MORNING REPORT

May 25th 2016

Patients Identity
Name
: FD
Age
: 29 y.o.
Sex
: Male
Religion
: Islam
Address
: Bima
Admission
: May 25th 2016 at
16.30.

Anamnesis
Chief Complain:

Waist Pain
Present History:
Patient came to the hospital with complained of waist
pain since 1 week BATH. The pain is getting worse
since one day BATH. The pain felt like getting hit by blunt
thing. The intensity of pain increase if patient standing or
changing his sleep position. Patient also complaint
weakness on his lower extremities and trembling on his
hands yesterday when the pain getting worse.
Since the waist pain, patients appetite decrease. Beside
that, patient hardly to eat because of oral candidiasis.

Anamnesis
Patient also complained harder to breathe since
one week age. It will get better if the patient
sleep using two pillows.
There are red spots on his skin that appear from
one week ago. The red spots do not itching.
Cough, vomitting, and joint paint were denied by
the patient. Urinated was said normal with yellow
color, but the patient felt a little bit pain
everytime he urinated

Past Medical History :

Patient said that she got autoimmune disease since 4
months ago.
Theres redness on both of his cheek if he got expossed to
sun light.
His joint would alse in pain and swollen.
Went to cardiologist one mont ago. The doctor said the
patient had tachycardia.
History of DM and hypertension were denied by the patient.

Family History :
Theres no one of family member has a same disease or
complained like him.

Social History
Patient is unmarried
Before diagnose with autoimmune disease,
patient work in his family store in Bima.
Eversince he diagnosed with autoimmune
disease, he moved to Denpasar with his
sister so he could received treatment for his
disease.
History of smoking and alcohol were denied.

Physical Examination
General appearance : Moderate ill
Level of Consciousness
: Compos mentis
GCS
: E4V5M6
Blood presure : 110/70 mmHg
Pulse rate
: 120 x/mnt
Respiratory rate
: 36 x/mnt
Axillary temp. : 36 C
BW
: 50 kg
BH
: 150 cm
BMI
: 22,2 kg/m2

Physical Examination
Eye
: an -/-, ikt -/-, pupil reflex +/+ isokor
ENT
: pharinx hiperemis (-), tounge: oral candidiasis (+)
Neck : JVP 0 cm H20, gland enlargement (-)
Thorax anterior
Cor:
In : ictus cordis not visible
Pal : ictus cordis unpalpable
Per : UB: ICS II, RB: PSL D ICS IV, LB: MCL S ICS VI
Aus : S1S2 single regular murmur (-)
Pul :

In : simetris
Pal : VF N/N
Per : sonor/sonor
+/+ -/-/Aus : ves +/+
rh -/- wh -/+/+
-/-/-

Physical Examination

Abdomen
In : distention (-)
Aus
: Bowel sound (+) normal
Pal : pain (-), lien and hepar unpalpable
Per: tymphanic
Extremities:
Warm +/+, edema -/+/+
-/-

Complete Blood Count

Blood Chmistry Panel

Blood Gas Analysis

UL
Parameter

Result

Reference Range

Leukosit

Neg

Negatif

Nitrit

Neg

Negatif

Ph

5,50

5-9

Protein

Neg

Negatif

Glukosa

Pos (+)

Normal

Neg

Negatif

Urobilin

Normal

1mg/dL

Bilirubin

Neg

Negatif

Blood

Neg

Negatif

Keton

UL cont

Rontgen Thorax
Cor : left border more
than MCL sinistra
Pulmo : normal
Sinus : Sinus pleura
dextra

and

sinistra

sharp
Diaphragm : normal
Bone : normal
CTR : 62,5%
Conclusion
cardiomegali

Assesment
Systemic Lupus Erythematosus on
treatment
- renal disturbance
- oral candidiasis

Planning

Therapy
IVFD Na Cl 0.9% 20 dpm
Azathioprin 1x50mg
Methylprednisolon 8mg 0 8 mg
Fluconazole 1x150mg

Monitoring
Vital sign and complain

Monitoring
Vital sign and complain

Wt

Present

Descriptor

Seizure

Psychosis

Organic Brain Syndrome

Definition
Recent onset. Exclude
metabolic, infectious or drug
cause.
Altered ability to function in
normal activity due to
severe disturbance in the
perception of reality. Include
hallucinations, incoherence,
marked loose associations,
impoverished thought
content, marked illogical
thinking, bizarre,
disorganized, or catatonic
behavior. Excluded uremia
and drug causes.
Altered mental function with
impaired orientation,
memory or other intelligent
function, with rapid onset
fluctuating clinical features.
Include clouding of
consciousness with reduced
capacity to focus, and
inability to sustain attention
to environment, plus at least
two of the following:
perceptual disturbance,
incoherent speech, insomnia
or daytime drowsiness, or
increased or decreased
psychomotor activity.
Exclude metabolic,
infectious or drug causes.
Retinal changes of SLE.
Include cytoid bodies, retinal
hemorrhages, serious

Cranial Nerve Disorder

Lupus Headache

CVA

Vasculitis

Arthritis

Myositis

Urinary Casts

Hematuria

Proteinuria

New onset of sensory or

motor neuropathy involving
cranial nerves.
Severe persistent headache:
may be migrainous, but
must be nonresponsive to
narcotic analgesia.
New onset of
cerebrovascular accident(s).
Exclude arteriosclerosis.
Ulceration, gangrene, tender
finger nodules, periungual,
infarction, splinter
hemorrhages, or biopsy or
angiogram proof of
vasculitis.
More than 2 joints with pain
and signs of inflammation
(i.e. tenderness, swelling, or
effusion).
Proximal muscle
aching/weakness,
associated with elevated
creatine
phosphokinase/adolase or
electromyogram changes or
a biopsy showing myositis.
Heme-granular or red blood
cell casts.
>5 red blood cells/high
power field. Exclude stone,
infection or other cause.
>0.5 gm/24 hours. New
onset or recent increase of
more than 0.5 gm/24 hours.

New Rash

Alopecia

Mucosal Ulcers

Pleurisy

Pericarditis

Low Complement

Increased DNA binding

Fever

Thrombocytopenia

New onset or recurrence

of inflammatory type
rash.
New onset or recurrence
of abnormal, patchy or
diffuse loss of hair.
New onset or recurrence
of oral or nasal
ulcerations.
Pleuritic chest pain with
pleural rub or effusion,
or pleural thickening.
Pericardial pain with at
least 1 of the following:
rub, effusion, or
electrocardiogram
confirmation.
Decrease in CH50, C3, or
C4 below the lower limit
of normal for testing
laboratory.
>25% binding by Farr
assay or above normal
range for testing
laboratory.
>38C. Exclude
infectious cause.
<100,000
platelets/mm3.
<3,000 White blood

Mild or Moderate Flare

Change in SLEDAI > 3 points
New/worse discoid,
photoscnsitive, profundus,
cutaneous vasculitis, bullous lupus
Nasopharyngeal ulcers
Pleuritis
Pericarditis
Arthritis
Fever (SLE)

Severe Flare
Change in SLEDAI > 12
New/worse CNS-SLE
Vasculius
Nephritis
Myositis
Pk < 60.000
Home anemia: Hb <7% or decrease
in Hb > 3%
Requiring: double prednisone
Prednisone>0.5 mg/kg/day
hospitalization

Increase in Prednisone, but not to

Prednisone >0.5 mg/kg/day
>0.5 mg/kg/day
New Cytoxan, Azathioprine,
Added NSAID or Plaquenil
Methotrexate, Hospitalization (SLE)
1.0 Increase in PGA, but not to
Increase in PGA to > 2.5
more than 2.5