Duty report

March 5th , 2019

Rika Febrianti, female, 31yo, FW-19

Chiefcomplain
 Eritemal rash increase since 3 days
ago
Present illness history
• Eritemal rash increase since 3 days ago, 7 days ago eritemal
rash appear at patient face, then become more eritem and
thicker, spread to extremity, back and chest, eritemal was pain
but not itchy.
• Fall off hair since 2 years ago
• Fever since 1 week ago, up and down, not followed by
sweating and chilling.
• joint pain (-)
• oral ulcers (-)
• cough (-) dispnea (-)
• red eyes (-)
• odinofagia (-)
• defecation in normal limit
• mixturation in normal limit
symptomp appear after patient get
ketoprofen and mefenamic acid +/- 1
weeks ago
history of allergic before (-)
history of yellow fever (-)
Physical Examination
Consciousness level: CMC

BP : 120/70 mmHg

HR : 91x/minute

RR : 20x/minute

T: 38 C
Skin: erythema(+), butterfly rash(+) on face, discoid rash(-)
Eye
Conjunctiva anemic -
Sclera icteric -
Neck
JVP 5-2 cmH20
Lung:
Inspection: simetris dextra = sinistra,
Palpation: fremitus dextra = sinistra
Percussion : sonor
Auscultation: vesicular, rh-/-, wh-/-

Cor:
Inspection: ictus is not seen.
Palpation: ictus is palpated at 1 finger medial LMCS ICS V
Percussion:
Left border: 1 finger medial LMCS ICS V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: pure rhythm, murmur (-)
Abdomen:
Inspection: enlargement (-)
Palpation: hepar and spleen are not palpable,
Percussion: tympani
Auscultation: bowel sound (+) normal

Extremities:
Physiologic Reflex +/+
Pathologic Reflex -/-
Oedema -/-
Rontgen Thorax
Laboratory
Hb 11,7 gr/dl
Ht 33 %
WBC 960/mm3
Platelet 111.000/mm3
Na/K/cl 130/3,8/99 Mmol/L
RBG 95 mg/dl
ureum 13 mg/dl
creatinin 0,6 mg/dl
albumin 3,6 g/dl
globulin 2,9 g/dl
SGOT 419 u/l
SGPT 143 u/l
Working Diagnose
• Drug Erruption cb Ketoprofen,
Mefenamic acid
• Susp SLE
• Bisitopenia cb secondary aplasia
• Susp Autoimune hepatitis
Therapy
Rest/ regular diet high calori high protein
IVFD NaCl 0,9% 8 h/kolf
Paracetamol 3x500 mg po
Prednison 3x10 mg po
Mometason furoat 2x1 ue
Planning
ANA profile
Anti DS-DNA
Hepatitis marker