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Subjective

Objective

Low back pain


Fever
Vomit
Sensorium
Temperature (C)
Body Weight (Kg)
Body Height (cm)

24th April
2014
Thursday

25th April
2014
Friday

26th April
2014
Saturday

27th April
2014
Sunday

28th April
2014
Monday

29th April
2014
Tuesday

30th April
2014
Wednesday

+
-

+
-

+
-

+
-

+
-

+
-

+
-

CM
37.2
39
153

CM
37.2
39
153

CM
37.3
39
153

CM
36.8
39
153

CM
37.3
39
153

CM
37.3
39
153

CM
37.2
39
153

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

N/N/Hyperemic

N/N/Hyperemic

N/N/
Hyperemic

N/N/
Hyperemic

N/N/
Hyperemic

N/N/
Hyperemic

N/N
/Hyperemic

Localized Status

Head

Eyes: Light reflex


Isocoric pupil
Pale of conjunctiva
palpebra inferior
Ear/nose/mouth

Face

Moon face
Butterfly rash
Acne on both cheeks

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

Neck

Enlargement of lymph
nodes

Thorax

Symetrical fusiform
Retraction
Heart rate
Respiratory rate

/
100
24

/
100
20

/
100
20

/
98
24

/
92
24

/
100
20

/
90
24

Back

Miliary spots

Abdomen

Soepel,
Peristaltic(+)Normal
Liver/spleen: Not
palpable

Pelvic

Costo-vertebral angle
(CVA) tenderness

Extremities

Pulse
Regular
Pressure and volume
Warm extremities
Capilary refill time (CRT)

Working diagnosis

-Methylprednisolone
-Hydroxychloroquine
Management -Ibuprofen
-Diet Common food 1800
kcal + 78gram protein

24th April
2014
Thursday

25th April
2014
Friday

26th April
2014
Saturday

27th April
2014
Sunday

28th April
2014
Monday

29th April
2014
Tuesday

30th April
2014
Wednesday

100
yes
adequate
yes
3''

100
yes
adequate
yes
3''

100
yes
adequate
yes
3''

98
yes
adequate
yes
3''

92
yes
adequate
yes
3''

100
yes
adequate
yes
2''

90
yes
adequate
yes
3''

Low back pain Low back


Low back
Low back
Low back
Low back
Low back pain ec
ec
pain ec
pain ec
pain ec
pain ec
pain ec
Severe SLE + LN Severe SLE + Severe SLE Severe SLE Severe SLE Severe SLE Severe SLE
+ Secondary
LN +
+ LN +
+ LN +
+ LN +
+ LN +
+ LN +
Amenorrhea
Secondary
Secondary
Secondary
Secondary
Secondary
Secondary
Amenorrhea Amenorrhea Amenorrhea Amenorrhea Amenorrhea Amenorrhea
3-3-3
2 x tablet
3 x 400 mg
+

3-3-3
2 x tablet
3 x 400 mg
+

3-3-3
2 x tablet
3 x 400 mg
+

3-3-2
2 x tablet
3 x 400 mg
+

3-3-2
2 x tablet
3 x 400 mg
+
Consult
Orthopedic
Department

Planning
Consultation

3-3-3
2 x tablet
3 x 400 mg
+

Yes

3-3-3
2 x tablet
3 x 400 mg
+

Subjective

Objective

Low back pain


Fever
Vomit
Sensorium
Temperature (C)
Body Weight (Kg)
Body Height (cm)

1st May 2014


Thursday

2nd May 2014


Friday

3rd May
2014
Saturday

4th May 2014


Sunday

5th of May
2014
Monday

+
-

+
-

+
-

+
-

+
-

+
-

+
-

CM
37.2
39
153

CM
36.7
39
153

CM
37.3
39
153

CM
36.8
39
153

CM
37.3
39
153

CM
37.3
39
153

CM
37.2
39
153

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

6th May 2014 7th May 2014


Tuesday
Wednesday

Localized Status

Head

Eyes: Light reflex


Isocoric pupil
Pale of conjunctiva
palpebra inferior
Ear/nose/mouth

Face

Moon face
Butterfly rash
Acne on both cheeks

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

Neck

Enlargement of lymph
nodes

Thorax

Symetrical fusiform
Retraction
Heart rate
Respiratory rate

/
94
24

/
96
28

/
100
24

/
92
22

/
110
26

/
100
26

/
100
26

Back

Miliary spots

Abdomen

Soepel,
Peristaltic(+)Normal
Liver/spleen: Not
palpable

Pelvic

Costo-vertebral angle
(CVA) tenderness

Extremities

Pulse
Regular
Pressure and volume
Warm extremities
Capilary refill time (CRT)

Working diagnosis

-Methylprednisolone
-Methylprednisolone Inj
-Hydroxychloroquine
Management
-Ibuprofen
-Diet Common food 1800
kcal + 78gram protein

1st May 2014


Thursday

2nd May 2014


Friday

3rd May
2014
Saturday

4th May 2014


Sunday

5th of May
2014
Monday

94
yes
adequate
yes
2''

96
yes
adequate
yes
3''

100
yes
adequate
yes
3''

92
yes
adequate
yes
3''

110
yes
adequate
yes
3''

100
yes
adequate
yes
2''

100
yes
adequate
yes
3''

Severe SLE +
LN + Secondary
Amenorrhea

3-3-3
2 x tablet
3 x 400 mg
+

Severe SLE + Severe SLE Severe SLE


LN +
+ LN +
+ LN +
Secondary
Secondary
Secondary
Amenorrhea + Amenorrhea Amenorrhea
Folliculitis + Folliculitis + Folliculitis +
Lumbal
Lumbal
Lumbal
spondylitis
spondylitis
spondylitis
3-3-3
2 x tablet
3 x 400 mg
+

3-3-3
2 x tablet
3 x 400 mg
+

3-3-3
Day 1
2 x tablet
3 x 400 mg
+

6th May 2014 7th May 2014


Tuesday
Wednesday

Severe SLE Severe SLE Severe SLE


+ LN +
+ LN +
+ LN +
Secondary
Secondary
Secondary
Amenorrhea Amenorrhea Amenorrhea
Folliculitis + Folliculitis + Folliculitis +
Lumbal
Lumbal
Lumbal
spondylitis
spondylitis spondylitis
3-3-2
Day 2
2 x tablet
3 x 400 mg
+

3-3-2
Day 3
2 x tablet
3 x 400 mg
+

3-3-3
2 x tablet
3 x 400 mg
+

Subjective

Objective

Low back pain


Fever
Vomit
Sensorium
Temperature (C)
Body Weight (Kg)
Body Height (cm)

8th May 2014


Thursday

9th May 2014


Friday

10th May
2014
Saturday

11th May
2014
Sunday

12th May
2014
Monday

13th May
2014
Tuesday

14th May
2014
Wednesday

+
-

+
-

+
-

+
-

+
-

+
-

+
-

CM
37.0
39
153

CM
37.2
39
153

CM
37.2
39
153

CM
36.9
39
153

CM
36,7
39
153

CM
37.0
39
153

CM
36,8
39
153

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

+
+
-/-

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

N/N/N

Localized Status

Head

Eyes: Light reflex


Isocoric pupil
Pale of conjunctiva
palpebra inferior
Ear/nose/mouth

Face

Moon face
Butterfly rash
Acne on both cheeks

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

Neck

Enlargement of lymph
nodes

Thorax

Symetrical fusiform
Retraction
Heart rate
Respiratory rate

/
100
26

/
110
24

/
110
28

/
98
24

/
100
24

/
100
20

/
110
26

Back

Miliary spots

Abdomen

Soepel,
Peristaltic(+)Normal
Liver/spleen: Not
palpable

Pelvic

Costo-vertebral angle
(CVA) tenderness

Extremities

Pulse
Regular
Pressure and volume
Warm extremities
Capilary refill time (CRT)

Working diagnosis

-Methylprednisolone
-Hydroxychloroquine
-Ibuprofen
Management
-Cotrimoxazole 2x80 mg
-Diet Common food 1800
kcal + 78gram protein

100
yes
adequate
yes
3''

110
yes
adequate
yes
3''

110
yes
adequate
yes
3''

98
yes
adequate
yes
3''

100
yes
adequate
yes
3''

100
yes
adequate
yes
2''

100
yes
adequate
yes
3''

Severe SLE
+ Secondary
Amenorrhea
Folliculitis +
Lumbal
spondylitis

Severe SLE
+ Secondary
Amenorrhea
Folliculitis +
Lumbal
spondylitis

Severe SLE
+ Secondary
Amenorrhea
Folliculitis +
Lumbal
spondylitis

Severe SLE
+ Secondary
Amenorrhea
Folliculitis +
Lumbal
spondylitis

3-3-3
2 x tablet
3 x 400 mg
+

3-3-2
2 x tablet
3 x 400 mg
+
+

3-3-2
2 x tablet
3 x 400 mg
+
+

3-3-3
2 x tablet
3 x 400 mg
+
+

Severe SLE + LN
+ Secondary
Amenorrhea

3-3-3
2 x tablet
3 x 400 mg
+

Severe SLE +
LN +
Severe SLE
Secondary
+ Secondary
Amenorrhea + Amenorrhea
Folliculitis + Folliculitis +
Lumbal
Lumbal
spondylitis
spondylitis
3-3-3
2 x tablet
3 x 400 mg
+

3-3-3
2 x tablet
3 x 400 mg
+

15th May 2014


Thursday

16th May 2014


Friday

17th May
2014

+
-

+
-

+
-

CM
37.0
39
153

CM
37,1
39
153

CM
37.0
39
153

+
+
-/-

+
+
-/-

+
+
-/-

N/N/N

N/N/N

N/N/N

Face

Moon face
Butterfly rash
Acne on both cheeks

+
+
+

+
+
+

+
+
+

Neck

Enlargement of lymph
nodes

Thorax

Symetrical fusiform
Retraction
Heart rate
Respiratory rate

/
102
24

/
96
22

/
100
24

Back

Miliary spots

Subjective

Objective

Low back pain


Fever
Vomit
Sensorium
Temperature (C)
Body Weight (Kg)
Body Height (cm)

Localized Status

Head

Eyes: Light reflex


Isocoric pupil
Pale of conjunctiva
palpebra inferior
Ear/nose/mouth

Abdomen

Soepel,
Peristaltic(+)Normal
Liver/spleen: Not
palpable

Pelvic

Costo-vertebral angle
(CVA) tenderness

Extremities

Pulse
Regular
Pressure and volume
Warm extremities
Capilary refill time (CRT)

Planning
Consultation

102
yes
adequate
yes
2''

96
yes
adequate
yes
3''

100
yes
adequate
yes
3''

Severe SLE +
Secondary
Amenorrhea +
Folliculitis +
Lumbal
spondylitis

Working diagnosis

-IVFD D5/% NaCl 0,45%


40gtt/micro
-Methylprednisolone
-Methylprednisolone Inj
-Hydroxychloroquine
Management -Ibuprofen
-Ranitidine Inj 30mg/IV
-Cotrimoxazole 2x 480 Inj
-Ambroxol 3x1 cth
-Diet Common food 1800
kcal + 78gram protein

Severe SLE + Severe SLE


Secondary
+ Secondary
Amenorrhea + Amenorrhea
Folliculitis + Folliculitis +
Lumbal
Lumbal
spondylitis
spondylitis

3-3-2
2 x tablet
3 x 400 mg
+
+
+

3-3-2
2 x tablet
3 x 400 mg
+
+
+
+

3-3-3
2 x tablet
3 x 400 mg
+
+

Laboratory findings on April 26th 2014:


Immunoserology
Hormone

Unit

Result

Reference

FSH

ng/mL

5.92

LH

ug/L

0.89

Estradiol

pg/dL

Total T3

ng/mL

0.48

0.8-2

Total T4

ug/dL

7.56

5.0-14

TSH

u/U/mL

0.66

0.27-4.2

Rheumatoid Factor (RF)


Thyroid

Autoimmune

Unit

ANA Test

ng/mL

59

<20

Anti ds-DNA

ug/L

810

0-200

CRP kualitatif

pg/dL
mg/dL

81.4

<200

Ureum

mg/dL

24.1

<50

Creatinin

mg/dL

0.45

0,57-0,87

Natrium

mEq/dL

132

135 155

Kalium

mEq/dL

2.7

3,6 5,5

Cloride

mEq/dL

108

96 106

Carbohydrate Metabolism
Random Blood Glucose
Renal

Electrolyte

Laboratory finding on May 6th 2014:


Complete Blood Count
Hematology

Unit

Result

Reference

Hemoglobin (HGB)

g%

14.4

12.0-14.4

Erythrocyte (RBC)

106/mm3

4.55

4.20-4.87

Leucocyte (WBC)

103/mm3

13.09

4.5-11.0

Hematocrite

41

38-44

241

150-450

Thrombocyte (PLT)

10 /mm

MCV

fl

90.1

85-95

MCH

pg

31.6

28-32

MCHC

g%

35.1

33-35

RDW

13.9

11.6-14.8

MPV

fl

7.8

7.0-10.2

PCT

0.19

PDW

fl

8.1

Hematology

Unit

Result

Reference

Hemoglobin (HGB)

g%

14.4

12.0-14.4

Erythrocyte (RBC)

106/mm3

4.55

4.20-4.87

Leucocyte (WBC)

103/mm3

13.09

4.5-11.0

Hematocrite

41

38-44

241

150-450

Complete Blood Count

Thrombocyte (PLT)

10 /mm

MCV

fl

90.1

85-95

MCH

pg

31.6

28-32

ESR

mm/hour

11

<20

Neutrophil

86.8

37-80

Lymphocyte

20-40

Monocyte

2-8

Eosinophil

1-6

Basophil

Difftel Count

Neutrophil Absolute

0.2

0-1

11.35

2.7-6.5

10 /L

Lymphocyte Absolute

10 /L

0.92

1.5-3.7

Monocyte Absolute

103/L

0.79

0.2-0.4

Eosinophil Absolute

103/L

0-0.1

Basophil Absolute

103/L

0.03

0-0.1

Albumin

g/dL

3.4

3.2 - 4.5

Total Bilirubin

mg/dL

0.39

<1

Direct Bilirubin

mg/dL

0.12

0-0.2

AST/SGOT

U/L

26

<32

ALT/SGPT

U/L

43

<31

Ureum

mg/dL

43

<50

Creatinin

mg/dL

0.34

0,57-0,87

Uric acid

mg/dL

2.2

<5.7

Liver

Renal

Dipstick urine/6 hour

Leu

Nit

Uro

Pro

pH

BLO

SG

Ket

Bil

Glu

3 May 2014

+-

3,5

1030

6th May 2014

+-

3,5

+++

1050

7th May 2014

+-

5,5

+-

1020

+-

8th May 2014

+-

15

1020

10th May 2014

+-

1020

12th May 2014

rd

+-

0,2

1010

th

0,2

+-

6,5

1015

th

14 May 2014

+-

0,2

+-

6,5

1030

15th May 2014

0,2

6,0

1020

13 May 2014

Consultation results from Dermatology department on March 26th 2014:


Diagnosis : Folliculitis
Advice : Apply Clindamycin cream 2 x 1 per day
Consultation results from Endocrinology department on May 5th 2014:
Diagnosis : Secondary Amenorrhea
Advice :-Recommend cortisol test on morning and day
-Treat underlying disease
Consultation results from Pulmonology department on May 10th 2014:
Diagnosis : Bronchopneumonia
Consultation results from Orthopedics department on May 2nd 2014:
Diagnosis: Spondilitis -The manifestation of musculoskeletal from SLE is the spine osteopenia