SCENARIO B

GROUP 4

Scenario B

Miss A, aged 20 years, came to ER with chief complain of whole body swelling which had been more prominent since 2 weeks before admission. Swelling has started when she woke up around the eyelids. This swelling eventually developed the whole body. Urine was less than usual. She had no complaint about the defecation. 1 year ago, patient frequently had tenderness around her joints especially at fingers joints. This tenderness came and faded on its own. c. Her hair was easily fallen. Stomatitis was often found without prominent cause. Her face was reddish especially at cheek if it was directly shone upon sunlight. Miss. A had consumed analgesics whenever she had these complaints but so far had no gotten better. Physical exam : general condition severely sick. Sensorium compos mentis. HR : 100x/min; RR : 28x/min; rapid and deep; temp 37.5 c; blood pressure 170/100 mmHg. Specific condition : anasarcal edema, stomatitis, ascites, and edema at extremities were found. Hb: 9,5 gr%, WBC : 8000/mm, ESR : 15 mm/hour; ureum 138 mg/dl, creatinine 3,2 mg/dl, albumin 2,5 g/dl, cholesterol 268 mg/dl, triglyceride 235mg/dl, urinary protein +++

Term clarification

Whole body swelling : to become distended or puffed up tenderness around joints : a sensation of pain felt when pressure is suddenly removed in the joints area moderate fever : a rise of body temperature above the normal whether the natural response stomatitis :any of numerous inflammatory disease of the mouth having various causes

reddish : an eruption on the body typically with little or no elevation above the surface analgesic : produce analgesia to decrease pain severely sick sensorium : ability of the brain to receive and interpret sensory stimuli ureum : a soluble weakly nitrogenous compound CH4N2O that is the chief solid component of mammalian urine and end product of protein decomposition anasarca edema : generalized edema with accumulation of serum in the connective tissue ascites : accumulation of serous fluid in the spaces between tissues and organs in the cavity of the abdomen

Problem identification

Miss A, aged 20 years, came to ER with chief complain of whole body swelling which had been more prominent since 2 weeks before admission. Swelling has started when she woke up around the eyelids. This swelling eventually developed the whole body. Urine was less than usual 1 year ago, patient frequently had tenderness around her joints especially at fingers joints. This tenderness came and faded on its own.

1 year ago, patient frequently had tenderness around her joints especially at fingers joints. This tenderness came and faded on its own. Her hair was easily fallen. Stomatitis was often found without prominent cause. Her face was reddish especially at cheek if it was directly shone upon sunlight. Miss. A had consumed analgesics whenever she had these complaints but so far had no gotten better.

Physical exam : general condition severely sick. Sensorium compos mentis. HR : 100x/min; RR : 28x/min; rapid and deep; temp 37.5 c; blood pressure 170/100 mmHg. Specific condition : anasarcal edema, stomatitis, ascites, and edema at extremities were found. Laboratory examination : Hb: 9,5 gr%, WBC : 8000/mm, ESR : 15 mm/hour; ureum 138 mg/dl, creatinine 3,2 mg/dl, albumin 2,5 g/dl, cholesterol 268 mg/dl, triglyceride 235mg/dl, urinary protein +++

Problem analysis

what is mechanism of :

swelling fever joints tenderness especially at finger joints stomatitis reddish fallen hair unless urine

what is correlation between sign and symptom with immunity why swelling started from the eyes when he woke up

how the swelling can develop the whole body is it has correlation between unless urine with edema what the effect to our body why the tenderness and fever came faded on its own what is the cause of sign and symptom how can the reddish happened in the face especially at cheek that consequence of sunlight

why nothing happened after she consumed analgesic what is the interpretation of physical examination what is the interpretation of specific condition what is the interpretation of laboratory examination what is correlation between sign and symptom with the examination


what is the different diagnosis what is the working diagnosis how to manage this disease what is the prognosis what is the complication

Hypothesis

Miss A, 20 years, suffer systemic lupus erythematosus cause of autoimmune disease.

Synthesis

Systemic lupus erythematosis is the most commonly known autoimmune disorder. This characteristic butterfly rash is made worse by exposure to sunlight. Lupus is a potentially fatal autoimmune disease that strikes 1 in 2,000 Americans.

SLE

SLE, or lupus, is the classic example of an autoimmune disease in which the immune system attacks not a specific tissue or organ in the body, but rather a wide range of self tissues. Like most autoimmune diseases of this type, lupus is seen most frequently in females, almost always setting in during the peak reproductive years. Lupus is 10 times more common in women than men.

Lupus

In SLE, the immune system primarily attacks parts of the cell nucleus. SLE affects tissues throughout the body.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Auto-antibodies formed against variety of self antigens Anti-double stranded DNA,RNA and histones Antibodies against cell surface antigens on RBCs and/or platelets Autoantibodies to erythrocytes or platelets can cause hemolytic anemia or thrombocytopenia due to complement-dependent cell lysis.

Tissue damage caused by Type III hypersensitivity reactions Immune circulating complexes formed against self deposit on tissues Immune complex deposition along the walls of small blood vessels cause damage to the endothelial cells, resulting in vasculitis and glomerulonephritis.

Systemic Lupus Erythematosus

Butterfly rash of lupus Damaged kidney (left) caused by immunoglobulin deposits (right)

OEDEMA

Increasing of osmotic pressure because of hipoalbuminemia and retention primer salt and water by kidney fluid get out from blood vessels go into tissue plasma volume decrease decreasing of glomerulus filtration together with decreasing of GFR and deceasing of natriuretic peptide secretion push up salt retention and water by kidney the edema is worsen its happen again make anasarcal edema.

Lupus

SLE particularly affects the kidneys. The tissues of the kidneys, including the blood vessels and the surrounding membrane, become inflamed, and deposits of chemicals produced by the body form in the kidneys. These changes make it impossible for the kidneys to function normally. Note the granular appearance of the cortex of these lupus affected kidneys its across the entire surface of both kidneys suggesting a chronic condition.

Lupus (joints)

Almost everyone with SLE has joint pain or inflammation. Any joint can be affected, but the most common spots are the hands, wrists, and knees. Usually the same joints on both sides of the body are affected. The pain can come and go, or it can be long lasting. The soft tissues around the joints are often swollen, but there is usually no excess fluid in the joint. Many SLE patients describe muscle pain and weakness, and the muscle tissue can swell.

ARTHRITIS

Lymphosit B sinovial produce IgG abnormal formation of immune complex in sinobial and cartilago activian jalusr clorin and alternative inflammation response arthritis.

ALLOPECIA

Hair fallen (alopecia) is an auto immune disease whereas hair follicle is became very small so the hair production is slow and the hair will be loss for some months. The follicle is go back normal and will be grow up again in one year. Beside that the inflammation treatment is appear hair fallen. Alopecia in arthritis disease usually secondary characteristic ( telogen efflufium) where as the hair root push in premature in resting state or telogen. Or the other reason is because superficial inflammation chronic in the skin with the sign red rash that the wide is3 4 cm and covered by encrustation and its so sticky, it will be a suppuration follicle. When its fallen itll be make a rash, and its bring the hair to fallen too.

Lupus

The inflammation of SLE can be seen in the lining, covering, and muscles of the heart. The heart can be affected even if you are not feeling any heart symptoms. The most common problem is bumps and swelling of the endocardium. SLE also causes inflammation and breakdown in the skin. Rashes can appear anywhere, but the most common spot is across the cheeks and nose.

People with SLE are very sensitive to sunlight. Being in the sun for even a short time can cause a painful rash. Some people with SLE can even get a rash from fluorescent lights.

Rashes caused by SLE are red, itchy, and painful. The most typical SLE rash is called the butterfly rash, which appears on the face particularly the cheeks and across the nose. SLE can also causes hair loss. The hair usually grows back once the disease is under control.

Mechanism of Fever
Microbes, toxins and other cytokine induce (endogenous pyrogens)

Pyrogens Cytokine (IL-1; TNF, IL-6) From Mononuclear Cells

Via Circulation

Anterior Hypotalamus

PGE2
Change in Set Point

Alteration in Autonimic Heat Loss/ Preservation Mechanism

Fever (Specific)

Miss a fever is came faded on its own because some reason:

The first is because the allergen (antibody) is sometime come to attack and sometime nothing; they are come faded on its own. The second reason is because miss A consumed analgesic drug. Some research get that if somebody consumed much analgesic (miss A consumed it when she go tenderness joints and its often happen) it can broken the center of thermo receptor in the hypothalamus so the thermo receptor is can work finely and the body temperature is disorder. The third is because of the inflammation. When some one got inflammation so their body temperature will be increase. When she got inflammation, the body temp is increase and after she consumed analgesic drugs the fever is decrease (because of anti phiretic)

Lab exam

Hb Adult men = 14 18 gr/dl Adult women = 12 - 16 gr/dl Old men = 12.4 14.9 gr/dl Old women = 11.7 13.8 gr/dl Result = 9.5 gr/dl

Drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) membantu dalam mengurangi peradangan dan sakit pada otot-otot, sendi-sendi, dan jaringan-jaringan lain. Contoh-contoh dari NSAIDs termasuk aspirin, ibuprofen (Motrin), naproxen (Naprosyn), dan sulindac (Clinoril). Corticosteroids lebih kuat/manjur dari pada NSAIDs dalam mengurangi peradangan dan memugar kembali fungsi ketika penyakit aktif. Corticosteroids terutama berguna ketika organ-organ internal terlibat Hydroxychloroquine (Plaquenil) adalah suatu obat antimalaria ditemukan terutama efektif untuk pasienpasien SLE dengan kelelahan, penyakit kulit dan sendi.

Pada pasien-pasien dengan penyakit otak atau ginjal yang serius, plasmapheresis Penelitian baru-baru ini mengindikasikan keuntungan-keuntungan dari rituximab (Rituxan) dalam merawat lupus. minyak ikan omega-3 dalam dosis rendah dapat membantu pasien-pasien lupus dengan mengurangi aktivitas penyakit dan kemungkinan mengurangi risiko penyakit jantung.

Untuk penyakit kulit yang resisten, obat-obat antimalarial lainnya, seperti chloroquine (Aralen) atau quinacrine, Obat-obat yang meneken imunitas (immunosuppressive medications) juga disebut obat-obat cytotoxic. Contoh-contoh dari obat-obat peneken kekebalan termasuk methotrexate (Rheumatrex, Trexall), azathioprine (Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), dan cyclosporine (Sandimmune). mycophenolate mofetil (Cellcept) telah digunakan sebagai suatu obat yang efektif untuk lupus, terutama ketika dihubungkan dengan penyakit ginjal.

Treatment

Menghindari stress 2 Menjaga agar tidak langsung terkena sinar matahari mengurangi beban kerja yang berlebihan menghindari pemakaian obat tertentu. odipus dapat

COMPLICATION

Enviroment

Infection

Genetic
Immune Complex

Fever
Accumulation in Blood Vessel Kidney Proteinuria Failure to filter Skin Inflammation H+ Stomatitis Possible : Anemia Hemolytic Atrophy of Hair follicle

Edema

Kreatinine and Water Ureum

Failure to clear apoptosis cell Acidosis Hyperte Met. nsion Rash RR and HR

THANK YOU

Adit: hubungan artitritis satu tahun yg lalu?apakah SLE itu mulai dari satu tahun yang lalu? Moses: efek obat? hubungan nyeri sendi sama konstimilator?