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ERYTHEMATOSUS
Patient Identity
Main complaint : Oral ulcer
Further anamnesis:
• Patient came with complaint of oral ulcer since 10 days ago. Frequency of vomitting 1-
2 times daily, containing food, no blood. Now, consumed Plaquenil 200 mg 1x1,
Methylprednisolon 8 mg 3x1, Lansoprazole 40 mg 2x1
• Fever (+) since 10 days ago, continously, decreased with paracetamol, but fever returns
few hours later.
• Patient feel itchy and redness in the face when exposed to sunlight
• Headache (+) and feels throbbing, cough with phlegm (seropurulent) (+) since 10 days
ago, shortness of breath (+)
• Pain throughout the joints, especially the spine since last 2 months
• Swelling finger joints and feel warm (PIP of digiti 2 of right hand)
• Irregular bowel movement, only 2 times on 15 days
• Urination was normal, foamy urine
• History of diabetes mellitus and hypertension (-)
• Family history with SLE (-)
• History of inpatient repeatedly and last in February 2018 with diagnose SLE
HISTORY TAKING
General Description
General condition: Moderate illness
Nutrition: normoweight
• Vital Signs
• Awareness : Conscious (GCS 15 E4M6V5)
• Blood pressure : 120/88 mmHg
• Heart rate : 68 x/ min, regular, strong
• Respiratory rate : 20 x/min, thoracoabdominal
• Temperature : 37,9°C (axilla)
• VAS : 5/10
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
• Head : Normocephal, straight black hair, and easy to fell out
• Face : Oedema
• Eyes : Pupils isocor, normal light reflex, conjungtiva pale
no subconjunctival bleeding, no icteric.
• Ear : No abnormalities, otorrhea (-)
• Nose : No abnormalities, epistaxis (-)
• Lips : Oral ulcer (+), cyanosis (-)
• Oral cavity : No abnormalities, gingival hypertrophy (-)
• Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 quiet.
• Neck : No lymphadenopathy, no enlargement of
thyroid gland, no deviation of the trachea.
PHYSICAL EXAMINATION
LUNG
• I : symmetry left and right
• P : normal vocal fremitus, tenderness (-)
• P : sonor
• A : vesicular breath sound
HEART
• I : Ictus cordis not visible
• P : thrill nor palpable
• P : normal heart borders
• A : normal SI/II heart sound, additional sound (-)
ABDOMEN
• I : distention (-)
• A : normal
• P : hepatosplenomegaly (-), right hipocondrium pain (+), CV tenderness (+)
• P : tympani, ascites (-)
PATIENT PROFILE
• Gait : Normal
RHEUMATOLOGICAL STATUS
LABORATORY FINDING
May 13rd, 2018
Leukosit 4.88 x 103 / uL 4000-10.000/µL
Eritrosit 3.08 x 106 / uL 4-6 x 106 / µL
LABORATORY FINDING
Blood Chemistry May 3rd, 2018
SGOT 157 U/L <38U/L
SGPT 55 U/L <41U/L
Albumin 2.8 gr/dL 3.5-5.0 gr/dL
Ureum 81 mg/dL 10-50 mg/dL
Kreatinin 1.51 mg/dL <1.1 mg/dL
Uric Acid 14.4mg/dL 2.4-5.7 mg/dL
Electrolyte May 3th 2018
Sodium 136 mmol/L 136-145 mmol/L
Potassium 4.4 mmol/L 3.5-5.1mmol/L
Chloride 105 mmol/L 97-111 mmol/L
LABORATORY FINDING
Urinalysis May 4rd, 2018
Color Clear Yellow Yellow
Blood 3+ Negatif
Billirubin Negatif Negatif
Urobilinogen Normal Normal
Keton Negatif Negatif
Protein 2+ Negatif
Nitrit Negatif Negatif
Glucose Negatif Negatif
pH 6 4.5-8.0
SG (Mass) 1.015 1.005-1.035
Leukosit Negatif Negatif
Vitamin C 0 Negatif
LABORATORY FINDING
LABORATORY FINDING
Urinalysis May 7th , 2018
Protein Esbach Negatif Negatif
EKG May 3rd, 2018
Chest Xray May 3rd, 2018
2. Hypoalbuminemia • Blood
chemistry test
Based on; control
Albumin 2.8 gr/dL
Immunological
dysregulation
Cleareance
dysfunction
Defective antigen
Dendritic cell presentation
B-Cell T-Cell
Antinuclear Antibody
- Abnormal complement
- Increased apoptosis
dysfunction Tissue
- Defective cytokine
- Defective phagocyte Damage production
activation
Anthony S Fauci et al, 2013. (Harrison’s Rheumatology, 3 th ed.)
Suspicion of SLE need to be considered if there is 2
(two) or more criteria as listed;
Vu Lam NC, V G Maria, L Marzela. SLE:Primary Care Approach to Diagnosis and Management. American Family Physician. 2018 : Vol 94
6. Gastrointestinal : nausea, vomit and abdominal pain
7. Lungs: pleurisy, pulmonal hypertension, parenkim
lesion
8. Cor : pericarditis, endocarditis, myocarditis
9. Reticulo-endotel : organomegaly (lymphadenopathy,
splenomegaly, hepatomegaly)
10. Hematology : anemia, leukopenia and
thrombocytopenia
11. Neuropsychiatry : psychosis, seizure, organic brain
syndrome, myelitis transversus, cognitive impairment,
cranial and peripheral neuropathy
Vu Lam NC, V G Maria, L Marzela. SLE:Primary Care Approach to Diagnosis and Management. American Family Physician. 2018 : Vol 94
ACR 1997 Criteria for
Systemic Lupus
Erythematosus
Reconciliation
Rekomendasi Perhimpunan Reumatologi Indonesia Untuk Diagnosis dan Pengelolaan Lupus Eritematosus Sistemik
PROGNOSIS
Vu Lam NC, V G Maria, L Marzela. SLE:Primary Care Approach to Diagnosis and Management. American Family Physician.
Criteria De nition
Malar rash Fixed erythema, at or raised, over the malar eminences, tending to spare the nasolabial folds
Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring occurs in
Discoid rash
older lesions
Photosensitivity Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
Arthritis Non-erosive arthritis involving two or more peripheral joints, characterised by tenderness, swelling or effusion
a. Pleuritis: convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion or
Serositis
b. Pericarditis: documented by ECG or rub or evidence of pericardial e usion
a. Haemolyticanaemiawithreticulocytosis,or
2.Leucopenia: <4000/mm3, or
Haematologic disorder
3.Lymphopenia: <1500/mm3, or
d. rombocytopenia: <100 000/mm3 in the absence of o ending drugs
a. Anti-DNA:antibodytonativeDNAinabnormaltitre,or
b. Anti-Sm:presenceofantibodytoSmnuclearantigen,or
c. Positive ndingofantiphospholipidantibodiesbasedon:(1)anabnormalserum
Immunologic disorder
concentration of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a
standard method, or (3) a false positive serologic test for syphilis known to be positive for at least 6 months and
con rmed by Treponema pallidum immobilisation or uorescent treponemal antibody absorption test
An abnormal titre of antinuclear antibody by immuno uorescence or an equivalent assay at any point in time
Antinuclear antibody
and in the absence of drugs known to be associated with ‘drug-induced lupus’ syndrome
THANK YOU