Ward Duty Report

Wednesday, 15/02/2017

GP on duty : dr. Ananita

Anumillah A Zidna
Farella Kartika Huzna
 Patients recapitulation

1. Ms.S,24 year old, SLE + Clinical TB

New Case + Anemia
 Identitas Pasien
Name : Mrs.S.M
Age : 24 tahun
Address : Known
Religion : Islam
Mariagge status : Married
 Anamnesis
Chief Complaint :
Fever since 1 week BEH
 Anamnesis
Present illness :
Patient came with chief complaint fever since 1 week BEH.
Fever was fluctuative up and down, low grade fever happened
all day. Nausea (-) , vomit (-) , diarrhea (-). Productive cough
since 1 month BEH, cough with phlegm yellowed in color, a
whistling sound when breathing denied. Sometimes patient
felt hard to breath. Hard to breath complain was not interfere
by activity but the position. Patient felt better if lying to the
right side, patient still can sleep in supine position. Prolonged
diarrhea denied coughing up blood denied, night sweats (+) ,
unintentional weight loss (+) 5 kg in 2 weeks, patient felt
fatique and reduce appettite. Patient had lupus since 1 year
ago and consumed metilprednisolon routinely 1 x 16 mg.
 Anamnesis
Previous illness
Lupus since 1 year ago
Never had TB medications before.

Familial history illness

Hypertension (-)
SLE (-)
There is no family member with the same
symptom
 Anamnesis
Medication history
Metilprednisolon 1x16 mg

Social history
Smoking (-)
Alcohol (-)
Narcotics (-)
 Physical examinations
General condition : Good
Conciousnes : Compos mentis
Vital signs :
Hemodinamic
BP : 110/60 mmHg
HR : 96x / minute, regular,
T : 37.5 0C
RR : 18x / minute
Height : 150 cm
Weight : 42 kg
 Physical examinations
Head : Normocephal
Hair : black , even distribution , attach strongly
Eye : sunken eyes (-), anemic conjungtiva +/+ ,
icteric sckleric -/- , light reflects+/+ isocor.
Nose : Secret -/- , septum deviation
Ears : Normotia, sign of inflammation (-),
tragus press ache (-)
Mouth : Dry mucose , cyanosis - , hyperemic
tounge (-)
Neck : enlargement lymph gland (-)
 Physical examinations
Thorax (Pulmo)
Inspection : lesion (-), simetric movement when
statics, and dynamics, intercostae retracrion (-)
Palpation : simetric movement when statics,
Vocal fremitus left+right, weakened on the right
side
Percution : Sonor in all lung fields , faint sound at
basal right pulmo
Auscultation : Weakened vesiculer breath
sounds (+) at right pulmo, Rhonki (+), wheezing
(-)
 Physical examinations
Thorax (cor)
Inspection : Ictus cordis cannot be seen
Palpation : Ictus cordis palpable
Percussiion: heart upper line : ICS II Linea
Parasternal Sinistra
heart right line : ICS II-III Linea Parasternal
Dextra
heart waist line : ICS V Linea Midclavicularis Sin
Auscultation: HS I-II reguler, gallop (-),murmur (-)
 Physical examinations
Abdomen:
Inspection: Flat, No swelling or deformity Caput
medusa (-), Spider Navy (-), Scar (-)
Auskultation: Bowel sound (+) normal
Palpation : Tenderness(+) on epigastric
No sign of Hepato and splenomegali,
ballotement (-)
Percution : tympani on abdominal field,
Extremities : All warm, edema (-), pale (-), CRT <
2sec
Skin : icterus (-), turgor good
 Laboratory Findings
Pemeriksaan Hasil Nilai rujukan
HGB ( Hemoglobin) 7,4 13 18 g/dL
PCV ( Hematocrit) 26% 40 52 %
Eritrocyte 4,1 4,3 6,0 juta/uL
Leukocyte 10060 4800 10800 / uL
Platelet count 566.000 150000 400000 / uL
Clinical chemistry
Zinc 14
TIBC 145
Ferritin >1200
Pemeriksaan Hasil Nilai rujukan
Red blood cells indices
MCV 63 80 96 fL
MCH 18 27 32 pg
MCHC 28 32 36 g/dL
RDW 19,60%
Retikulocyte 2,5%
White Blood Cells
Basophils 119 < 35 U/L
Eosinophyls 42 <40 U/L
Bands 17* 20-50 mg/dl
Segmented 0,5 0,5-1,5 mg/dl
neutrophils
Limphocytes 501 <140 mg/dl
Monocytes Negative Negative
 Laboratory Findings
Roentgen Thorax
Impression : infiltrat
at the apex of pulmo
Tb Paru
Right Pleural efussion
There is no anomaly
with the cardiac
 Resume
24 years old girl came with chief complaint fever since 1 week BEH. Fever
was fluctuative up and down, low grade fever happened all day. Nausea
(-) , vomit (-) , diarrhea (-). Productive cough since 1 month BEH, cough
with phlegm yellowed in color, a whistling sound when breathing denied.
Sometimes patient felt hard to breath. Hard to breath complain was not
interfere by activity but the position. Patient felt better if lying to the right
side, patient still can sleep in supine position. Prolonged diarrhea denied
coughing up blood denied, night sweats (+) , unintentional weight loss (+)
5 kg in 2 weeks, patient felt fatique and reduce appettite. Patient had lupus
since 1 year ago and consumed metilprednisolon routinely 1 x 16 mg.
Physical examination conjungtiva anemic +/+, ronkhi +/+ , Weakened
vesiculer breath sounds (+) at right pulmo, Rhonki (+).
Laboratory findings: anemia mikrocytic hypocromic, thrombocytosis,
eosinophyls , segmenented neutrophyls , limphocytes , Zinc , TIBC
, Ferittin , rdw, retikculocytosis. From x-foto thorax found infiltrat at
the apex of pulmo and Right Pleural efussion
 Problem List
1. Anemia Mikrocytic Hypocromic
2. Clinical TB New case
3. Thrombocytosis
4. SLE
 Problem Analysis
1. Anemia Mikrositik Hipokrom
Assesment : Anemia chronic disease
Anamnesa : Fatique , SLE since 1 year ago
PE : Conjungtiva anemis +/+
LF : Hb 7,4 , Ht 26% , MCV 67, MCH 18, MCHC 28, Zync 14, TIBC 145, Ferritin >1200, retikulosit 12,5%
Diagnostic Plan : peripheral blood picture, bone marrow punction
Therapy : PRCS Tranfusion 800 cc, IVFD NaCl 0,9% before tranfusion

2. Clinical TB New case

Assesement : Clinical TB new case
Anamnesa : Fever was fluctuative up and down, low grade fever happened all day. Nausea (-) , vomit (-) ,
diarrhea (-). Productive cough since 1 month BEH, cough with phlegm yellowed in color, a whistling sound
when breathing denied. Sometimes patient felt hard to breath. Hard to breath complain was not interfere
by activity but the position. Patient felt better if lying to the right side, patient still can sleep in supine
position.
PF :Ronkhi (+) , weaked vesikuler sound at the right pulmo.
PP : Rontgen thorax : x-foto found infiltrat at the apex of pulmo, Right Pleural efussion
Diagnostic plan : sputum BTA, pungsi pleura, kultur sputum dan cairan pleura, konsultasi paru, cek rapid
anti-HIV, albumin
Therapy : start the OAT
Edukasi : wear a mask to avoid transmission to others.
 Pengkajian
3. Trombositosis
Assesment : Infection dd/ trombositosis essential
LF : trombosit 556.000
Diagnostic plan : peripheral blood picture, Bone marrow punction
Therapy : -

4. SLE
Anamnesis : Lupus since 1 year ago
PE :butterfly rush (-)
LF : ANA test (+) , Anti Ds-DNA (+)
Theraphy : metilprednisolon 1 x 16 mg.
 Prognosis
Quo ad Vitam : ad bonam
Quo ad Functionam : ad bonam
Quo ad Sanationam : ad bonam
 Woman 24 years
old

Fever 1 week BEH

Productive cough Patient felt better

1 month phlegmn Prolonged diarrhea if lying to right General weaky
yellowed side

Medication
History SLE metilpredinosolon
1x16mg

Physical Diagnostic
examination : Support : HB
Conjunctiva +/+ (Anemia) , chest
anemia , x-ray (Right pleura
abnormality lung effusion)

SLE , hypochromic
anemia, Clinical
Tb new case.
SLE

eradication
Management

Bacterial
infections
Oral
antitubercul
Preventive osis
 Analysis SLE

Autoimmune
disease which
autoantibodis are
made against of
vriaty
autoantigen

ANA Tes (+) , Anti

DS-DNA (+)

Autoimune

Immune complex
Systemic Direct effect
formating

Infection bacterial (Next slides)

TB
 Immune
complex
formating

Roentgen Cardiac
Hematology Kidney Brain
Thorax Function

Hemolytic Thrombocyto Lupus Pleural

ITP Normal Normal
Anemia sis Nefritic effusion