Kesya

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)