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Case Report
Case Report
CASE REPORT
Systemic Lupus
Erythematosus
Definitio
n:
Epidemiolo
Ethnics /
Prevalence of SLE gy
VARIES
Races
Geographics
Sex
= 4 : 1
>> childbearing
age
hypertensi
on
genetic
hormones
Drug
allergy
Sunreactive
Skin type
Etiolo
gy?
environme
nt
medication
smoking
transfusio
n
Family
history
Pathogen
esis
Environmental
Genetic
Factors
Factors
Pathogen
esis
AutoAntibodies
SelfAntigens
Ag Ab
Complex
Clinical
Manifestations
Constitution
al
Cardiovascula
r
Mucocutaneo
us
Pulmonar
y
Target
Organs
Neurologic
etc
Musculoskele
tal
Renal
Hematologi
c
S erositis
Diagnosis
O ral ulcers
A rthritis
P hotosensitivity
B lood disorders
R enal involvement
A nti-nuclear
antibodies
I mmunologic
phenomena
N eurologic disorder
M alar rash
D iscoid rash
1
1
of R)
4 C
(A
Treatment
Biologic DMARDs
Non-biologic DMARDs
NSAIDs
Corticosteroids
Anti-malarials
Prognosis
Highly variable!
Benign Rapidly progressive
Fatal
Average 10-year survival rate:
Comorbidities >
: 90% Infection
Lipid Disorders
Hypertension
Diabetes Mellitus
Bone-related
conditions
Malignancies
CASE REPORT
Physical Examination
Neck
Enlargement of lymph nodes (-)
Thorax
The chest was fusiform symmetrical, no retraction of chest
wall.
Heart rate was 112 beats per minute, regular, no murmur.
Respiratory rate was 24 times per minute, regular, no ronchi.
Abdomen Seopel, peristaltic was normal.
Hepar and lien was not palpable
Extremiti Pulse was 112 beats per minute, regular, pressure and volume
was normal, warm acral,
capillary refill time less than three
es
second
Blood pressure was 90/60 mmHg.
Hematology
Hemoglobin
(HGB)
Eritrosit (RBC)
Leucocyte
(WBC)
Hematokrit
Trombosit
(PLT)
MCV
MCH
MCHC
RDW
MPV
Reference
g%
9.10
12.0-14.4
106/mm3
2.40
4.75-4.85
103/mm3
10.30
4.5-11.0
25.30
36-42
103/mm3
171
150-450
fL
Pg
g%
%
fL
105.40
37.90
36
22.20
9.50
75-87
25-31
33-35
11.6-14.8
7.0-10.2
Neutrofil
Limfosit
Monosit
Eosinofil
Basofil
Neutrofil
Absolut
Limfosit
Absolut
Monosit
Absolut
Eosinofil
Absolut
Basofil
Absolut
Difftel Count
%
77.30
%
11.70
%
8
%
2.70
%
0.300
37-80
20-40
2-8
1-6
0-1
103/L
7.97
2.7-6.5
103/L
1.20
1.5-3.7
103/L
0.82
0.2-0.4
103/L
0.28
0-0.1
103/L
0.03
0-0.1
Carbohydrate Metabolism
Kidney
Ureum
mg/dL
17.70
<50
Creatinin
mg/dL
0.35
0.57-0.87
Electrolyte
Natrium
(Na)
Kalium (K)
Chloride
(Cl)
mEq/L
132
135-155
mEq/L
3.4
3.6-5.5
mEq/L
104
96-106
Neck
Thorax
Abdomen
A : suspected SLE
P:
Bed rest
IVFD D5% NaCl 0,45% 20 gtt
Diet MB 1800 kkal with 7 gr of protein
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Thorax
Discussion
Theory
Case
from SLE
Theory
The characteristic malar or
butterfly rash involves the
cheeks and nasal bridge.
Musculoskeletal findings
include arthralgia, arthritis,
tendinitis, and myositis.
Case
This patient have a
manifestation butterfly
rash.
History of photosensitivity
(-).
This patient had alopecia
with history of easily
pulled-off hair preceding
the onset of alopecia.
Arthralgia was the main
complaint she had when
she was first admitted to
the hospital
Theory
Case
Haematologic disorder
as part of the ARA
criteria
Immunologic disorder
as part of the ARA
Anemia
Conclusion