Morning Report

9th October 2014

Supervisor :
Dr. Rulli, SpPD
 Mrs. L 29 yo/ w28
1. Septic Condition
1. Pneumonia
2. Lung TB with secondary infection
2. SLE with MEX SLEDAI 14
3. Nefritis Lupus
4. Pressure Ulcer at left scapulae
5. Oral Candidiasis
Mrs. L/29yo/w28
Chief Complaint : Cough
Patient complains about persistent cough that worsen
since 3 days before admission. Its productive cough with whitish
sputum. Cough is accompanied with fever since 3 days ago. She
cant sleep at night because she keeps getting woken up from
coughing. Because of the cough, this is the third time she got
hospitalized, first time was in June and second in August 2014.
Patient complains weakness all over her body, but theres
no symptoms of headache, nausea, nor vomiting. She also
complains about weakness of her legs and she cant walk for 2
months now. Patient also complains about pain when passing
urine, and the volume of urine is minimal.
 According to her family, shes getting skinnier. She suffered from
decrease of bodyweight more than 30 kg and hair loss since 1 year ago., her
appetite is decreasing since 3 days ago, and she got cold sweats at night.
Therere 3 wounds, first at her left lower back since 7 months ago,
second is at her left shoulder and third is at her elbows since 1,5 year ago.
Therere rashes at her face and upper arms. 5 months ago she was diagnosed
with Lupus and ha been given medication, such as methylprednisolon,
chloroquin, calc and paracetamol.

Patient is diagnosed with SLE since 5 months ago at RSSA, 1 year ago patient
suffered from redness at her face and pain at both of her legs, gradually onset
, then the rash is spreaded allover her face and her body, and both hands.
Accompanied with low grade fever, intermittenly. Patient then admitted
herself to hospital but after 7 months medicated and get physiotherapy there
is no changes, then patient hospitalized in rssa and diagnosed with SLE after
performed laboratory examination
She denies the history of diabetes and hypertension.
Theres no family history of the same illness. She is a
housewife, married, has 1 child age 5 years old. She uses
injected contraception every 3 months. Patient never
consumes alcohol nor smokes.

Family Medical History : There is no one in her family that

got same disease like her.

Social History : Patient is a housewives, married and have

1 children 5 years old, patient never smoking or using
alcohol
 Physical examination
BP = 120/80 mmHg PR = 90 bpm, regular RR = 24 tpm regular Tax : 37.3C
strong
General appearance : looked moderately ill, GCS456 , BMI : Looked underweight

Head Pale conjunctiva - Malar Rash (+)

Icterus Sclera - oral candidiasis

Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS V MCL Sinistra

LHM ictus, heart waist ( +)
RHM: SL D
S1, S2 single, murmur -, gallop
Regio scapula S: ulcer, diameter 5cm, pus +
Lung: Symetric, SF D= S s s Rh - - Wh - - VV
s s ++ -- bV bV
s s ++ -- bV bV

Abdomen Soufel, Bowel Sound (+)

Hepar : liver span 8 cm, not palpable
Lien : traube space tympani

Extremities Oedema pitting -/-, CRT <2

multiple skin sclerosis on leg D/S, diameter 2-4cm, skinny, irreguler margin
Vasculitis (+) palmar manus D/S, digiti pedis D/S , Muscle Atrophy on
gastrocnemius D/S
Leukocyte 4440 Laboratory finding
3.500-10.000/L Natrium 124 136-145 mmol / L

Haemoglobine 11.90 11,0-16,5 g/dl Kalium 3.57 3,5-5,0 mmol / L

MCV 86.00 80-97

MCH 28.30 26,5-33,5 Chlorida 100 98-106 mmol / L

PCV 36.20 35-50% Ca 8,8 7,6 11,0mg/dL

Phospor 3,3 2,7 - 4,5 mg/dL
Trombocyte 151.000 146.000- SGOT 19 11-41U/L
390.000/L

Eo/Ba/Neu/Ly/Mo 0.5/0.2/92.0/ SGPT 25 10-41U/L

5.9/1.4
Ureum 31.60 10-50 mg/dL Albumin 3,20 3,5 5,5 g/dL

Creatinine 0.39 0,7-1,5 mg/dL Total Lymphocyte 261.96

Count
RBS 83 < 200 mg/dL LED 54 Mm/hour

Osm 259
URINALYSIS
Lab Value Lab Value
Urinalysis (Yellow, Cloudy) 10 x
SG >=1.030 Epithelia 1,1

PH 6.0 Cylinder -

Leucocyte +1 Hyaline -

Nitrite - Granular -

Protein +2 Leukocyte
Glucose - Erythrocyte
Erythrocyte +3 40 x
Erythrocyte 297.8
Eumorfik +
Dismorfik -
Keton urine +2 Leukocyte 29,1
Urobilinogen - Crystal -
Bilirubin - Bacteria 137,1 x 103
Chest X-Ray (8 October 2014)
 Chest X-Ray (8 October 2014)
AP position, asymmetry, enough KV, enough inspiration
Trachea in the middle
Mediastinum normal
Soft tissue and bone normal
Hemidiaphragma R and left are dome shaped
Costophrenical angle R and L are sharp
Lung : Multiple Cavity at Right Lung, Bronchovascular
Pattern increased at Right lung, Infiltrat at Perihiller Right
and Left Lung
CTR: 50%, heart waist +, apex of heart was normal
Conclusion: Pneumonia, Suspect Tuberculosis
 CUE AND CLUE PL IDx PDx PTx PMo

Female/ 27 yo 1. 1.1. Pneumonia Sputum Bed Rest VS

Productive Cough with
Greenish Sputum Septic 1.1.1 Culture O2 2-4 lpm nc Subj.
High Grade Fever, gradually Condi Bacterial and Free diet
onset tion 1.1.2 Antibiotic
Chronic Cough
Night Sweating Fungal Sensitivity Infus Levofloxacin 1x750mg
Decrease of Body Weight 1.2. Lung TB With Test Intravenous
Secondary Infus Fluconazole 1x200mg
Physical Examination Infection
RR : 38 x/minute Waiting Peroral :
PR : 100 x/minute for the Nacetylcysteine 3x200mg
Tax 38
Oral candidiasis result of Paracetamol 3x500mg if t >
Rhonki at midldle and sputum 37,2 degree Celcius
basal of lung culture LJ
Laboratory Examination media (4
Total Lymphocyte Count december
261.960 2014)
CXR : Pneumonia + S. Tbc
 CUE AND CLUE PL IDx PDx PTx PMo

Female/ 27 yo 2. SLE Confirmed Confirmed Peroral : VS

Malar Rash
History of Arthritis with Methylprednisolone 12-12-8mg Subj.
Low Grade Fever MEX (tappering off 4mg/week) MEX
Decrease of Body Weight SLEDAI Chloroquin 1x250mg SLEDA
Alopecia
Medicated with 14 Azathioprine 2x50mg I
Methylprednisolone 3x16mg, (Nefritis,
Klorokuin 1x250mg, Kalk Mucocut
1x500mg, Paracetamol
2x500mg, Omeprazole aneus,
2x20mg, Nacetylcysteine fever,
3x200mg Lympho
Physical Examination penia,
Tax 38 vasculitis
Oral ulcer )
Malar Rash (+)
Vasculitis (+)

Laboratory Examination
Limfocyte 261,96
Urinalysis :
Protein +2
Eritrosit +3 (297,8)
 CUE AND CLUE PL IDx PDx PTx PMo

Female/ 27 yo 3. Protein Confirmed Diagnosis VS

Diagnosed with SLE since 5
months ago Nefritis esbach Subj.
Lupus
Physical Examination Biopsi Renal
Malar Rash (+)
Vasculitis (+)

Laboratory Examination
Albumin 3.20
Urinalysis :
Protein +2
Eritrosit +3 (297,8)
 CUE AND CLUE PL IDx PDx PTx PMo

Female/ 27 yo 4. Pus Culture Proper Positioning / 2 hour VS

General Weakness
SBedridden for 5 months Pressure and Wound Toilet Subj.
Wound at left Scapula Ulcer at Antibiotic
Left Sensitivity
Physical Examination
Wound at Left Scapula Area Scapula Test

Female/ 27 yo 5. Oral KOH Test Nystatin Drop 3 x 100.000 IU VS

Physical Examination Candidia Subj.
White Plaque on tongue and sis
bucal

Laboratory Examination
Total Lymphocyte Count
261.96
 Condition this morning
GCS 456
TD 110/80
PR 94
RR 36
Tax 38.10 C
 Total Score MEX Sledai
Nefritis : +6
Vaskulitis : +4
Limphophenia : +1
Mucocutaneus : +2
Fever : +1