MORNING REPORT

Thursday, April 13th 2017

PHYSICIAN IN CHARGE :

Jaga I A : dr. Adys, dr. Mirza, dr. Tio

Jaga I B : dr. Lucke (CVCU), dr. Indri (HCU),
IGD : dr. Reza (ER), dr. Rina (ER)
Chief Jaga : dr. Maya
Consultant : dr. Supriono, SpPD, K-GEH
FASILITATOR : Prof. Dr. dr. Djanggan Sargowo, SpPD, SpJP (K),
FIHA
 SUMMARY OF DATABASE
Mrs. W / 24 y.o/ W. 24B

AUTOANAMNESIS/ HETEROANAMNESIS
Chief Complain : Wound in pedis
Patient came with chief complained wound in her pedis dextra and sinistra since 1 months
before admission. Initially the colour of the wound is redness only in small lesion and became
larger. After that the wound became a blister contained of fluid.
She went to Surgeon in private hospital Kediri was diagnosed as selulitis pedis. She got
antibiotics and refered to intenist. Her internist said she diagnosed lupus because there was a
malar rash. So her internist reffered to RSSA to confirm diagnosis. But she didn’t get any
medication before.
Currently she is pregnant with her first gestation about 25 week. She routinely controlled
to gynecologist and got a vitamin (but patient forgot the name of the medicine) taken first daily.
She didn’t complained about nausea and vomiting in her second semester. History of recurrent
miscarriage is denied, and she was pregnant during the first 10 months of marriage. HPHT
October 20, 2017. There were no previous history of vaginal discharge, do not be a history of a
previous vaginal spotting or bleeding.
No history of joint pain, arthritis, or stiffness in the morning, intermitenly fever, cough and
shortness of breath before.
She said that she had malar rash since 1 months ago. Her face was getting redness after
exposure to ultraviolet.
Medical History
Patient never hospitalized before.

Family History
No history of autoimmune disease such as lupus, antiphospholipid syndrome or other
autoimmune disease in her family.

Lifestyle and Social History

• She worked as a labour in cigarrate factory about 4 years. Her husband also worked with the
same company with her.
• She lived with her mother and her husband. Married about 10 months, no history of
misscarriage or abortus before.

Allergy
• No history about food or drugs allergy.
 PHYSICAL EXAMINATION
General appearance looked moderately ill Looked normoweight
GCS 456
BP 100/70 mmHg PR = 90 bpm,regular, strong RR = 20 tpm Tax= 36.8 0C
Head ConjuctivaAnemic (-) Sclera Icteric (-), cyanosis (-) edema (-)
Neck JVP R + 0 cm H20, 300 position, lymphadenopathy (-)
Chest Heart Ictus invisible & palpable at ICS V MCLS
S1, S2 single, murmur - gallop -
RHM Sternal Line Dextra, LHM ~ ictus cordis
Lung Symmetric Stem fremitusD=S V v Rh - - Wh - -
v v - - - -
v v -- - -
Abdomen Rounded, Soefl, Bowel Sound (+) normal, TFU 2 cm above umbilical.

Extremities Warm acral(+)

Papulaeritematouswith multiple erosions and pustulain pedisdextra and sinistra.
UOP 60 cc/hours
Clinical Picture
 LABORATORY FINDINGS
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 7250 4.700 – 11.300 /µL Ureum 9.70 16.6-48.5
Haemoglobine 11.50 11,4 - 15,1 g/dl Creatinin 0.49 < 1.2
PCV 34.70 38 - 42% Anti Cardiolopin IgM > 80.00 Normal < 7 MPL U/mL
Elevated >= 7 MPL
U/mL
Thrombocyte 297.000 142.000 – 424.000 /µL Anti Cardiolipin IgG 24.80 Normal < 10 GPL
U/mL
Elevated >= 10 GPL
U/mL
MCV 83.60 80-93 fl ANA test 0.40 <1

MCH 27.70 27-31 pg Anti ds-DNA IgM 6.90 Negatif < 20 IU/mL
Positif >= 20 IU/mL
Eo/Bas/Neu/ 0.4/0.4/84.2/11.4 0-4/0-1/51-67/ Anti ds-DNA IgG 6.60 Negatif < 20 IU/mL
Limf/Mon /3.6 % 25-33/2-5 Positif >= 20 IU/mL
Coombs test +2
SGOT 18 0-40 U/L
SGPT 10 0-41 U/L
Albumin 2.81 3.5-5.5 g/dL
 Urynalisis
Lab Value Lab Value
Urinalysis 10 x
SG Epithelia 17,7 /hpf
PH 6.0 Cylinder Negative /hpf
Glucose Negative Hyaline -
Protein Negative Granular -
Keton Negative
Bilirubin Negative

Urobilinogen Negative 40 x
Nitrit Negative Erythrocyte 5,7/hpf
Leucocyte Trace Leukocyte 6,8/hpf
Blood Negative Crystal -
Bacteria 1605,7 x 103 / ml
ECG (11 April 2017)
 ECG
 Sinus Tachycardia, HR 90 bpm
 Frontal Azis : Normal
 Horizontal Axis : Counter Clock Wise Rotation
 PR interval : 0.16”
 QRS complex : 0.08”
 QT interval : 0.36”
T inversion in V1
Conclusion : Sinus Tachycardia, HR 90 bpm
 Problem Initial Planning Planning Planning
CUE AND CLUE
List Diagnose Diagnose Therapy monitoring

Mrs. W / 24 y.o/ W. 1. Anti 1.1 Primary • D Dimer - Bed rest GCS, BP, HR,
24B Phospolipid (Idiopathic) • USG - O2 2-4 lpm nasal canule RR
Syndrome Dopler - HCHP diet
SUBJECTIVE 1.2 Secondary Inferior Peroral Aspilet 1x80 mg Planning
• Wound in her pedis dextra 1.2.1 Extremity Peroral Methylprednisolon Education
and sinistra since 1
months before admission.
Autoimmune 3x8 mg Educate the
disease Peroral Klorokuin 1x250 mg patience
OBJECTIVE 1.2.2 Infection about the
Physical Examination importance of
GCS 456, BP 100/70 mmHg,
HR 90 bpm, RR 20 tpm
treatment
compliance to
Extremity : Papula reduce risk of
eritematouswith multiple complication
erosions and pustulain
pedisdextraand sinistra.

Laboratory :
• IgManti cardiolipin>
80 MPL U/mL
• IgGanti Cardiolipin
24.80 MPL U/mL
 Planning Planning Planning
CUE AND CLUE Problem List Initial Diagnose
Diagnose Therapy monitoring

Mrs. W / 24 y.o/ W. 2. Mild 2.1 - High Protein Diet Subjective,

24B Hipoalbumin Hipercataboli Vital Sign
emia c State
Subjective 2.2 Low protein
• First gestation intake
about 25 week.
• G1P000Ab000 gr
25-26 weeks

Laboratorium
Albumin 2.81 gr/dL
 Problem Planning Planning Planning
CUE AND CLUE Initial Diagnose
List Diagnose Therapy monitoring

Mrs. W / 24 y.o/ W. 3. - Peoral Folic Acid 3x1 Subjective,

24B G1P000Ab - Consult to Obstetri Vital Sign
000 gr 25- Gynecology to
SUBJECTIVE 26 weeks evaluation and join care
• Pregnant with her first
gestation about 25
week.
• History of recurrent
miscarriage is denied,
and she was pregnant
during the first 10
months of marriage.
• HPHT October 20, 2017.
• There were no previous
history of vaginal
discharge, do not be a
history of a previous
vaginal spotting or
bleeding

OBJECTIVE
Physical Examination
GCS 456, BP 100/70
mmHg, HR 90 bpm, RR 20
tpm

Abdomen: Rounded, Soefl,

Bowel Sound (+) normal, TFU 2
cm above umbilical.
 Problem Analysis
Risk Factor APS

APS

Antiphospholipid antibody ?

Vascular
Pregnancy
Trombosis

Trombosis in placenta vascular? Wound Loss ?

Hypercatabolic state?
Decrease of Anexin 5 (anticoagulant)?

Pregnancy
Hipoalbuminemia
Morbidity
 Risk Factor Analysis
Factual Theory In This Patient
APS Disorders : Lupus, Sjogren’s syndrome or Gender : Young and
other autoimmune disorders middle aged women
Infections : hepatitis C, syphilis, CMV, are more likely to
parvovirus B19 develop APS than
Medications : Hydralazine and some anti males
epileptic drugs
Genetics
Gender : Young and middle aged women are
more likely to develop APS than males

Elsevier, Journal of Autoimmunity 48-49 (2014)

www.elsevier.com/locate/jautimm
 Clinical
Criteria APS
 Management Analysis
Problem Theory Analysis

APS Aspilet 1x80 mg

Lupus Recommendation, 2011

 Key Message Pathophysiology

• Despite the strong association between aPL and

thrombosis, the pathogenic role of aPL in the development
of thrombosis has not been fully elucidated.
• Autoantibodies associated with APS are directed against a
number of plasma proteins and proteins expressed on, or
bound to, the surface of vascular endothelial cells or
platelets. The involvement of aPL in clinically important
normal procoagulant and anticoagulant re- actions and on
certain cells altering the expression and secretion of
various molecules may offer a basis for definitive
investigations of possible mechanisms by which aPL may
develop thrombotic events in patients with APS
Elsevier, Journal of Autoimmunity 48-49 (2014)

www.elsevier.com/locate/jautimm
Elsevier, Journal of Autoimmunity 48-49 (2014)

www.elsevier.com/locate/jautimm
 Key Message Social
• We should educate that APS affect
predominantly young patients, the causes and
therapy should be adequate to minimize the
complication.
• We should educate the patient to preserve
pregnancy with routinely controlled to
obstetrician.
 Condition This Morning
• BP 110/70 mmHg
• HR 88 bpm
• RR 20 tpm
• UOP 60 cc/hours
THANK YOU