Case Report

Systemic Lupus
Erythematosus
WIDYA AULIA C014182261
SITI AZREEN AZIRA BINTI ADZHAR C014182197
PATIENT’S IDENTITY

Name : Mrs. Hamsina

DOB : November, 24th 1988
Age : 30 years old
Gender : Female
Address : Bonto Parang
Religion : Islam
Occupation : Student
Date of hospital admission : November, 5th 2019
Hospital/room : Wahidin Sudirohusodo
Hospital, Lontara 1
Medical record : 900742
 HISTORY TAKING
• Chief Complaint :
Rashes throughout the face
• Present History :
• The patient complain there was rashes throughout her face since 3 months ago
• Photosensitivity is present.
• Hair loss present
• The patient also complaint of joints pain all over her joints since 1 month ago.
• Fever is present since 4 months ago .
• Sometimes patient Cough since 3 days ago dyspneu is absent ,chest pain
absent,nausea and vomiting is absent.
• Patient had loss more than10kg of weight since 3 months ago.
• There is no history of melena. Normal defecation and urination.
• History with the same complain referred from Takalar Hospital with the diagnosis of
suspected Systemic Lupus Erhythomatous.
 HISTORY TAKING

Personal History
No History of smoking

Past History :
No history of hypertension and diabetes
mellitus.
No history of cardiac disease

Family History :
No family history with the same symptoms
PHYSICAL
EXAMINATION
General Description:
General condition: Moderate illness
Consciousness : GCS E4M6V5
Vital Sign:
Blood Pressure : 110/80 mmHg
Heart Rate : 82x/minute
Respiratory Rate : 20x/minute
Temperature : 36.7oC
 PHYSICAL EXAMINATION
HEAD AND NECK
 Face : pale (+) cyanosis (-), jaundice (-),
malar
rash(+)
 Hair : easily remove (+)
 Eye : anemic (+), icterus (-)
 Ear : otorrhea (-), tophi (-)
 Nose : rhinorrhea (-), epistaxis (-)
 Mouth : oral ulcers (+), bleeding (-)
 Tonsil : T1 – T1, hyperemia (-)
 Pharynx : hyperemia (-)
 Neck : JVP R+2 cmH2O, lymphadenopathy
(-),
bruit (-)
PHYSICAL EXAMINATION
THORAX
I : symmetry left and right ,
P : mass (-), tenderness (-)
P : sonor in both lung fields symmetric
A : vesicular breath sound, rhonchi (-),
wheezing (-).
HEART
I : Ictus cordis not visible
P : Thrill palpable LMS ICS IV
P : Normal heart borders
A : Normal SI/II heart sound, no
additional sound
ABDOMEN
I : convex, follow the motion of breath
A : normal, peristaltic (+)
P : hepatomegaly (-), splenomegaly (-),
mass(-), tenderness (-),tenderness
on epigastrium
P : tympany (+)
 PHYSICAL
EXAMINATION
EXTREMITIES
I : Discoid rash throughout the body
P: mass (-), tenderness (-),edema (+)
RHEUMATOLOGY EXAMINATION

GAIT
Normal gait
ARM
ROM Normal, Discoid rash
LEG
ROM Normal, Discoid rash
SPINE
NORMAL
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LABORATORY EXAMINATION

Hematology Result (6/11/2019) Range

WBC 3.8x 103 4000-10.000/µL

HGB 9.3 12.0 – 16.0 g/dL

PLT 131.000 150.000-400.000/µL

MCV 93 80-97 fL
MCH 30 26,5-33,5 pg
Neutrophyl 46.60 52-75%
Lymphocyte 40.3 20-40%
LABORATORY EXAMINATION

Chemical 06-11-2019 Liver function 06/11/2019

Ureum 16 10-50 mg/dl

SGOT 107 < 38
SGPT 25 < 41
Creatinine 0.59 <1,1 mg/dl

Natrium 128 136-145 mmol/l

Kalium 2.2 3,5-5,1 mmol/l

Chloride 91 97-111 mmol/l

Albumin 1.4 3,5 – 5,0 gr/dl

 LABORATORY EXAMINATION
Hematologi 06/11/2019
Urinalysis 06/11/2019
Coomb’s Test (-) Negatif
RBC +1 0-3 Sel LE (-) Negatif
WBC +1 0-5

Hematology(6/11/2019)

Eritrosit Anisopoikilositosis, normositik normokrom, ovalosit (+), akantosit(+), inklusion

body (-), sel muda(-)

Leukosit Normal, PMN>Limfosit, morfology normal, sel muda(-)

Trombosit Decrease, morfology normal

Conclusion Anemia normositik normokrom with description abnormalities in liver

function,thrombositopeni
RADIOLOGY EXAMINATION

THORAX PHOTO (6/11/2019)

• Normal
ACR DIAGNOSTIC CRITERIA
 Malar rash
 Discoid rash
 Serositis
 Oral ulcers
 Arthritis non-erosive
 Photosensitivity
 Hematology disorders
 Renal involvement
 Antinuclear antibodies
 Immunologic phenomena (eg, dsDNA; anti-Smith [Sm] antibodies)
 Neurologic disorder

SCORE: 4/11
MEX SLEDAI SCORE
 Neurological Deficit = -
 Renal Involvement = -
 Vasculitis = 4
 Hemolysis = -
 Thrombocytophenia = -
 Arthritis = 2
 Mucocutaneus disorder = 2
 Serositis = -
 Fever & Fatigue = 1
 Leukopenia = 1
 lymphopenia = - SCORE: 10
DIAGNOSIS

1. SYSTEMIC LUPUS ERYTHEMATOSUS

(ACR 4/11) SEVERE ACTIVITY (MEX SLEDAI
10)
2. ANEMIA EC SUSPECT CHRONIC DISEASES
3. HYPOKALEMI
4. HYPOALBUMINEMIA
5. ELEVATED LIVER ENZYM
TREATMENT

• Methylprednisolon 500 mg/24hours/intravena

• Methotrexate 10mg/week
• Cavit D3/24hours/oral
• Folic acid 1 tab/24hours/oral
• Maxilive 1tab/12hours/oral
• KCL 25 meq/intravena
• Albumin 25%/24hours/intravena
PLANNING

• ANA Profile
SLE
SYSTEMIC LUPUS
ERYTHEMATOUS
 Definition

Systemic lupus erythematosus

(SLE) is an autoimmune disease
which is the immune system of the
body mistakenly attacks healthy
tissue and involve many organs in
the body.
 Etiology

0 0 0 0
1 2 3 4
SLE causes is This occurs The most Some of the
unknown, but through the
production of
common other factors
it is likely that type of auto- include
“auto-
a combination antibodies” that antibody that sunlight,stres
of genetic, attack a person’s
environmental develops in s, certain
own cells thus
and possibly contributing to people with drugs and
hormonal the SLE is called agents such
factors work inflammation of an as virus
together to various part of
the body and
antinuclear
cause SLE. may cause antibody
damage to (ANA)
organs and
tissues
PATOPHYSIOLOGY
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(SLICC CRITERIA FOR SLE)

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(SLICC CRITERIA FOR SLE)

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DIAGNOSIS
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ACTIVITY INDEX
SLE DISEASE
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DIAGNOSIS
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THERAPY
Prognosis

Prognosis is variable, depending on

the system involve. With close
follow-up and treatment, 80-90% of
people with lupus can expect to live a
normal life span even medical
science has not yet developed a
method for curing lupus. Mortality
within 5 years of diagnosis is usually
due to organ failure or overwhelming
sepsis, both of which are modifiable
 Complication

Neuropsychiatric Nephritic
SLE Lupus
Thank
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