi st. II (JNC 7)

December 17th 2020

Nurfathanah
PATIENT IDENTITY
• Name : Mrs. FU
• Age : 20 years old
• Address : Morowali
• Religion : Moslem
• Ethnic : Buginese
• Marital Status : Married
• Hospital : Wahidin Sudirohusodo
• Room : Emergency Room
• Admission : 9/3/2021
HISTORY TAKING

• Patient admitted with complaints distended and

gradually abdominal swelling since 3 days ago, There is
nausea and vomiting, abdominal pain (+).

• 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

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 Normochrom - Peripheral Blood Smear

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