Case

presentation
A 20 YEARS-OLD WOMAN CAME WITH
WEAKNESS AND UNCONSCIOUS SINCE
ABOUT 6 HOUR BEFORE ADMISSION

By:
Reijefki Irlastua, S.Ked
Nurfitria Rahman, S.Ked

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI,
FINASIM
 Introduction
Systemic lupus erythematosus (SLE) is one of the most common
autoimmune disease

a chronic, relapsing, multisystemic autoimmune with protean

manifestations in which almost any organ can be affected
SLE

Prevalence varies with ethicicity, but is estimated to be about 1 per 1000

overall with a female to male ratio of 10:1

Manifestation: rash, arhthritis, and fatigue. Severe end of the

spectrum,SLE can cause nephritis, neurological problems, anemia and
thrombocytopenia
Treatment aims are threefold: managing acute periods of potentially life-
threatening ill health, minimizing the risk of flares during periods of
relative stability, and controlling the less life-threatening, but often
incapacitating day to day symptoms
 Introduction
The term lupus (Latin for wolf) was first use
during the Middle Ages to describe erosive skin
lesions evocative of a wolf bite
1846 Ferdinand von Hebra introduced
the butterfly metaphor to discribe the
malar rash.
Lupus was first recognized as a systemic
disease with visceral manifestations by
Moriz Kaposi (1837-1902).
 Pathogenesis

loss of
tolerance

genetic
predisposition
immune
and
activation
environtment
al exposures

SLE
Criteria SILCC
Patient Identifications
Name : Mrs. SF
Birthdate : May 13rd 1996 (20yo)
Sex : Female
Occupation : Student
Status : Single
Address : Ogan Komering ilir,
South Sumatera
Date of admission : December 26th
2016
Medical record : 985602
 Chief complaint

weakness and unconscious since about six hour

before admission
 Course of present illness
dizzy (+), pain along her weakness (+),

admission
Six hours before
fever (+) body (+), immediately
hair loss (+) rash (+), unconscious (+)

Six month BA
swollen on her vomit (+),
One Years BA

rash after sun

eksposure (+) stomach and significant
foot (+) weight loss
She diagnosed
as fever and skin get medication Panti
disease. for her pain and Bhaktiningsih
swollen on her Hospital
stomach Mohammad
Hoesin General
Hospital.
 Past medical history

Other medical Family disease

conditions history
Asthma (+) from
grandmother
Hypertension (-)
Hypertension (-)

Diabetes (-)
Diabetes (-)
Allergy (+)
 Physical examinations
General status
General appearance : Looked moderately sick
Consciousness : Compos mentis
Blood Pressure : 110/90 mmHg
Pulse Rate : 90x/minute
Respiratory rate : 20x/minute
Body Temperature : 36,6oC
Body Weight : 40 Kg
Body Height : 156 cm
 Physical Examinations
Specific examinations
Head : normocephaly, hair loss (+)
Eyes : pale conjunctiva palpebral (+/+), icteric sclera (-/-), pupils
are round and isocor, light reflex (+), no restricted movement
Nose : septum deviations (-), no discharge
Mouth : pale (+), stomatitis (+) cyanotic (-), papil atrophy (-),
symmetric pharyngeal arch, uvula in the middle, no tonsil
enlargement
Ears: shape is normal, no discharge
Neck : no lymph node enlargement, no thyroid gland enlargement,
JVP (5-2) cm H2O
 Physical Examinations
Thorax (Pulmo)
Inspection : static was symmetrical, and dynamic was symmetrical, no
retractions of intercostal space
Palpation : decreased on the left lung
Percussion: dull on left lung
Auscultation : vesicular (+) decerased on left lung, wheezing (+)

Thorax (Heart)
Inspection : ictus cordis was not visible
Palpation : ictus cordis was not palpable
Percussion: heart border showed no enlargement of the heart
Auscultation : first and second heart sound was normal (M1>M2, T1>T2,
A1<A2, P1<P2), murmur (-), gallop (-)
 Physical Examinations
Abdomen
Inspection : rash (+)convex, there was linea nigra, and scars, no
venectation
Auscultation : bowel sounds (+) normal
Palpation : enlargement of liver (2 finger), flat surface- chewy
Percussion: was not done

Extrimities
Pale palmar (+), palmar erythema (-), swelling (+), deformities (-)
Discussion
 Patients Constituional symptoms : weakness (+),
Complaint Fever along the day (+)

Epidemiology: SLE commonly found

Identity

at women at age 15-40 years.
Women : Man 5,5-9 : 1 S
This Women is 20 years.

Alopecia (+) Malar rash (+) L

Physical
Examinations
Stomatitis (+) Photsensitivity (+)
Pain (Arthritis) (+) E
ANA (+)
Laboratory Comb test (+)
Non-reactive anti HIV-Reagen
 Diagnosis

Working diagnosis
SLE
 Differential diagnosis
Discoid skin lesions
Erythematous macules
Interstitial lung disease
Rheumatoid arthritis
 Management

Oxygen 3-4L/min
Non-

Rest
Avoid herself from
Pharmacology exposure of exposure of
sun

IVFD KAEN 3B gtt

xx/minute
Inj. Metil prednisolon
1x125 mg
Pharmacology Inj. Ciprofloksasin 2x200
mg
Paracetamol 3x500 mg (if
T38,5C)
 Prognosis

quo ad
vitam is
bonam

quo ad
quo ad
sanationa
functionam
m is dubia
is malam
ad malam
THANK YOU