SCENARIO BSCENARIO B

GROUP 4GROUP 4

Scenario B Scenario B Miss A, aged 20 years, came to ER with chief complain of whole body swelling which 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 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 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 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. 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 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 was often found without prominent cause. Her face was reddish especially at cheek if it was directly shone upon sunlight.it was directly shone upon sunlight.

Miss. A had consumed analgesics whenever she had these complaints but so far had Miss. A had consumed analgesics whenever she had these complaints but so far had no gotten better.no gotten better.

Physical exam : general condition Physical exam : general condition severely sick. Sensorium severely sick. Sensorium compos mentis. compos mentis. HR : 100x/min; RR : 28x/min; rapid and deep; temp 37.5 °c; blood pressure 170/100 HR : 100x/min; RR : 28x/min; rapid and deep; temp 37.5 °c; blood pressure 170/100

mmHg.mmHg. Specific condition : anasarcal edema, stomatitis, ascites, and edema at extremities Specific condition : anasarcal edema, stomatitis, ascites, and edema at extremities

were found.were found. Hb: 9,5 gr%, WBC : 8000/mm³, ESR : 15 mm/hour; ureum 138 mg/dl, creatinine 3,2 Hb: 9,5 gr%, WBC : 8000/mm³, 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 +mg/dl, albumin 2,5 g/dl, cholesterol 268 mg/dl, triglyceride 235mg/dl, urinary protein +++++

Term clarificationTerm clarification Whole body swellingWhole body swelling : to become : to become

distended or puffed updistended or puffed up tenderness around jointstenderness around joints : a sensation of : a sensation of

pain felt when pressure is suddenly removed in pain felt when pressure is suddenly removed in the joints areathe joints area

moderate fevermoderate fever : a rise of body : a rise of body temperature above the normal whether the temperature above the normal whether the natural responsenatural response

stomatitisstomatitis :any of numerous :any of numerous inflammatory disease of the mouth having inflammatory disease of the mouth having various causesvarious causes

…… reddishreddish : an eruption on the body typically : an eruption on the body typically

with little or no elevation above the surfacewith little or no elevation above the surface analgesicanalgesic : produce analgesia to decrease : produce analgesia to decrease

painpain severely sickseverely sick sensoriumsensorium : ability of the brain to receive and : ability of the brain to receive and

interpret sensory stimuliinterpret sensory stimuli ureumureum : a soluble weakly nitrogenous : a soluble weakly nitrogenous

compound CH4N2O that is the chief solid component of mammalian compound CH4N2O that is the chief solid component of mammalian urine and end product of protein decompositionurine and end product of protein decomposition

anasarca edemaanasarca edema : generalized edema with : generalized edema with accumulation of serum in the connective tissueaccumulation of serum in the connective tissue

ascitesascites : accumulation of serous fluid in the : accumulation of serous fluid in the spaces between tissues and organs in the cavity of the abdomenspaces between tissues and organs in the cavity of the abdomen

Problem identificationProblem identification Miss A, aged 20 years, came to ER with chief Miss A, aged 20 years, came to ER with chief

complain of whole body swelling which had complain of whole body swelling which had been more prominent since 2 weeks before been more prominent since 2 weeks before admission.admission.

Swelling has started when she woke up Swelling has started when she woke up around the eyelids. This swelling eventually around the eyelids. This swelling eventually developed the whole body.developed the whole body.

Urine was less than usualUrine was less than usual 1 year ago, patient frequently had tenderness 1 year ago, patient frequently had tenderness

around her joints especially at fingers joints. around her joints especially at fingers joints. This tenderness came and faded on its own.This tenderness came and faded on its own.

…… 1 year ago, patient frequently had tenderness 1 year ago, patient frequently had tenderness

around her joints especially at fingers joints. This around her joints especially at fingers joints. This tenderness came and faded on its own.tenderness came and faded on its own.

Her hair was easily fallen.Her hair was easily fallen. Stomatitis was often found without prominent Stomatitis was often found without prominent

cause.cause. Her face was reddish especially at cheek if it Her face was reddish especially at cheek if it

was directly shone upon sunlight.was directly shone upon sunlight. Miss. A had consumed analgesics whenever Miss. A had consumed analgesics whenever

she had these complaints but so far had no she had these complaints but so far had no gotten better.gotten better.

……

Physical exam : general condition Physical exam : general condition severely severely sick. Sensorium sick. Sensorium compos mentis. HR : compos mentis. HR : 100x/min; RR : 28x/min; rapid and deep; temp 100x/min; RR : 28x/min; rapid and deep; temp 37.5 °c; blood pressure 170/100 mmHg. 37.5 °c; blood pressure 170/100 mmHg.

Specific condition : anasarcal edema, stomatitis, Specific condition : anasarcal edema, stomatitis, ascites, and edema at extremities were found.ascites, and edema at extremities were found.

Laboratory examination : Hb: 9,5 gr%, WBC : Laboratory examination : Hb: 9,5 gr%, WBC : 8000/mm³, ESR : 15 mm/hour; ureum 138 mg/dl, 8000/mm³, ESR : 15 mm/hour; ureum 138 mg/dl, creatinine 3,2 mg/dl, albumin 2,5 g/dl, creatinine 3,2 mg/dl, albumin 2,5 g/dl, cholesterol 268 mg/dl, triglyceride 235mg/dl, cholesterol 268 mg/dl, triglyceride 235mg/dl, urinary protein +++urinary protein +++

Problem analysisProblem analysis what is mechanism of :what is mechanism of :

swellingswelling feverfever joints tenderness especially at finger joints joints tenderness especially at finger joints stomatitisstomatitis reddishreddish fallen hairfallen hair unless urineunless urine

what is correlation between sign and symptom what is correlation between sign and symptom with immunitywith immunity

why swelling started from the eyes when he why swelling started from the eyes when he woke upwoke up

……

how the swelling can develop the whole bodyhow the swelling can develop the whole body is it has correlation between unless urine with is it has correlation between unless urine with

edemaedema what the effect to our bodywhat the effect to our body why the tenderness and fever came faded on its why the tenderness and fever came faded on its

ownown what is the cause of sign and symptomwhat is the cause of sign and symptom how can the reddish happened in the face how can the reddish happened in the face

especially at cheek that consequence of sunlightespecially at cheek that consequence of sunlight

……

why nothing happened after she consumed why nothing happened after she consumed analgesicanalgesic

what is the interpretation of physical examinationwhat is the interpretation of physical examination what is the interpretation of specific conditionwhat is the interpretation of specific condition what is the interpretation of laboratory what is the interpretation of laboratory

examinationexamination what is correlation between sign and symptom what is correlation between sign and symptom

with the examinationwith the examination

……

what is the different diagnosiswhat is the different diagnosiswhat is the working diagnosiswhat is the working diagnosishow to manage this diseasehow to manage this diseasewhat is the prognosiswhat is the prognosiswhat is the complicationwhat is the complication

Hypothesis Hypothesis

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

SLESLE

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

LupusLupus

In SLE, the immune In SLE, the immune system primarily system primarily attacks parts of the attacks parts of the cell nucleus. cell nucleus.

SLE affects tissues SLE affects tissues throughout the body. throughout the body.

SYSTEMIC LUPUSSYSTEMIC LUPUSERYTHEMATOSUS (SLE)ERYTHEMATOSUS (SLE)

Auto-antibodies formed against variety of selfAuto-antibodies formed against variety of self antigensantigens

Anti-double stranded DNA,RNA and histonesAnti-double stranded DNA,RNA and histones Antibodies against cell surface antigens on Antibodies against cell surface antigens on

RBC’sRBC’s and/or plateletsand/or platelets Autoantibodies to erythrocytes or platelets can Autoantibodies to erythrocytes or platelets can

cause hemolytic anemia or thrombocytopenia cause hemolytic anemia or thrombocytopenia due to complement-dependent cell lysis.due to complement-dependent cell lysis.

Tissue damage caused by Type IIITissue damage caused by Type III hypersensitivity reactionshypersensitivity reactions

Immune circulating complexes formed against Immune circulating complexes formed against selfself deposit on tissuesdeposit on tissues

Immune complex deposition along the walls of Immune complex deposition along the walls of small blood vessels cause damage to the small blood vessels cause damage to the endothelial cells, resulting in vasculitis and endothelial cells, resulting in vasculitis and glomerulonephritis.glomerulonephritis.

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

Systemic Lupus ErythematosusSystemic Lupus Erythematosus

OEDEMAOEDEMA

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

LupusLupus

SLE particularly affects the kidneys. SLE particularly affects the kidneys. The tissues of the kidneys, including The tissues of the kidneys, including the blood vessels and the the blood vessels and the surrounding membrane, become surrounding membrane, become inflamedinflamed, and deposits of chemicals , and deposits of chemicals produced by the body form in the produced by the body form in the kidneys. These changes make it kidneys. These changes make it impossible for the kidneys to function impossible for the kidneys to function normally. normally.

Note the granular appearance of the Note the granular appearance of the cortex of these lupus affected cortex of these lupus affected kidneys – it’s across the entire kidneys – it’s across the entire surface of both kidneys suggesting a surface of both kidneys suggesting a chronic condition.chronic condition.

Lupus (joints)Lupus (joints)

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

ARTHRITISARTHRITIS

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

ALLOPECIAALLOPECIA Hair fallen (alopecia) is an auto immune disease Hair fallen (alopecia) is an auto immune disease

whereas hair follicle is became very small so the hair whereas hair follicle is became very small so the hair production is slow and the hair will be loss for some production is slow and the hair will be loss for some months. The follicle is go back normal and will be grow months. The follicle is go back normal and will be grow up again in one year. Beside that the inflammation up again in one year. Beside that the inflammation treatment is appear hair fallen.treatment is appear hair fallen.

Alopecia in arthritis disease usually secondary Alopecia in arthritis disease usually secondary characteristic ( telogen efflufium) where as the hair root characteristic ( telogen efflufium) where as the hair root push in premature in resting state or telogen. Or the push in premature in resting state or telogen. Or the other reason is because superficial inflammation chronic other reason is because superficial inflammation chronic in the skin with the sign red rash that the wide is3 – 4 cm 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 and covered by encrustation and its so sticky, it will be a suppuration follicle. When it’s fallen it’ll be make a rash, suppuration follicle. When it’s fallen it’ll be make a rash, and it’s bring the hair to fallen too.and it’s bring the hair to fallen too.

LupusLupus The inflammation of SLE can be The inflammation of SLE can be

seen in the lining, covering, and seen in the lining, covering, and muscles of the heart. The heart muscles of the heart. The heart can be affected even if you are can be affected even if you are not feeling any heart symptoms. not feeling any heart symptoms. The most common problem is The most common problem is bumps and swelling of the bumps and swelling of the endocardiumendocardium. .

SLE also causes inflammation SLE also causes inflammation and breakdown in the skin. and breakdown in the skin. Rashes can appear anywhere, Rashes can appear anywhere, but the most common spot is but the most common spot is across the cheeks and nose. across the cheeks and nose.

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

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

Anterior Hypotalamus

Change in Set Point

Alteration in Autonimic Heat Loss/ Preservation Mechanism

Fever (Specific)

PGE2

Via Circulation

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

The first is because the allergen (antibody) is sometime come to The first is because the allergen (antibody) is sometime come to attack and sometime nothing; they are come faded on its own. attack and sometime nothing; they are come faded on its own.

The second reason is because miss A consumed analgesic drug. The second reason is because miss A consumed analgesic drug. Some research get that if somebody consumed much analgesic Some research get that if somebody consumed much analgesic (miss A consumed it when she go tenderness joints and its often (miss A consumed it when she go tenderness joints and its often happen) it can broken the center of thermo receptor in the happen) it can broken the center of thermo receptor in the hypothalamus so the thermo receptor is can work finely and the hypothalamus so the thermo receptor is can work finely and the body temperature is disorder. body temperature is disorder.

The third is because of the inflammation. When some one got The third is because of the inflammation. When some one got inflammation so their body temperature will be increase. When she inflammation so their body temperature will be increase. When she got inflammation, the body temp is increase and after she got inflammation, the body temp is increase and after she consumed analgesic drugs the fever is decrease (because of anti consumed analgesic drugs the fever is decrease (because of anti phiretic)phiretic)

Lab examLab exam

HbHb• Adult men = 14 – 18 gr/dl• Adult men = 14 – 18 gr/dl• Adult women = 12 - 16 gr/dl• Adult women = 12 - 16 gr/dl• Old men = 12.4 – 14.9 gr/dl• Old men = 12.4 – 14.9 gr/dl• Old women = 11.7 – 13.8 gr/dl• Old women = 11.7 – 13.8 gr/dlResult = 9.5 gr/dlResult = 9.5 gr/dl

Drugs Drugs Nonsteroidal antiinflammatory drugs (NSAIDs) Nonsteroidal antiinflammatory drugs (NSAIDs)

membantu dalam mengurangi peradangan dan sakit membantu dalam mengurangi peradangan dan sakit pada otot-otot, sendi-sendi, dan jaringan-jaringan lain. pada otot-otot, sendi-sendi, dan jaringan-jaringan lain. Contoh-contoh dari NSAIDs termasuk Contoh-contoh dari NSAIDs termasuk aspirinaspirin, , ibuprofen (Motrin)ibuprofen (Motrin), , naproxen (Naprosyn)naproxen (Naprosyn), dan , dan sulindac (Clinoril)sulindac (Clinoril). .

CorticosteroidsCorticosteroids lebih kuat/manjur dari pada NSAIDs lebih kuat/manjur dari pada NSAIDs dalam mengurangi peradangan dan memugar kembali dalam mengurangi peradangan dan memugar kembali fungsi ketika penyakit aktif. Corticosteroids terutama fungsi ketika penyakit aktif. Corticosteroids terutama berguna ketika organ-organ internal terlibatberguna ketika organ-organ internal terlibat

Hydroxychloroquine (Plaquenil)Hydroxychloroquine (Plaquenil) adalah suatu obat adalah suatu obat antimalaria ditemukan terutama efektif untuk pasien-antimalaria ditemukan terutama efektif untuk pasien-pasien SLE dengan kelelahan, penyakit kulit dan sendi.pasien SLE dengan kelelahan, penyakit kulit dan sendi.

……

Pada pasien-pasien dengan penyakit otak atau Pada pasien-pasien dengan penyakit otak atau ginjal yang serius, ginjal yang serius, plasmapheresisplasmapheresis

Penelitian baru-baru ini mengindikasikan Penelitian baru-baru ini mengindikasikan keuntungan-keuntungan dari keuntungan-keuntungan dari rituximab rituximab (Rituxan)(Rituxan) dalam merawat lupus. dalam merawat lupus.

minyak ikan omega-3 dalam dosis rendah dapat minyak ikan omega-3 dalam dosis rendah dapat membantu pasien-pasien lupus dengan membantu pasien-pasien lupus dengan mengurangi aktivitas penyakit dan kemungkinan mengurangi aktivitas penyakit dan kemungkinan mengurangi risiko penyakit jantung.mengurangi risiko penyakit jantung.

…… Untuk penyakit kulit yang resisten, obat-obat antimalarial Untuk penyakit kulit yang resisten, obat-obat antimalarial

lainnya, seperti lainnya, seperti chloroquine (Aralen)chloroquine (Aralen) atau atau quinacrinequinacrine, , Obat-obat yang meneken imunitas (immunosuppressive Obat-obat yang meneken imunitas (immunosuppressive

medications) juga disebut obat-obat medications) juga disebut obat-obat cytotoxiccytotoxic. . Contoh-contoh dari obat-obat peneken kekebalan Contoh-contoh dari obat-obat peneken kekebalan

termasuk termasuk methotrexate (Rheumatrex, Trexall)methotrexate (Rheumatrex, Trexall), , azathioprine (Imuran)azathioprine (Imuran), , cyclophosphamide (Cytoxan)cyclophosphamide (Cytoxan), , chlorambucil (Leukeran)chlorambucil (Leukeran), dan , dan cyclosporine cyclosporine (Sandimmune)(Sandimmune). .

mycophenolate mofetil (Cellcept)mycophenolate mofetil (Cellcept) telah digunakan telah digunakan sebagai suatu obat yang efektif untuk lupus, terutama sebagai suatu obat yang efektif untuk lupus, terutama ketika dihubungkan dengan penyakit ginjal. ketika dihubungkan dengan penyakit ginjal.

Treatment Treatment

Menghindari stress 2Menghindari stress 2 Menjaga agar tidak langsung terkena Menjaga agar tidak langsung terkena

sinar matahari sinar matahari mengurangi beban kerja yang berlebihan mengurangi beban kerja yang berlebihan menghindari pemakaian obat tertentu. menghindari pemakaian obat tertentu.

odipus dapat odipus dapat

COMPLICATION

Water

Enviroment Infection

Immune Complex

Accumulation in Blood Vessel

Kidney

Proteinuria

Edema

Failure to filter

Kreatinine and Ureum

Rash

Skin Stomatitis

Inflammation

Failure to clear apoptosis cell

Atrophy of Hair follicle

Hypertension

H+

Acidosis Met.

RR and HR

Possible : Anemia Hemolytic

Genetic

Fever

THANK YOU

Adit: hubungan artitritis satu tahun yg lalu?Adit: hubungan artitritis satu tahun yg lalu?apakah SLE itu mulai dari satu tahun yang apakah SLE itu mulai dari satu tahun yang lalu?lalu?

Moses: efek obat?Moses: efek obat?

hubungan nyeri sendi sama hubungan nyeri sendi sama konstimilator?konstimilator?