MORNING REPORT

(SLE + CAP + Anemia + Hyperkalemia + Hypoalbuminemia + Congenital Curly Toe)

December 17th 2020

Nurfathanah
PATIENT IDENTITY

 Name : Ms. SNH

 Age : 21 years old
 Address : Makassar
 Religion : Moslem
 Ethnic : Buginese
 Marital Status : Single
 Hospital : Wahidin Sudirohusodo
 Room : Emergency Room
 Admission : 27/3/2021
HISTORY TAKING

 Patient admitted with complaint pain all joints

especially fingers acompanied by a feeling stiffness
since 2 months ago, there is no swelling in the joint.
pain was not persistent, pain improved by taking
methylprednisolone .
 Fatigue 2 months ago and worsened since 1 month
ago, especially when activity. There is no history of
bleeding. History of transfution (-).
HISTORY TAKING
 No fever, no history of fever, no headache. Hair
loss since 1 month ago.
 Malar rash since 1 month ago, no stomatitis.
 Cough accompanied by white mucus since 1
month, no shortness of breath, no chest pain
 No nausea, no vomiting, decreased appetite, weight
loss. No history consumption of herbs
HISTORY TAKING

 Defecation was normal. Urination yellow color, slight

volume.
 No Family history with the same complaint.
PHYSICAL EXAMINATION

 General condition: Moderate illness

Nutrition: normoweight
 Height : 155 cm
 Weight : 45 kg
 BMI : 18,7 kg/m2 (normoweight)
 Vital Signs
 Awareness : Composmentis (GCS 15 E4M6V5)
 Blood pressure : 110/70 mmHg
 Heart rate : 86 x/ min, regular
 Respiratory rate : 18 x/min, thoracoabdominal
 Temperature : 36,7 °C (axilla)
 VAS : 1/10
PHYSICAL EXAMINATION

 Head : Normocephal, straight black hair, and easy to pull out

 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 : Bronchovesicular breathing sounds, rales (+) both lung, 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, Curly Toe abnormalities
PATIENT PROFILE
LABORATORY FINDING
Laboratory 27/3/2021
Leukosit 3.900 4000-11.000/µL
Hemoglobin 6,2 13.0 – 16.0 g/dL
MCV 77 80-100 fL
MCH 24 27-34 pg
Trombosit 105.000 150.000-450.000 / µL
Neutrofil 73 50-70%
Limfosit 18,5 20-40%
Ureum/creatinin 57/ 0,59
Alb 2,0
RBS 83

PT/INR/APTT 11/1,06/35,4
LABORATORY FINDING
Laboratory 27/3/2021
Na 131
K 5,2
GOT 18
GPT 4
Uric Acid 9,0
MSCT THORAX (28/3/2021)
RHEUMATOLOGICAL STATUS

Rheumatological status MEX Sledai : score 10

 Gait : Normal  Neuropsychiatric disorder (-) 8
 Arm : Normal  Vaskulitis (-) 4
 Leg : Normal  Renal disorder (-) 6
 Spine : Normal  Hemolisis (-) 3
 Trombositopenia (+) 3
 Miositis (-) 3
ACR 1997 : score 3/11  Artritis (+) 2
 Mucocutan disorder (+) 2
 Malar Rash
 Serositis (-) 2
 Hemolytic Disorder: lymphopenia,
leukopenia  Demam (-) 1
 Non Erosive Arthritis
 Fatigue (+) 1
 Leukopenia (+) 1
 Limfopenia (+) 1
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

1. Systemic Lupus Eritematous •
ACR score 3/11 MEX SLEDAI
score 10, Moderate activity
Based on:
- Fatigue, hair loss, and joints
stiffness in the morning (+)
- Anemis
- ACR 1997 score 3/11
- Mex SLEDAI score 11
Check CRP, Check ANA - Pulse Metilprednisolone 500
Profile mg in 100 ml NaCl 0,9% / 24
hours (3 days)
- Hydroxychloroquine 200
mg/12 hours/oral
- Cavit D3 1 tab/24 hours/oral

2. Community Acquired -Levofloxacine 750 mg/24

Pneumonia CURB-65 Skor 0 hours/intravenous
Based on: -Avetylcystein 200 mg/8
- Cough accompanied by white hours/oral
mucus
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

3. Hyperurisemia Asimptomatik Allopurinol 100 mg/24 jam/oral

Based On :
• Uric Acid 9,0 mg/dL

4. Anemia Microcytic • Coomb’s Test

Hypochromic ec Suspect Anemia • Peripheral Blood Smear
of Chronic Disease
Based on:
- Conjunctival pale
- Weakness
-Hb 6,2; MCV 77 ;MCH 24
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

5. Hypoalbuminemia • Protein Total - Human Albumin 25% 100

Based On : ml/drips intravenous
• Alb 3,0 g/dL

6. Hyperkalemia - Kalitake 1 scahet/8 hours/oral

Based on:
- Kalium 5,2 mmol/L
Problem List
Problem Plan Diagnostic/Monitoring Plan Therapy

5. Congenital Curly Toe

Based On :
• Extremity : Curly Toe
abnormalities
THANK YOU