Komang Keisa Wulandari/F/9 tahun/15/2/2009/18018023 SLICC (Saat pertama kali masuk) Ruam malar Ruam lupus ertitematous kutaneus Palpable purpure Fotosensitivitas Discoid lupus Alopecia Ulserasi oral/nasal Penyakit sendi Perikarditis (berdasarkan echo) Kejang Keterlibatan ginjal: Proteinuria +3 Nefritis (biopsy) Hematologis: WBC 11.89 Neu % 90.84 Neu # 10.8 Ly% 4.9 Ly# 0.58 (more than2 times) Hb 9.6 Plt 131 Blood smear: anemia normokromik normositer. Pemeriksaan serologis C3: 37 (89-160) Titer ANA (belum dilakukan pemeriksaan) Anti ds DNA(belum dilakukan pemeriksaan) Anti Sm (belum dilakukan pemeriksaan) SKOR TOTAL 5 (SLE) 0 0 0 0 0 0 0 0 1 1 1 1 0 1 28 April -29 April History : Patient was hospitized on April 28th-29th with epileptic status, CKD St V, hypertension crisis, Uremic encephalopathy and grad II Hypertension. Patient was planned for HD but patient refused Lab: AST/SGOT ALT/SGPT Bilirubin Total MCHC 32.38 Bilirubin Direk 219.70 Bilirubin PLT Indirek Protein 5.53 MPV Total 29.49 Albumin WBC 62.18 Globulin NE% 30.95 Gamma LY% GT BUN MO% 4.35 Kreatinin 1.02 EO% HCT MCV MCH BA% NE# LY# MO# EO# Hb 38.41 79.94 25.88 1.51 18.34 9.13 1.28 0.30 12.44 LFG 44.9 18.40 0.51 0.19 0.32 8.6 3.5 5.1 55 99.90 10.04 6,3 May 10th History: Patient was admitted again because of seizure 3 times, no fever with diarrhea > 7 times/day for one day, with abdominal enlargement because of ascites BP : 140/100 mmHg Patient was diagnosed with: Hypertension crisis, epileptic status, CKD stg V, Accute diarhhea without dehydration ec viral infection. Thorax AP: Pleuropneumonia Laboratorium: (UL) 22/5/18 Sel Epitel Sedimen Gepeng Silinder Sedimen Lain-lain Berat Jenis Kekeruhan pH Leukosit Nitrit Protein Glukosa Keton Darah Urobilinogen Bilirubin Warna Leukosit Sedimen Eritrosit Sedimen : 34 Granula + Bakteri 1.013 Keruh (+) 6.50 (1+) 25 Negatif (3+) 600 (1+) 30 (1+) (3+) Normal Negatif Yellow 26 205 Lab : Echocardiography Hypertrophic Cardiomyopathy, Mild TR, mild AR, mild Pericardial efussion circumferential, EF 71%. Blood smear: Conclusion normositic normocromic anemia MCV MCH MCHC RDW PLT MPV WBC NE% LY% MO% EO% BA% NE# LY# MO# EO# BA# RBC HGB HCT SC LFG 82.87 28.08 33.89 13.22 131.30 8.95 11.89 90.84 4.90 3.24 0.11 0.91 10.80 0.58 (more than 2 examination 0.38 0.01 0.11 3.42 9.60 28.33 2,8 23 May 23rd 2018 Hemodialysis was done 6 times until patient consulted to us. The 7th HD was canceled because patient got seizure. The condition of this patient right now: - Patient compos mentis - Patient got fever since May 12th until today (, with the highest ToX39Oc - Patient got seizure before HD, and after that patient fully recovered - Patient has been breathlessness since 1 week before consulted (RR =40x/day), and getting worse after seizure. - Patient looked swelling in all of the body (face, abdomen and extremities) - No arthritis or dermatology disorder, no hairloss Patient had consulted to the trophic infection division on May 18th 2018 due to fever with the result: In this patient we get Pelod score 2, with improvement of septic marker, this condition is not appropriate for sepsis Procalcitonin: May 13th 33,82 May 16th 13,79 CRP: May 21st 58,23 From nephrologist Patient is suspected with RPGN and reassess to Hypertension crisis, ACKD et causa chronic glomerulonephritis and vitamin D defisiensi, Suspect Sepsis and is consulted to us due to suspected with SLE also. Teraphy Antihypertension Antibiotic (Cefoperazone sulbactam day 13th) Planned for Metilprednisolon pulse dose for three days (if the BP < P95) Carvedilol We do evaluation for SLE based on anamnesis and physical examination: And got SLICC score 5 Definitive for SLE. (without dsDNA, and ANA titer)
