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Acute
Glomerularnephri
tis
Preceptor:
dr. Ulinar M., Sp.A
Compiled by:
Michael S. Rampangilei
07120080106
FACULTY OF MEDICINE UNIVERSITY OF PELITA HARAPAN
DEPARTMENT OF PEDIATRICS CLINICAL CLERKSHIP
BHAYANGKARA TK. 1 R. SAID SUKANTO HOSPITAL
DECEMBER 23RD-MARCH 1ST 2014 PERIOD
IDENTITY
Name
:N
Gender
: Male
Age
: 10 Years 6 Months
Address
: Cigudeg
Weight
: 29kg
Height
: 130cm
Date of admission : 22nd December 2013
Date of examination
: 22nd December 2013
ANAMNESIS
: (-)
: (-)
Morbili
: (+)
Pertussis
: (-)
Varicela
: (-)
Diphteriae
: (-)
Malaria
: (-)
Polio
: (-)
Enteritis
: (-)
Family History
Parents married: once for a mother, once for a
father
Patients father is healthy
Patients mother is healthy
People surrounding the patient is healthy
History of siblings
Year
Gestation
al age
Method of
delivery
Sex
Birthweig
ht
2003
9 months
Normal
Male
3000 gram
Pregnancy history
Gestational age: 40 weeks (normal)
Born at Home
Delivered by a midwife
Born by normal delivery, cried directly after
delivery
Weight: 3000 gram (normal: 2500-4000 gram)
Height: 49cm (normal: 45-54 cm)
Vaccination
BCG
: 1x
Varicella
: 0x
DPT
: 3x
Polio
: 4x
Hepatitis B
Measles
: 3x
: 2x
Other vaccinations
:-
Food intake
Breastfeeding since born until 9 months old
Started be given formula milk since the age of
10 months. The milk was dancow.
Fruits have been given since the age of 10
months (banana and papaya)
Vegetables been given since the age of 10
months (carrot and celery)
Condensed food been given since the age of
1,5 year old (rice, egg, beef meat, chicken
meat, and fish).
Quantity and quality of the food intake, in
overall is considered as sufficient
PHYSICAL
EXAMINATIO
N
Done on December 22rd 2013 (1st day of medical care)
Vital signs
General condition
Level of consciousness
Blood Pressure
Pulse Rate
: 150/80 mmHg
: 90x/minute, regular, adequate
Respiratory Rate
Axillary temperature
: 22x/minute
: 36,7C
Nutritional status
Weight
: 29 kg
Height
: 130 cm
: 29/30= 96,67%
: 130/137 =
General examination
Head :
Normocephaly
Deformity (-)
Eyes :
Pale conjunctiva -/ Icteric sclera -/ Secretions -/ Pupil is rounded, isochore 3mm/3mm
Direct light reflex +/+
Indirect light reflex +/+
Edema Palpebra +/+
Nasal:
Septum is in the middle, deviation (-)
Secretions -/ Nasal flaring -/-
Ear:
External acoustic meatus +/+
Timpanyc membrane is intact +/+
Cerumen -/ Secretions -/-
Mouth
Wet lips
Oral mucous is wet, kopliks spot (-)
Tongue is wet, coated tongue (-)
Pharyx is hyperemic (+)
Tonsil is T2/T3
Neck :
Intact trachea in the middle
Mass (-)
Enlarged lymph nodes (-)
Thorax
Pulmo
Inspection: symmetrical breathing movements
Palpation: Stem fremitus on the right and the left were
equivalent
Percussion: Sonor in both lungs field
Ausculation: Vesicular breath sound +/+, wheezing -/-,
rhonchi -/ Cardio
Inspection: Ictus cordis was unseen
Palpation : Ictus cordis was palpated on the 5th intercostal
left midclavicular line
Percussion : Cardiomegaly (-)
Auscultation : S1 and S2 regullar, gallop (-), murmur (-)
Abdomen
Inspection: Flat abdomen
Auscultation: Bowel sound (+) 2-3x/minute
Palpation: Tenderness (-), hepatomegaly (-),
splenomegaly (-), muscular defense (-)
Percussion: Timpany on all abdominal region
Extremities :
Warm
Capillary refill time < 3 seconds
Edema (-)
LABORATORY
S
EXAMINATION
Result
Unit
Normal Value
Hemoglobin
10,7
g/dl
Hematocrit
31
Leukocyte
9,200
/L
5.000-10.000
Thrombocyte
242.000
150.000-500.000
SGOT
23
/L
SGPT
10
/L
Basophil
0-1
Eosinophil
1-3
Batang
2-6
Segmen
63
50-70
Limfosit
25
20-40
Monosit
12
0-1
Hematology I
HitungJ enis
Examination
Result
Unit
Normal Value
Urinalysis
Color
Yellow
Clearity
Cloudy
pH
5.5
5.5-8.5
Weight
1.025
1.000-1.030
Protein
+3
Negative
Bilirubin
+1
Negative
Glucose
Negative
Keton
Negative
Blood/ Hb
+1
Negative
Nitric
Negative
Urobilinogen
0,1
Leukocyte
IU
0,1-1,0
Negative
Sediment
Leukocyte
Erithrocyte
Epithelial cells
Cyclinder
Crystal
Others
6-7
/ 40x FOV
Negative
7-14
/ 40x FOV
Negative
5-8
/ 40x FOV
Negative
/ 40x FOV
Negative
+amorf
/ 40x FOV
Negative
Negative
Result
Unit
Normal Value
Hemoglobin
11,5
g/dl
Hematocrit
33
Leukocyte
7.600
/L
5.000-10.000
Thrombocyte
361.000
/L
150.000-500.000
Erythrocyte
4.38
Million/ul 4.5-5.5
Hematology I
Examination
Result
Unit
Normal Value
Ureum
125
mg/dl
10 - 50
Creatinine
2,2
mg/dl
0,5 1,5
mg/dl
<200
Clinic Chemistry
Result
Unit
Normal Value
CompleteFeces Exam
Color
Brown
Consistency
Soft
Mucus
Blood
Leukocyte
+1-2
Negative
Erythrocyte
0-1
Negative
Microscopic
Examination
Result
Unit
Normal Value
Hemoglobin
10,7
g/dl
Hematocrit
30
Leukocyte
7,700
/L
5.000-10.000
Thrombocyte
342.000
150.000-500.000
LED
60
<15
Basophil
0-1
Eosinophil
1-3
Batang
2-6
Segmen
61
50-70
Limfosit
31
20-40
Monosit
0-1
Hematology III
HitungJ enis
Examination
Result
Unit
Normal Value
Total Protein
30
g/dl
6.0 8.7
Albumin
2,2
g/dl
3.5 5.2
Globulin
2,6
g/dl
2.5 3.1
Bilirubin Total
0,20
Mg/dL
<1.5
Bilirubin Direct
0,07
Mg/dL
<0.5
Indirect Bilirubin
0,13
Mg/dL
<1.0
SGOT
71,4
<37
SGPT
50,1
<40
Total Cholesterol
156
Mg/dL
<200
HDL
18
Mg/dL
35 - 55
LDL
90
Mg/dL
<160
Tryglyceride
242
Md/dL
<200
Ureum
172
Mg/dL
10 50
Creatinine
1,8
Mg/dL
0,5 1,8
Sodium
132
Mmol/L
135 145
Potassium
4,4
Mmol/L
3,8 5,0
Chloride
106
Mmol/L
98 - 106
Lemak Lengkap
Electrolytes
Examination
Result
Unit
Normal Value
Urinalysis
Color
Yellow
Clearity
Cloudy
pH
5.5
5.5-8.5
Weight
1.020
1.000-1.030
Protein
+3
Negative
Bilirubin
Negative
Glucose
Negative
Keton
Negative
Blood/ Hb
+2
Negative
Nitric
Negative
Urobilinogen
0,1
Leukocyte
IU
0,1-1,0
Negative
Sediment
Leukocyte
4-5
/ 40x
Negative
FOV
Erithrocyte
21-23
/ 40x
Negative
FOV
Epithelial cells
/ 40x
Negative
FOV
Cyclinder
Granular 1 -2
/ 40x
Negative
FOV
Crystal
/ 40x
Negative
FOV
Others
Negative
Result
Unit
Normal Value
Hemoglobin
10,4
g/dl
Hematocrit
31
Leukocyte
13.600
/L
5.000-10.000
Thrombocyte
284.000
/L
150.000-500.000
Ureum
47
Mg/dL 10 - 50
Creatinine
0,9
Hematology I
RESUME
: 150/80 mmHg
DIAGNOSIS
A 10 years 6 months old boy patient,
with weight 29 kg, and height 130
cm, been sick for 8 days, and
receiving his 4th day of medical care,
with working diagnosis of:
Acute Glomerulonephritis with
Secondary Hypertension
Acute Tonsillopharyngitis
Growth and development is
appropriate with age
Fundamental vaccination have been
completely given
TREATMENT
IVFD Ringer Lactate maintenance
2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
PROGNOSIS
Quo ad vitam
: Dubia ad Bonam
Quo ad functionam
: Dubia ad Bonam
Quo ad sanationam
: Dubia
FOLLOW-UP
2ND day of medical care
Fever (-), eyelids are still swollen and still the complain of nausea
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
General condition
Pulse Rate
Respiratory Rate
: 20x/minute
(Normal: 16-20x/minute)
Released from the hospital IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
Fever (-), eyelids are still swollen, fullness of the abdomen, shortness of breath
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
Headache
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
General condition
Pulse Rate
Respiratory Rate
Cefotaxime IV 2x750mg
Captopril 2 x 5mg
General condition
Pulse Rate
Respiratory Rate
Acute Glomerulonephritis
Background
Definition:
The failure of kidneys to process and regulate its physiological function due to the
immunologic mechanism that triggers inflammation and proliferation of glomerular tissue
which in turn result in the damage to the basement membrane, mesangium, or capillary
endothelium.
Fundamental Kidney
Anatomy and Function
Etiology
Infectious
Streptococcus species (ie, group A, beta-hemolytic)
Serotype 12 - upper respiratory infection
Serotype 49 - skin infection
Staphylococci
Mycobacteria
Brucella suis
Treponema pallidum
Corynebacterium bovis
CMV
EBV
Non-Infectious
Primary Renal Disease
Membranoproliferative Glomerulonephritis
Berger Disease
Pure Mesangial Proliferation
Systemic Disease
HSP
Vasculitis (Wegener Granulomatosis)
SLE
Polyarteritis nodosa
Goodpasture Syndrome
Miscellaneous Disease
Guillain-Barr syndrome
Irradiation of Wilms tumor
Diphtheria-pertussis-tetanus (DPT) vaccine
Pathophysiology
fPSGN
Inflamation of
Glomerular
tufts
Endothelial,
Epithelial,
Mesangial Cellular
Proliferation
Hyalinization/Sc
lerosis
Formation
of Immune
Complexes
Glomeruli
Deposition
Extracapillary
Endocapillary
Glomerular
Basement
Thickening
NPSGN
50% Kidney
Enlargement
Increased number
of cells in
Glomerular tufts
Glomeruli
Deposition
DIAGNOSIS
Disease Presentation
HISTORY
Identification of an underlying systemic disease (if any) or
recent infection. Use of intravenous medications
Triad of sinusitis, pulmonary infiltrates, and nephritis Wegener
granulomatosis
Nausea and vomiting, abdominal pain, and purpura, HenochSchnlein purpura
Arthralgias, associated with systemic lupus erythematosus (SLE)
Hemoptysis, occurring with Goodpasture syndrome or idiopathic
progressive glomerulonephritis
Skin rashes, observed with hypersensitivity vasculitis or SLE
Risk Factor: Male, aged 2-14 years, who suddenly develops puffiness of
the eyelids and facial edema in the setting of a poststreptococcal
infection.
Urine:
Dark and scanty
PHYSICAL EXAMINATION
Patients present with a combination of edema, hypertension,
and oliguria.
The physician should look for the following signs of fluid
overload:
Periorbital and/or pedal edema
Edema and hypertension due to fluid overload (in 75% of
patients)
Crackles (ie, if pulmonary edema)
Elevated jugular venous pressure
Ascites and pleural effusion (possible)
Progression of Disease
Progression to sclerosis is rare in the typical patient
0.5-2% of patients with acute GN, the course progresses toward renal failure, resulting in
kidney death in a short period.
Workup
Complete Blood Count
Urinalysis and Sediment
Blood Urea Nitrogen
Serum Ureum and Creatinine
Electrolytes
Erythrocyte Sedimentation Rate
Ultrasonography
Streptozyme Tests
Blood and Tissue Culture
NAPR
Renal Biopsy
Differential Diagnosis
The following 4 renal syndromes commonly
mimic the early stage of acute
glomerulonephritis (GN):
Anaphylactoid purpura with nephritis
Chronic GN with an acute exacerbation
Idiopathic hematuria
Familial nephritis
Lupus nephritis
Gross hematuria is unusual in lupus nephritis.
GN of chronic infection
Manifest as acute nephritis
Unlike PSGN, in which the infection may have resolved by the time
nephritis occurs, patients with nephritis of chronic infection have
an active infection at the time nephritis becomes evident.
Circulating immune complexes play an important role in the
Management
Antibiotics
Penicillin V(500 mg PO q12hr or 250 mg PO q6hr for 10 days)
250 mg of penicillin V = 400,000 U of penicillin.
Loop Diuretics
Antihypertensives
Amlodipine (6 years: 2.5-5 mg/day PO)
Labetalol (0.4-1 mg/kg/hr by continuous IV
infusion; not to exceed 3 mg/kg/hr)
Nifedipine (0.25-0.5 mg/kg/day (extended
release) PO in 1 or 2 daily doses initially; not to
exceed 3 mg/kg/day (120 mg/day)
Hydralazine (Maximum dose in children: 7.5
mg/kg/day divided q12hr PO)
Nitroprusside 10 mcg/kg/min (6 mcg/kg/min in
neonates)
Prognosis
Long-term studies on children with PSGN have
revealed few chronic sequelae
Long-term studies show higher mortality rates
in elderly patients
Patients may be predisposed to crescent
formation
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