Duty report

December 10th , 2018

risa anggraini, female, 27 yo, FW-17

Chiefcomplain
 nausea and vomite since 1 months
ago
Present illness history
• Nausea and vomite since 1 months ago, frek
2-3x/day, volume 1/3 glass,
• Pain at joints since 4 months ago,
• Decrease of bodyweight since 1 month ago, ± 10 kg
• Decrease of appetite since 1 month ago
• Fatique since 1 month ago
• Pale since 3 weeks ago
• Epigastric pain since 2 week ago
• Breathlessness(-)
• Patient has been known SLE since 5 months ago and
got metilprednisolon, hydrobet,osteocal,amlodipin,
and candesartan
Physical Examination
Consciousness level: CMC

BP : 130/90 mmHg

HR : 84x/minute

RR : 20x/minute

T: 37,2 C
 Eye
Conjunctiva anemic +
Sclera icteric -
face: malar rash(+), discoid rash(-)
Neck
JVP 5-2 cmH20
Lung:
Inspection: simetris dextra = sinistra,
Palpation: fremitus dextra = sinistra
Percussion : sonor
Auscultation: bronchovesicular, 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 -/-
Laboratory
Hb 6.2 gr/dl
Ht 18%
WBC 4070/mm3
Platelet 244.000/mm3
Ca/Na/K/Cl 8,0/125/4.0/98
Ureum/creatinin 260/8,1
RBG 88
PT/aPTT 11,9/40,7
TP/Alb/Glb 6,6/3,1/3,5
Working Diagnose
• Systemic Lupus Erythematous on
therapy
• Moderate Anemia normocytic
normochrom ec chronic disease
• AKI stage III cb pre renal cb dehidration
• hyponatremia cb GI loss
Therapy
rest/ soft diet high calori high protein
IVFD NaCl 0,9% 8 h/kolf
Lansoprazol 1x30 mg
Metilprednisolon 8-4-4 mg po
Osteocal 1x1000 mg
Hydrobet 1x200mg
Domperidone 3x10mg
Folic acid 1x5mg
Bicnat 3x500mg