MORNING REPORT

Summary of Data Base

MrsDF/22 yo/w.28
Chief complaint: Abdominal pain
Autoanamnesa with patient
Patient suffered from abdominal pain since 2 weeks before admission. The pain
sometimes emerges and disappeared and was not affected by position change. The pain was
felt like stabbed by needle. Patient also had nausea and vomiting since2 weeks before
admission. Patient was difficult to swallow. The output of the vomiting was yellowish reddish
fluid. Patient also suffered from diarrhea since 2 weeks before admission. The consistency was
fluid with brown greenish color. She had diarrhea 5x/day.
Patient had oral ulcer since 2 weeks before admission. Patient felt pain in the upper
mouth. When patient spitted, it was followed by blood dots. Patient was difficult to swallow
and she felt that there was mucus in her throat.
Patient also suffered from dizziness since 3 days before admission. Patient was like there
was blurred vision when the dizziness came. Patient had fever since 2 weeks before
admisison. The fever was fluctuating. Patient had decreased bodyweight in the last 6 months.
Patient loss 5 kg of BW in 2 months.
Patient had history of rash in her face since 7 years ago. The rash emerged when patient
was exposed by the sun light. Patient also had joint pain in her both hand and knee since 2
months ago. Patient also had menstruation cycle problem , amenorhea. Patient had married
and has 1 child. Hair was easily fell. Patient was diagnosed lupus since 6 months ago. Anti-
DsDNA test was positif
MEDICATION HISTORY : Patient was medication, those
were metil prednilon, sangobion, omeprazole. Patient also
consumed jamu to treat her diarrhea

PAST MEDICAL HISTORY : Patient was diagnosed SLE since

6 months ago. Hypertension -, Diabetes Mellitus -
SOCIAL HISTORY: She is a house wife and works as taylor in
her house, She married once and has 1 child. first
menstruation on age 13, non-regular 28-day cycle, not
using a injected contraception per 3 months until present.
FAMILY HISTORY : No family members with same
complaints such as patient. Mother of patient had HT
history
REVIEW OF SYSTEM : Her passing stool was in high
frequency and passing urine was within normal limit
 Physical examination
BP = 90/60 mmHg PR = 80 bpm, regular RR = 20 tpm, Tax : 36,6C
strong

General appearance looked moderately ill GCS 456

Head Pale conjunctiva (+) Icteric sclera (-) Malar rash (+) Oral ulcer (+)

Neck JVP R + 0 cmH2O 30 degree

Chest Heart: Ictus invisible, palpable at ICS V MCL S

LHM ictus
RHM: SL D
S1, S2 single, murmur (-) gallop (-)
Lung: Symmetric, SF D=S
Percussion Sonor Sonor
Sonor Sonor
Sonor Sonor
Auscultation vesicular vesicular Ronkhi - - Wheezing - -
Vesicular vesicular -- --
vesicular vesicular -- --
Abdomen Soefl, liver span 8 cm, traubes space tympany, bowel sound (+) normal,
Shifting dullness (-) undulation (-)

Extremities Warm acral, tenderness + at PIP I, II, III, IV, V dextra and sinistra
CRT < 2
 LABORATORY FINDING
Lab Value Lab Value
Leucocyte 27200 3500-10.000/L Na 130 136-145mmol/l

Haemoglobin 7.70 11-16,5g/dl K 3.87 3,5-5,0 mmol/l

MCV 78.20 80-97 fl Cl 109 98-106 mmol/l
MCH 27.10 26,5-33,5 pg SGOT 172 11-41U/L
SGPT 33 10-41U/L
Thrombocyte 79.000 150.000-390000/L Albumin 2.42 3.5-4.5 mg/dl

Ureum 39.0 16,6-48,5mg/dL RBS 90 <200

Creatinin 1.13 <1,2 mg/dL

diffcount 0.0/0.0/50.0/4 0-4/0-1/51-67/25-
1.9/8.1 33/2-5
ECG (2/01/17)
CXR
 CUE AND CLUE Problem List Initial Diagnosis Planning Planning PMo
Diagnosis Therapy
Female/22 yo/ward 28 1. SLE MAX Sputum Bed rest Subjective
Ax : SLE DAI 6 culture and O2 room Vital Sign
Oral ulcer sensitivity IVFD NaCl 0.9% Urine
Atritis test 1000cc ~ 20 production/24hour
Persisten fever tpm Urine production
Dizziness ANA test Diet HCHP
Visual disturbance 2100kkal/day PEdu:
Photosensitivity Paracetamol Disease
Diagnosed SLE 6 months ago. 3x500mg Underlying disease
With metil prednisolon Metil Treatment
medication prenisolon Prognosis
History of DsDNA test + 2x16mg
PE : Ca Lactate
Oral ulcer 1x500mg
Malar rash
tenderness + at PIP I, II, III, IV, V
dextra and sinistra

Lab :
WBC=27.200
HB=7.7
dsDNA test= +
 CUE AND CLUE Problem List Initial Planning Planning Therapy PMo
Diagnosis Diagnosis
Female/29 yo/ward 28 2. Dyspepsia 1.1 PUD Endoscopy Diet HCHP 2100 Subjective
Ax : syndrome 1.2 kkal/day Vital Sign
Abdominal pain Gastrtis Injection
Nausea erosiva omeprazole
Vomiting 1x30mg
PE : Injection
Abdominal tenderness in upper metoclopramide
abdominal regio 3x10mg

An: 3. Acute 3.1 ETEC Stool Rehidration Subj

Diarrhea since 2 weeks. The consistency Watery 3.2 EIEC Examination 1000cc/day Vital sign
was fluid with brown greenish color. DIarrhea Urine
Frequency was 5x/day. output

PE: 4. Anemia 4.1 SI Bed rest Subj

Anemic conjungtiva : + normokrom Chronic TIBC Waiting from PDx Vital sign
normositer infection Blood CBC per 3
Lab finding : 4.2 smear day
Hb : 7.7 Deficiency
MCV : 78.2 Fe
MCH: 27.10
 CUE AND CLUE Problem List Initial Planning Planning Therapy PMo
Diagnosis Diagnosis
Female/29 yo/ward 28 5. 1.1 Bed rest Subjective
Lab : Hipoalbumine Hypercata Diet HCHP Vital Sign
Alb : 2.42 mia bolic state 2100kkal/day
1.2 Low
intake
Thank You