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Case Table
Case Table
Case Table
Objective
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
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''
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
3rd May
2014
Saturday
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
Localized Status
Head
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
3rd May
2014
Saturday
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
+
3-3-3
2 x tablet
3 x 400 mg
+
3-3-3
Day 1
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
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
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
+
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
Localized Status
Head
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
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
+
+
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
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
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
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
Leu
Nit
Uro
Pro
pH
BLO
SG
Ket
Bil
Glu
3 May 2014
+-
3,5
1030
+-
3,5
+++
1050
+-
5,5
+-
1020
+-
+-
15
1020
+-
1020
rd
+-
0,2
1010
th
0,2
+-
6,5
1015
th
14 May 2014
+-
0,2
+-
6,5
1030
0,2
6,0
1020
13 May 2014