16/12/2015 17/12/2015

S :
O:

Pale (+) Fever (-)

Sens : Alert
T : 36,8 C
BW : 40kg
BH : 160cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior-/-, Ear/Nose/Mouth:
normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 100x/I, reguler, murmur (-)
RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic,
Hepar: NOT palpeble
Lien: NOT palpeble
Extremities : pulse 100x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (-)

Lab Test
Coomb Test: +
Reticulosit: 9,84%
Ferritin: 1212.0 ng/ml
Iron overloaded A :
Pericardial Effusion
P :
IVFD NaCl
Anemia dd chronic disease
0,9% 40gtt/I (micro)
Diet:Normal food 1800kcal
R/
Scheduled for PRC transfusion

18/12/2015 20/12/2015
S:
O:

Pale(+), fever (-)

Sens : Alert
T : 37,5 C
BW : 40kg
BH : 160cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior-/-, Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 100x/I, reguler, murmur (-) RR :
24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien: palpeble SIII
Extremities : pulse 100x/i, reguler, adequate pressure and volume, warm, CRT <3,
pretibial edema (-)
Mantoux test (-)

P:
IVFD NaCl 0,9%
40gtt/I (micro)

A:

Pericardial effusion
AIHA
Iron Overloaded

2x40mg
Spironolactone 2x25mg
Defeoxamide 2gr in 250cc of Nacl 0.9%
Diet:Normal food 1800kcal
R/
Scheduled for ASTO, ANA, Anti Ds DNA test
Complete blood test

Furosemide

21/-12/2015 23/12/2015
S:
O:

A:

P:

Pale (+)
Sens : Alert
T : 37.2 C
BW : 40kg
BH :160cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 118x/I, reguler, murmur (-)
RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpable 2cm BAC
Lien: Not palpable
Extremities : pulse 118x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (-)
Laboratorium result :
ASTO: <200
ANA test: 77
Anti ds-DNA: 226.0
Hb/Ht/Leu: 9,1/26,7/2700
LED: 47mm/jam
Pericardial effusion
AIHA
Iron Overloaded
IVFD NaCl 0,9% 40gtt/I (micro)
Furosemide 2x40mg
Spironolactone 2x25mg
Diet:Normal food 1800kcal
Blood transfusion PRC 200cc

24/12/2015 26/12/2015
S:
Pale (+) Fever(-)
O:
Sens : Alert
T : 37,2 C
BW : 40kg
BH : 160cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+, Ear/Nose/Mouth:
normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR :104x/I, reguler, murmur (-) RR :
26x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC
Lien: Not palpeble
Extremities : pulse 104x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (-)
A:
Pericardial effusion
Suspect SLE
AIHA
P:
IVFD NaCl 0,9%
Iron Overloaded
40gtt/I (micro)
Furosemide
2x40mg
Spironolactone 2x25mg
Diet:Normal food 1800kcal
R/
DL,Blood glucose,Electrolyte,AGDA,RFT

27/12/2015 29/12/2015
S:

O:

Pale(+)
Nausea(+)
Yellowish Skin(+)
Malar rash(+)
Sens : Alert
T : 37,1 C
A:
SLE
BW : 40kg
Pericardial effusion
BH : 160cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+, Ear/Nose/Mouth:
normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (+), HR : 120x/I, reguler, murmur (-) RR :
28x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC
Lien: Not palpable
Extremities : pulse 120x/i, reguler, adequate pressure and volume, warm, CRT <3,
pretibial edema (-)
Lab Resuts
Hb:1,6
Trombosit: 594
HT: 4,7
Bilirubin total: 3,1
Bilirubin Direct: 1,8
Ureum: 205
Creatinine: 1,6
Blood Glucose : 221 mg/dL
AIHA

P:

O2 Nasal Canule
IVFD NaCl 0,9% 40gtt/I (micro)
Furosemide 2x40mg
Spironolactone 2x25mg
Diet:Normal food 1800kcal
Metilprednisolone 1gr/day
Ranitidine 40mg/12hours/IV
R/
Consul to Nephrology
PRC transfusion
Urinalysis

30/12/2015 31/12/2015
S:

O:

A:
P:

Pale(+)
Nausea(+)
Yellowish Skin(+)
Malar rash(+)
Sens : Alert
T : 37,1 C
BW : 40kg
BH : 64cm
Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (+), HR : 120x/I, reguler, murmur
(-) RR : 28x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien: Not
palpable
Extremities : pulse 120x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (-)
Lab results
Urinalysis
Leu/Nit/Uro/Pro/pH/Bio
+ /- /0,2 / 15/ 6 /Sg/Ket/Bil/Glu
1,01,/-/-/Hb: 2,4
RBC: 0.74
Ht: 7
WBC: 14,05
Na/Cl/Ca/K
139/104/8,1/4,1
SLE
Pericardial effusion
AIHA
O2 Nasal Canule
IVFD NaCl 0,9% 40gtt/I (micro)
Furosemide 2x40mg
Spironolactone 2x25mg
Diet:Normal food 1800kcal
Metilprednisolone 1gr/day
Ranitidine 40mg/12hours/IV
Ondasentrone 1amp/8hours
PRC transfusion 200cc
R/
Scheduled for blood transfusion (PRC)