CHAPTER III

CASE REPORT
Name

: Evi Sitohang

Age

: 15 years 6 month 25 days

Sex

: Female

Date of Admission

: July, 10 th 2013

Main Complaint

: history of fever

Patient experienced this since three days ago, a high fever, and can be reduced with fever
lowering medicine. No fever while in IGD. Nosebleeding (+) , it is experienced since three
days ago. While in IGD cotton tampon was inserted in the right nostril. Bleeding other than
nosebleeding (-), pale history (+) family realized os since a week ago. Nausea (-), vomiting
(-), reddish rash on both cheeks (+) appear since a week ago. History of leg swelling (+),
defecation (+) with feces color is black like coffee. Urination (+) with urine color like meatwashed water.
History of previous illness: Patient had previously been treated at Adam Malik hospital on
the 6th March, renal biopsy is recommended but the family is not ready.
History of drug use: Physical Examination

Weight/Age: 76,92%
Height/Age: 92,59%
Weight/Height: 76,92%

Presens status
Sens. Compos Mentis, Body temperature: 37,1oC, Pulse: 87bpm, Respiratory Rate: 24bpm.

Localized status

Head : reddish rash on both cheeks , Eye : Light reflexes(+/+), isochoric pupil, pale
conjunctiva palpebra inferior (+/+), icteric sclera (-/-) , Ear : Normal
appereance ,Mouth : Sianosis (-), Nose: Normal appereance, reddish spots on the
nostril/ cotton tampons (+)

1. Neck

: Lymph node enlargement (-)

2. Thorax

: Symmetrical fusiformis, retraction (-). HR: 84bpm, reguler,

murmur (-). RR: 24bpm, reguler. Crackles (-/-)

3. Abdomen

: Soepel. Peristaltic (+) normal. Liver/Spleen/Renal : undeterminate

4. Extremities

: Pulse 84bpm, regular, adequate pressure and

volume, warm acral, CRT < 3

Differential Diagnosis
-

Bleeding disorder

Suspect lupus Nefritis + hypertension stage II

Working Diagnosis
Suspect lupus Nefritis + hypertension stage II
Treatment
- IVFD D5% 4 gtt/i
Nifedipin 2x10 mg

FOLLOW UP
July, 10th 2013
S: Fever (+)
O: Sens: CM, Temp: 38oC, Body weight: 18 kg
Head

Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva palpebra inferior

(-/-), icteric (-/-) , Ear : Normal appereance ,Mouth : Sianosis (-), Nose:
reddish spots on the nostril/ cotton tampons (+)/ reddish spots on both

Thorax

cheeks
Symmetrical fusiformis, retraction (-), HR: 80bpm, regular,murmur (-). RR:

Abdomen
Extremitie

24bpm, reguler.Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 80bpm, regular, adequate pressure and volume, CRT < 3.

s
A: Suspect nefritis lupus + suspect SLE
T: IVFD D5% 4gtt/i
Nifedipin 2x10 mg
Inj. Ceftriaxon 1 gr/12 hour
Diet low-salted regular meal 1580
Transfusion trombosit 4 unit

Laboratory Result:
5.

July , 11th 2013

.DarahLengkap (CBC)
Hemoglobin (HGB)
Eritrosit (RBC)
Leukosit (WBC)
Hematokrit
Trombosit (PLT)
MCV
MCH
MCHC
RDW
MPV
PCT
PDW
HitungJenis
Neutrofil
Limfosit
Monosit
Eosinofil
Basofil
Neutrofil Absolut
Limfosit Absolut
Monosit Absolut
Eosinofil Absolut
Basofil Absolut

g%
106/ mm3
103/ mm3
%
103/ mm3
fL
Pg
g%
%
fL
%
fL

7.60
2.69
2.93
23.20
86
86.20
28.30
32.80
15.80
9.10
0.08
10.2

11.715.5
4.204.87
4.5- 11.0
3844
150 450
8595
28 32
33 35
11.6 14.8
7.0 - 10.2

%
%
%
%
%
103/L
103/L
103/L
103/L
103/L

76.60
20.10
2.70
0.30
0.300
2.24
0.59
0.08
0.01
0.01

37 80
20 40
28
16
01
2.7 6.5
1.5 3.7
0.2 - 0.4
0.20 - 0.40
0 - 0.1

Laboratory Result:
2. July , 11th 2013
FAAL HEMOSTASIS
PT + INR
WAKTU PROTROMBIN
kontrol
Pasien
INR
APTT
Kontrol
Pasien
Waktu trombin
Kontrol
Pasien
KIMIA KLINIK
HATI
Bilirubin total
Bilirubin direk
Fosfatase alkali (ALP)
AST/SGOT
ALT/SGPT
Protein total
Albumin
Globulin
GINJAL
Ureum
Kreatini
Asam urat
IMUNOSEROLOGI
AUTOIMUNE
Anti ds-DNA

Detik
Detik

13.00
12.8

Detik
Detik

32.0
38.0

Detik
Detik

14.0
16.4

mg/dl
mg/dl
U/L
U/L
U/L
g/dl
g/dl
g/dl

0.27
0.12
47
42
22
6.1
2.6
3.5

<1
0-0.2
< 187
< 32
< 31
6.4-8.3
3.2-4.5
2.6-3.6

mg/dl
mg/dl
mg/dl

41.50
0.99
7.2

< 50
0.50-0.90
< 5.7

504.0

Laboratory Result:
3. July , 11th 2013
URINALISIS
Urin lengkap
warna
glukosa
bilirubin
keton
berat jenis
pH
Protein
Urobilinogen
Nitrit
Darah
Sedimen urine
Eritrosit
Leukosit
Epitel
Casts
Kristal

LPB
LPB
LPB
LPB
LPB

Kuning jernih
negatif
negatif
negatif
1.005
7.0
Positif 1
Negatif
negatif
positif

kuning
negatif
negatif
negatif
1.005-1.030
5-8
Negatif

10-20
0-1
1-2
Negatif
Negatif

<3
<6

Negatif
negatif

negatif

Laboratory Result:
2. July , 17th 2013
HEMATOLOGI
Sel LE

Negatif

Negatif

July,11th 2013
S: Fever (+)
O:Sens: CM, Temp: 38,5oC
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

Thorax

palpebrainferior(-/-),reddish spots on both cheeks (butterfly rash)

Symmetrical fusiformis, retraction (-),HR :82bpm, reguler, murmur (-). RR

Abdomen
Extremitie

22bpm, regular. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 82bpm, regular, adequate pressure and volume, warm acral, CRT

< 3..

A: suspect nefritis lupus + suspect SLE

P:: IVFD D5% 4gtt/i
Nifedipin 2x10 mg
Tranfusion trombosit 4 unit
Inj. Ceftriaxon 1 gr/12 hour
Paracetamol 3x400 mg
Diet low-salted regular meal 1580

July, 12th 2013

S:Fever (-)
O:Sens: CM, Temp: 37oC,
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-), facial redness

Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis.HR : 92bpm, reguler, murmur(-).RR : 30bpm, reguler.

Abdomen
Extremitie

Crackles (-/-)
Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 92bpm, regular, adequate pressure and volume, warm acral, CRT

< 3

A: suspect nefritis lupus + suspect SLE

P:IVFD D5% 4gtt/i
Nifedipin 2x10 mg

Inj. Ceftriaxon 1 gr/12 hour/iv

Paracetamol 3x400 mg
Methylprednisolon 1200
Diet low-salted regular meal 1580
july, 13th 2013
S:Fever (-)
O:Sens: CM, Temp: 37oC
Head

Facial redness, Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva

palpebrainferior(-/-)
Ear/Mouth/Nose: normal

Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-), HR : 98bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :32 bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 98bpm, regular, adequate pressure and volume, warm acral, CRT

< 3.

A: suspect nefritis lupus + suspect SLE

P:IVFD D5% 4gtt/i
Nifedipin 2x10 mg
Inj. Ceftriaxon 1 gr/12 hour
Inj. Ranitidin 1 amp/8 hour
Diet MBRG 1380 kkal + 80 gr protein
Metylprednisolon 1200 kg in the 100cc D5%

July, 14th 2013

S:Fever (-)
O:Sens: CM, Temp: 37oC
Head

Facial redness, Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal

Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformi, retraction (-), HR : 96bpm, reguler, murmur (-).

Abdomen
Extremitie

RR : 30bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 96 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: suspect nefritis lupus + suspect SLE
P:IVFD D5% 4gtt/i (micro)
Nifedipin 2x10 mg
Inj. Ceftriaxone 1 gr/12 hour
Inj. Ranitidin 1 amp/8 hour
Diet MBRG 1380 kkal + 80 gr protein
Metylprednisolon 1200 kg in the 100cc D5%

July, 15th 2013

S:Fever (-)
O:Sens: CM, Temp: 37,1oC,
Head

Facial redness, Eye : Light reflexes(+/+), isochoric pupil, pale conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal

Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR : 92bpm, reguler, murmur (-).

Abdomen
Extremitie

RR : 26bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 92 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: suspect nefritis lupus + suspect SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 2x10 mg

Inj. Ceftriaxone 1 gr/12 hour

Inj. Ranitidin 1 amp/8 hour
Diet MBRG 1380 kkal + 80 gr protein
Metylprednisolon 1200 kg in the 100cc D5%
July, 16th 2013
S:Fever (-), pain in the joints (-)
O:Sens: CM, Temp: 37,1oC,
Head

Facial redness - brownish, Eye : Light reflexes(+/+), isochoric pupil, pale

conjunctiva palpebrainferior(-/-),
Ear/Mouth/Nose: normal

Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR : 96bpm, reguler, murmur (-).

Abdomen
Extremitie

RR : 24bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 96 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: suspect nefritis lupus + suspect SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 2x1
Inj. Ceftriaxone 1 gr/12 hour (H7)
Inj. Ranitidin 1 amp/8 hour (H7)
Metylprednisolon 1200 kg in the 100cc D5%
Inj. Vit K 1 amp/h/im(H1)
Diet MBRG 1380 kkal + 80 gr protein
July, 17th 2013
S: Fever (-)
O: Sens: CM, Temp: 37,2oC,

Head

Facial redness - brownish, Eye : Light reflexes(+/+), isochoric pupil, pale

conjunctiva palpebrainferior(-/-),
Ear/Mouth/Nose: normal

Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :106bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :40bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 106 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: suspect nefritis lupus + SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 2x1
Inj. Ceftriaxone 1 gr/12 hour
Inj. Ranitidin 1 amp/8 hour
Inj. Vit K 1 amp/h/im
Diet MBRG 1380 kkal + 80 gr protein
Hidrocortison cream 1 %
Hidrocortison cream 2,5 %
July, 18th 2013
S: Fever (-)
O: Sens: CM, Temp: 37oC,
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :106 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :36bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 104 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: suspect nefritis lupus + SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 2x1
Inj. Ceftriaxone 1 gr/12 hour

Inj. Ranitidin 1 amp/8 hour

Inj. Vit K 1 amp/h/im
Diet MBRG 1380 kkal + 80 gr protein
Hidrocortison cream 1 %
Hidrocortison cream 2,5 %
July, 19th 2013
S: Fever (-), bleeding (-)
O: Sens: CM, Temp: 36,5oC,
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :92 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :24bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 104 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: nefritis lupus + suspect SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 2x1
Inj. Ceftriaxone 1 gr/12 hour
Inj. Ranitidin 1 amp/8 hour
Inj. Transamin 500 mg/ 8 h/ iv
Methylprednisolon 3x24 mg
Plan : USG kidney
Urinalisa
July, 20th 2013
S: Fever (-), bleeding (-)
O: Sens: CM, Temp: 37oC,

Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :94 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :26bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 94 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: nefritis lupus + suspect SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 2x1
Inj. Ceftriaxone 1 gr/12 hour
Inj. Ranitidin 1 amp/8 hour
Inj. Transamine 500 mg/ 8 h/ iv
Methylprednisolon 3x24 mg
July, 21th 2013
S: Fever (-), bleeding (-)
O: Sens: CM, Temp: 36,8oC,
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :92 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :24bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 92 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: nefritis lupus + suspect SLE
P: IVFD D5% 4gtt/i (micro)
Nifedipin 10 mg 3x1
Inj. Transamin 500 mg/ 8 h/ iv
Methylprednisolon 42 mg (5-5-4) (H3)

July, 22th 2013

S: Fever (-), headache(-)
O: Sens: CM, Temp: 37oC, TD 170/90 mmHg
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :100 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :22bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 100 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: nefritis lupus + suspect SLE
P: Nifedipin 3x10 mg
Methylprednisolon 72 mg (5-5-4)
July, 23th 2013
S: Fever (-),headache(-)
O: Sens: CM, Temp: 37,3oC,
Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :102 bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :28bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 102 x/i, regular, adequate p/v, warm acral, CRT < 3.

s
A: nefritis lupus + suspect SLE
P: Nifedipin 3x10 mg
Methylprednisolon 72 mg (5-5-4)
Plan : USG kidney
July, 24th 2013
S: Fever (-), pain in the body (+)

O: Sens: CM, Temp: 37,1oC,

Head

Eye

Light

reflexes(+/+),

isochoric

pupil,

pale

conjunctiva

palpebrainferior(-/-),
Ear/Mouth/Nose: normal
Thorax

Neck : enlarged lymph nodes (-)

Symmetrical fusiformis, retraction (-)HR :103bpm, reguler, murmur (-).

Abdomen
Extremitie

RR :24bpm, reguler. Crackles (-/-)

Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Pulse 92 x/i, regular, adequate p/v, warm acral, CRT < 3. TD : 130/90

mmHg

A: lupus nephritis + suspect SLE + post kidney biopsy

P: Nifedipin 10 mg 3x1
Inj. Ketorolac 10 mg/ 6 h
Methylprednisolon 42 mg (5-5-4) (H7)
USG kidney Result July, 17th 2013
Shape and size kidney is good, differentiation between cortex and medulla of both kidneys is not
clear, its not seen dilatation of PCS and urether, no stone
Conclusion
Suggestive acute bilateral renal failure

Histopatologi kidney Result July, 18th 2013

Macroscopic
Received kidney tissue with long 0,5 cm, elastic, the color white gray
Microscopic
Preparation of kidney tissue appears 2 glomerulus with proliferation of mesangeal cells is light.
Tubules with small size are dilatated with cell epithels experience vacuoles degeneration of the
cytoplasm, in most lumens contain eosiniphilic amorf mass. Blood vessels are within normal
limits, seem to be mild fibrosis on interstitial with minimal infiltration of inflammatory cell
lymphocytes.