Duty ReportAugust 28th , 2015

Leni oktavia, 36 y.o , HCU

Cc:◦ Black stool since 3 days ago

Present Illness History◦ Black stool since 3 days ago, watery, coloured like ter◦ Swollen at whole body since 8 months ago, but now

already decreased◦ Joint pain since 1 year ago, particularly in the morning◦ Red patch like butterfly at the face since 8 months ago◦ Hair falls (+)◦ Fever come and go since 3 months ago◦ Patient went to doctor since 1 month ago, diagnosed

with SLE, got ranitidine and vitamins

Physical ExaminationConsciousness level: CMC

BP : 150/90

HR : 98x/min

RR : 25x/minute

T: 36,7C

Face : malar rash (+)Eye

◦Conjunctiva are anemic +/+◦Sclera are icteric -/-

Mouth : ulcer (+) poor oral hygieneNeck

◦JVP 5-2 cmH20

Lung: ◦Inspection: symetric◦Palpation: fremitus symmetric◦Percussion: sonor ◦Auscultation: vesicular, rales

-/-,wheezing -/-

Cor: Inspection: ictus is seen. Palpation: ictus is palpated at 1 finger medial LMCS ICS V

Percussion:Left border: 1 finger medial LMCS ICS VRight border: linea sternalis dextraUpper border: RIC II Auscultation: pure rhythm, murmur (-)

Abdomen:◦ Inspection: enlargement (-)◦ Palpation: liver and spleen unpalpable◦ Percussion: tympani◦ Auscultation: bowel sound (+) normal

Flank : knocking pain at CVA -/-Extremities:

◦ Physiologic Reflex +/+◦ Pathologic Reflex -/-◦ Edema +/+

Laboratory

Hb 6

WBCHtThrombocyteUr/crRBGpHpCO2pO2HCO3-BE ecfSO2

760017157.000379/17,11067,12101673,3-26,099%

Working DiagnoseMelena c.b uremic bleedingCKD stage V c.b nephritis lupus with

metabolic acidosisModerate anemia normositic

normochrome c.b acute bleedinghypocalcemia

TherapyRest/ fasting 8 hour then liquid diet 6x100 cc

low salt low protein 40 gramBolus prosogan 2 amp, followed by drip

prosogan 2 ½ amp in 500 cc NaCl 0,9% 10 hours/kolf

Drip meylon 200 mEq in 200 cc NaCl 0,9% fast drip

Sucralfat syr 3 x cth II Inj lasix 1x1 amp Inj ca gluconas 1x1 amp