CASE

Name : WIP
Age : 15 years
Sex : Female
Date of Admission : May 12
rd,
,201
The aim of this paper is to report a case of systemic lupus erythematosus in a 15 years old girl.
Case
WIP, female, 15 years old, Indonesian, admitted to !" Adam Mali# $eneral !os%ital on May 12
rd
,
201, &it' main (om%laint of %ale s'e 'as )een ex%erien(ing sin(e 1 mont' ago" !istory of s%ontan
)leeding *+, and also fe(es &it' )la(# (olo-r *+,, nose)leeding*+,, g-ms )leeding *+,, red s%ot on t'e
s#in *+,, malar ras' *+, 'as )een ex%erien(ing for 1 mont' ago and if %atient ex%ose to t'e s-n lig't t'e
lession getting &orse" .o-g' *+, sin(e 2 &ee#s ago, s%-t-m */, no 'istory dire(t (onta(t &it' ad-lt
%erson &it' (o-g', (ommon (old */,, na-sea */," Fe0er *+, ex%erien(ing )y t'e %atient sin(e 1 mont',
('ara(teristi( of fe0er &as s-)fe)ris and )a(# to t'e normal &it' anti%i-reti#, sei1-re */, s'i0er */,"
Malaise *+, sin(e 1 mont', 'airfall 'as )een ex%erien(e sin(e 2 mont' ago, 'istory of )a(#)one %ain
*+, es%e(ially &'en ins%iration" 3o&er a%%etite *+,, t'e 'ig'est )ody &eig't s'e rea('ed &as 2#g
aro-nd 10 mont' ago, no& s'e &eig't 45 #g" 'istory re%la(e of t'r-s' *+, sin(e 1 mont' ago" Patient
'as )een ex%erien(ing amenorr'ea for t'e %ast 5 mont's" 6'e 'istory of menstr-ation &as fo-nd not
reg-lar and s'e 'ad menar('y at age of t'irteen" Pre0io-sly, t'e %atient &as admitted for 1 &ee# at
6e)ing 6inggi !os%ital &it' diagnose anemia e( *7,, s'e 'ad -ndergone )lood transf-sion as m-('
)ag P8." 9n 12
t'
May 201, t'e %atient &as dis('arged from 6e)ing 6inggi !os%ital and &as reffered
to !"Adam Mali# $eneral !os%ital" S'e &as admitted 'ere for t&o &ee# from 12
t'
may to 25
t'
may
&it' t'e diagnosis of Se0ere S3:"
History of previous illness : Denied )y %atient;s mot'er
History of previous medications : Negati0e
History of labor : Normal deli0ery, 'andled )y mid&ife, (ried
as soon as )a)y &as )orn, no (yanosis t'e
%atient is 1st ('ild"
History of growth and
Development : $ro&t' and de0elo%ment &'en toddler
s-ita)le &it' toddler in same age" !e &as 5
t'

grader elemantary s('ool st-dent"
History of feeding : 0 < 2 mont's : )reast feeding
2 < 12 mont's : %orridge mil#, )reast feeding
1 years < no& : reg-lar diet
History of immunization : .om%lete imm-ni1ation
Physical examination
Presens status
Sensori-m : .om%os mentis
6em%erat-re : 42,5=.
!eart 8ate : 12 )%m, reg-lar, m-rm-r */,
8es%iratory 8ate : 25 x>min-te, reg-lar, rales */,
?lood Press-re : 110>@0 mm!g normal
Weig't : 45 #g ??>A B
!eig't : 155 (m 6?>A B
N-trition Stat-s : ??>6? B
Dys%nea, (yanosis, i(teri(, and edema &ere not %resent
ocalized Status
S#in Malar ras' *+,
!ead !air &as easily %-lled off *+,
Fa(e Moon fa(e *+,, ?-tterfly ras' *+,, A(ne at )ot' ('ee#s */,
:yes 3ig't reflex: *+>+,, %-%ils &ere iso('ori(, no %ale of (onC-n(ti0a %al%e)ra
inferior
Nose Normal in a%%earan(e
:ar Normal in a%%earan(e
Mo-t' !y%eremi( */,
6o-nge> 6eet' Normal in a%%earan(e
6onsil> P'arynx Normal in a%%earan(e
Ne(# :nlargement of lym%' nodes */,
?a(# Miliary s%ots */,
6'orax Symmetri(al f-siform, no retra(tion,
!8: 12 )%m, reg-lar, m-rm-r */,
88: 25 r%m, reg-lar, rales */>/,
A)domen Soe%el, %eristalti( *+, normal, li0er>s%leen: not %al%a)le
Pel0i( .osto/0erte)ral angle tenderness */,
:xtremities P-lse D12 )%m, reg-lar, %>0 &as adeE-ate, &arm extremities, .86 F2G
Striae on #nee *+,
?lood %ress-re 110>@0 mm!g *N: 102/120> 24/@@,
P-)erty stage 6anner stage ?4P4
aboratory finding on !ay "#
rd
#$"%:
Complete &lood
Count
Hematology 'nit (esult (eference
Hemoglobin )H*&+ gH D"10 12"0/1"
Erythrocyte )(&C+ 10
2
>mm
4
2"0 "20/"5@
eucocyte ),&C+ 10
4
>mm
4
10"40 "5/11"0
Hematocrite H 25"40 45/
-hrombocyte )P-+ 10
4
>mm
4
1@1 150/50
!C. Fl 105"0 55/D5
!CH %g 4@"D0 25/42
!CHC gH 42"00 44/45
(D, H 22"20 11"2/1"5
!P. Fl D"50 @"0/10"2
PC- H 0"12
PD, Fl 11"
Difftel Count
/eutrophil H @@"40 4@/50
ymphocyte H 11"@0 20/0
!onocyte H 5"00 2/5
Eosinophil H 2"@0 1/2
&asophil H 0"400 0/1
/eutrophil Absolute 10
4
>I3 @"D@ 2"@/2"5
ymphocyte Absolute 10
4
>I3 1"20 1"5/4"@
!onocyte Absolute 10
4
>I3 0"52 0"2/0"
Eosinophil Absolute 10
4
>I3 0"25 0/0"1
&asophil Absolute 10
4
>I3 0"04 0/0"1
iver
Albumin g>d3 4"2 / "5
Carbohydrate
!etabolism
(andom &lood *lucose mg>d3 142"D0 F200
(enal
'reum mg>d3 1@"@0 F50
Creatinin mg>d3 0"45 0,5@/0,5@
Electrolyte
/atrium m:E>d3 142 145 < 155
0alium m:E>d3 4" 4,2 < 5,5
Cloride m:E>d3 10 D2 < 102
,or1ing Diagnosis2 Se0ere systemi( l-%-s eryt'ematos-s
!anagement 2
Met'yl%rednisolone 4/4/4
Diet (ommon food 1550 #(al &it' @5 gram of %rotein
Planning 2
/ ?alan(e fl-id> 2 'o-r
/ Di%sti(# -rine at morning
/ .ons-lt to endo(rinology
/ .'e(# (om%lete )lood (o-nt, 8F6, -rinalysis, ele(trolyte and )lood gl-(ose le0el"