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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
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
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
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
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
,
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