Case Report

Systematic Lupus Eritematouse (SLE)

NADA YULIANDHA
NIM I 111 11 040
K E PA N I T E R A A N K L I N I K I L M U P E N YA K I T D A L A M
R S T I N G K AT I I K A R T I K A H U S A D A , K U B U R AYA
2016

embimbing ; dr. Iqbal Lahmadi, Sp. PD

Summary of Database
Ny. SN / 31 yo
Chief complaint : prolong fever
She complaint with prolong fever which was
came and gone, worse at night especially right
after her activities in a day
This complaint accompanied by a burned-like
skin figure, worse under the sunlight, there was
also oral scars which occurred without any
spesific reason at any time, grayish hair on her
age and easily hairfall, and also persistent pain
on both of her joint extremities for the last 4
months.
Past medical history (-)

Physical examination
BP = 100/80
HR : 88 tpm,
mmHg
regular
General appearance looked severely ill
Head
Anemic (-) ; Icteric (-)
Mouth
Oral ulcers (+); vulnus
Thorax
Heart
Lung

RR = 20 tpm Temp. 39.6 C

GCS 456 = 15
Hair fall (+); malar rash (+)
combutio a/r oral (+)

Invisible Palpable at Ictus ICS VI MCL S,

Heart sound irreguler, mur mur (-), gallop (-)
Simetric, D = S

SS
SS

Abdomen

Extremities

v v
v v

Rh - -

Wh - - -

SS v v
- - Flat, Bowel sound (+). Soefl, Hepar : Liver spleen
enlargement (-). Abdominal pain on palpation (-)
Oedema in lower extremity -/- ; swollen joint (+) ; pain on
palpation (+)

Clinical Conditions

Clinical Conditions

Laboratory Examination
Lab

Value

Lab

Value

Leukocyte

5.100

3500-10000/L

Ureum

64

15-45

Haemoglobin

8.0

11,0-16,5g/dl

Creatinin

1,9

0,9-1,3

Haematocrite

26.1

35-55 g/dl

RBG

103

100-200

MCV

85.9

80-97

ALT

42

10-41U/L

MCHC

30.8

31-38

AST

12

11-41U/L

Thrombocyte

212.000

150000390000/L

Urinalysis
Lab

Value

Lab

Value

Colour

Dark
Yellow

Light
yellow

Leukosit

(++)

75.0-100.0
fl

Clearness

Disturbed

Clear

Epitel

(+)

25.0-35.0
pg

Mass

1.020

1.0101.020

Cylinder

Hialin (+)

15-45
mg/dL

pH

5.0

4.5 8.0

Eritrocyte

Uncounta
ble

Leucocyte

(+++)

Negative

Protein

(+++)

Negative

Keton

(-)

Negative

Blood

(++++)

Negative

Urobilinoge (-)
n

Negative

Glucose

(-)

Negative

Bilirubin

Negative

Nitrit

(-)

Negative

(-)

CXR

PA position, relative
symmetric
Soft tissue and bone
normal
Trachea right in the middle

ICS D/S normal

sharp right
costophrenicocostalis
angle
sharp left
costophrenicocostalis
angle
Hemithorax D/S increase
of bronchovascular
Heart : site normal, CTR

CUE AND CLUE

PROBLEM

INITIAL

PLANNING

LIST

DIAGNOSE

DIAGNOSE

PLANNING THERAPY

PLANNING
MONITORI
NG

-Middle-aged
female
(31yo), childbearing age
-prolong
fever 39.6,
fatigue,
malaise
-Malar rash
-Hair fall
-Oral ulcers
-Oral
combutio
-symetric
swollen joint
-Normochrom
normocytic
anemia
-Hematuria
-ANA (+)
-Lupus score
= 7/11

1.
Photosen
sitivity
with
athritis
and
nephritic
syndrom
e

1.1 Lupus
1.1.1 SLE
1.1.2 Drug
induced
lupus

- Lipid
profile
- Retyculo
cyte
count
coomb
1.2
test
Fibromyalgi - Anti
a
dsDNA
- Anti-RNP
1.3 Sjogren - Renal
syndrome
biopsy
1.4 Early
rheumathoi
d athritis
1.5
Secondary
GN
1.5.1 AntiGBM

- Free diet
- IVFD NS 20
dpm
- Inj.
Methylprednisol
on 125mg/8
hours
- Inj. Antrain
amp/8hours
- Inj. Ranitidin
50mg/12hours
- PO Captopril
3x6.25mg
- Iodine gargling
3-4 times/day

Complain
t
-VS
Laborator
y findings

CUE AND CLUE

PROBLEM

INITIAL

PLANNING

LIST

DIAGNOSE

DIAGNOSE

PLANNING THERAPY

PLANNIN
G
MONITO
RING

Middle-aged 2.
female
Normochr
(31yo),
omic
child-bearing
Normocyt
age
ic anemia
fatigue (+),
malaise (+)
Anemic
conjungtiva
(+)
Hb = 8.0
MCV = 89.8
MCH = 30.8

2.1 due to
problem
list number
1

- PO Folic acid 1 x
3 tab
- PO Vitamin B12
3x1
- PO Ferro sulfat
2-3 tabs/day

Lab
findings
,

CUE AND CLUE

PROBLEM

INITIAL

PLANNING

LIST

DIAGNOSE

DIAGNOSE

PLANNING THERAPY

PLANNIN
G
MONITO
RING

Middle-aged 3. Heart
female
failure
(31yo),
stage B
child-bearing
age
CTR from
chest x-ray :
cardiomegal
y (+)

3.1 Due to
problem
list no. 1

Compla
in
VS
Lab
exam

Introduction
What is it?
Unknown etiology,
which tissues & cells
are damaged by
deposition of
pathogenic
autoantibodies &
immune complexes
Epidemiology : 90%
women in childbearing age

SLE
Treatment
strategies
Conservat
ive for
non-life
threateni
ng

Lifethreateni
ng SLE

Pathogenesis

Clinical Maniafestations

Diagnosis

Recommended Monitoring

THANK YOU