Date

P
Therapy

16/12/
2015
17/12/2015

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 (-)

Pericardial
Effusion
Anemia dd
chronic
disease
-Iron
overloaded

Diagnostic

- IVFD NaCl
0,9% 40gtt/I
(micro)
- Diet:Normal
food
1800kcal

- Scheduled for
PRC
transfusion

Lab Test
Coomb Test: +
Reticulosit: 9,84%
Ferritin: 1212.0 ng/ml

Date
18/12/

S
Pale(+),

O
Sens : Alert

A
- Pericardial

P
Therapy
- IVFD NaCl 0,9%

Diagnostic
Scheduled

201520/12/2015

fever (-)

T : 37,5 C
effusion
AIHA
BW : 40kg
- Iron
BH : 160cm
Overloaded
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
(-)

40gtt/I (micro)
- Furosemide
2x40mg
- Spironolactone
2x25mg
- Defeoxamide 2gr
in 250cc of Nacl
0.9%
- Diet:Normal food
1800kcal

for ASTO,
ANA, Anti
Ds DNA
test
Complete
blood test

Mantoux test: (-)

Date

P
Therapy

Diagnostic

21/12/1523/12/2015

Pale(+)

Sens : Alert
- Pericardial
T : 37.2 C
effusion
- AIHA
BW : 40kg
Iron
Overloaded
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 (-)

IVFD NaCl 0,9%

40gtt/I (micro)
Furosemide
2x40mg
Spironolactone
2x25mg
Diet:Normal food
1800kcal
Blood transfusion
PRC 200cc

Laboratorium result :
ASTO: <200
ANA test: 77
Anti ds-DNA: 226.0
Hb/Ht/Leu:
9,1/26,7/2700
LED: 47mm/jam

Date
24/12/
2015
26/12/20

S
Pale (+)
fever (-)

O
Sens : Alert
T : 37,2 C
BW : 40kg

A
- Pericardial
effusion
- AIHA

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

Diagnostic
DL,Blood
glucose,Electroly
te,AGDA,RFT

15

BH : 160cm
- Iron Overloaded - Furosemide
Head: eye reflect +/+, - Suspect SLE
2x40mg
- Spironolactone
isocor, pale conj. Palpebra
2x25mg
inferior
+/+,
Diet:Normal
Ear/Nose/Mouth: normal
food 1800kcal
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 (-)

Date
27/12/
2015
29/12/2015

S
Pale(+)
Nausea(+)
Yellowish
Skin(+)
Malar
rash(+)

Sens : Alert
- SLE
- Pericardial
T : 37,1 C
effusion
BW : 40kg
- AIHA
BH : 160cm
Head: eye reflect +/+,
isocor, pale conj.

P
-

Therapy
O2 Nasal Canule
IVFD NaCl 0,9%
40gtt/I (micro)
Furosemide 2x40mg
Spironolactone
2x25mg
Diet:Normal food

Diagnostic
-PRC
transfusion
-Urinalysis
-Consul to
Nephrology

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:221mg/dl

1800kcal
- Metilprednisolone
1gr/day
- Ranitidine
40mg/12hours/IV

Date
30/12/20
1531/12/20
15

S
Pale(+),
Yellowish
skin(+)
Slight
Malar
rash(+)
Nausea(+)

Sens : Alert
- SLE
- Pericardial
T : 37,1 C
effusion
BW : 40kg
AIHA
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

P
Therapy
- 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

Diagnostic
Scheduled for
blood
transfusion
(PRC)