Proteinuria negatif and azotemia

IN
PATIENT 27 y.o Man WITH Abses Hepar

Iswanto Korompot
Moderator : Dr. Anik Widijanti, SpPK(K)

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 MEDICAL HISTORY
Man/ 26 y.o/admitted at jun 25th
Chief complaint: abdominal pain
History of Present Illness:
• patient complained of abdominal pain accompanied by
heat which then spread out to the upper right abdomen
since 1 week ago
• Patient complained fever since 2 days ago
• The body of the patient has become yellowish since 1
week ago
• The patient complained of diarrhea 6 days ago.
• Patients complain of not defecating and fart since 2 days
ago. Urination without complaint
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 MEDICAL HISTORY
Past medical history:
 Surgical History is denied
 Had never been sick like this before
 DM, HT, lung TB, and asma were denied

Family medical history

 There were no history of similar disease

Social history:
 Worked as a seller
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 P examination
General appearance : moderately ill, GCS : 456
BMI : 17,57
BP : 120/70 mmHg RR : 24 x/min BB : 49 Kg
HR : 100x/min Tax : 38 oC TB : 167cm

Skin ikterik
Head&ne Conj An -/-, SI -/-, JVP : R + 0 cm H2, sclera
c: ikterik+
Thorax Lungs: simetric movement, vesicular sound,
: rhonchi -/-, wheezing -/-
Heart: Ictus not visible, palpable at ICS V MCL,
heart sound single S1 & S2, no murmurs &
gallop
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 P examination
Abdomen Liver span 13 cm, bowel sound ↓
: Traube Space tympany
tenderness +
Extremitie Edema -/-
s

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 LABORATORY RESULTS
Hematolog 25/6 27/6 3/7 Ref. Range
y
Hb 10,60 10,10 8,4 13.4 - 17.7 g/dl
Erythrocyte 3,94 3,92 3,09 4,0 - 5,5 x 106/µl
Leukocyte 47,01 13,6 28,62 4,3 - 10,3 x 103/µl
Platelet 387 487 803 142 - 424 x 103/µl
Hct 29,40 31,6 26% 40 - 47 %
MCV 74,60 80,60 84,1 80 - 93 f
MCH 26,90 25,8 27,2 27 - 31 pg
RDW 13,20 14,6 15,6 11,5 - 14,5 %
Dif 0/0/0/89/6 1/0/0/88/5 1/0/0/83/8 0-4/0-1/
/5 /6 /8 0-1/51-67/25-
, 33/2-5
 LABORATORY RESULTS
Clinical Chemistry 25/6 Reference range

Ureum 231,20 16,6 - 48,5 mg/dl

Creatinine 3,41 < 1,2 mg/dl
AST 354 0 - 40 U/L
ALT 538 0 - 41 U/L
Albumin 2,23 3,5 – 5,5 g/dL
Globulin 3,32
RBG 105 < 200 mg/dL
Bilirubin total 6,19 <1,0
Bilirubin direk 6,18 <0,25
Bilirubin indirek 0,01 <0,75
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 LABORATORY RESULTS

Serum 25/6 3/7 Reference

Electrolyte range
Na 122 128 136 - 145
mmol/L
K 5,57 3,56 3,5 - 5,0
mmol/L
Cl 89 103 98 - 106
mmol/L

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 LABORATORY RESULTS
Faal Hemostasis Result Ref. range
PPT
Pasien 15,30 9,4-11,3
detik
Kontrol 10,2 detik
INR 1,47 <1,5
APTT
Pasien 34,3 detik 24,6-30,6
kontrol 25,8

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 Reference
Urinalysis 25/6 Range
Color Yellow
Clarity clear
pH 5,5 4,5 – 8,0
SG 1,025 1,005-1,030

Glucose Neg Negative

Protein Neg Negative
Ketones Neg Negative
Bilirubine 2+ Negative
Urobilinogen Neg Negative
Nitrite Neg Negative
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 Urinalysis 25/6 Reference Range
Leukocytes Neg Negative
Blood Neg Negative
Microscopic
Epithelial cells 2,0 ≤ 1/LPF
Casts Neg Neg/LPF
RBC 2,9 ≤ 3/HPF
Eumorfic -
Dysmorfic -
WBC 1,9 ≤ 5/HPF
Crystals
Bacteria 1341,7 ≤ 23 x 103 /ml

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 OTHER EXAMINATION

USG:
-cairan complex intraperitoneal Susp Liver abses
-Hepatomegali
CXR:
Kesan Elevasi diafragma kanan
EKG:
Sinus takikardi 102x/mnt

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N PCCL PL IDx PDx
O
1. Man, 26 yo 1. Chol Susp Liver Blood
Laboratory result estas Abses dt: Smear,
- An normochrom is 1. Hepato- Retikulosit,
normocytic intra ma , AFP, GGT,
- Hypoalbuminemia hepa 2. Amoebia- Alp, Total
- Azotemia prerenal tal sis Protein,
- Elevated AST, ALT 2. Chol 3. Cholestitis Alb, Glo,
- Hyperbilirubinemia estas akut marker
direk is hepatitis
- Leukocytosis ekstr
Physical exam ahep
• Fever atal
• Sclera ikterik
• Liver span 13 cm,

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N PCCL PL IDx PDx
O
... Distended
Abdomen
USG
• Susp Liver Abses
• hepatomegali
Anamnesa
- Fever
- Abdominal Pain
- Diarhea 6 days
ago
- Weight loss

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N PCCL PL IDx PDx
O
2. Suhu >380C sepsis sepsis dt - Procalcit
Tachycardi no.1 dd onin
Respiration >20 UTI - Blood
SOFA Score:5 culture
Leukositosis - Re-UL
- BGA
3. Bowel sound : - Ileus Ileus - CT
Distended paralitic dd Paralitic dt abdome
abdomen + konstipasi no.2 dd n
Anamnesa: post diare cholangitis - -BNO
Not defecated 2 acut
days ago
Post diare

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NO PCCL PL IDx PDx
4. • Anemia Renal CKD DD - Monitoring
normokrom Insufisien AKI Ur, Cr
normositik si - UL
• Azotemia(Ureum: - SI, TIBC,
231,20mg/dl Feritin
Creatinin: 3,41 - USG Renal
mg/dl)
• eGFR= 22,75
ml/mnt/1,73m2(
MDRD)
• BUN:Cr=31,6
• Hiperkalemia
• Hiponatremia

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NO PCCL PL IDx PDx
5. • Creatinin 3,41 Proteinuri Proteinuri - Re UL
• Proteinuria a negatif a negatif
negatif dt
preanalitic
factor
(sample
exchange)

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,
• Hipoalbuminemia ringan 3,5-3,9
• Sedang 2,5-3.5
• Berat <2,5 g/dl (Agung M dan Hendro W 2005)

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 JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

TOTAL: 2

Date of download: ,
Copyright © 2016 American Medical
3/15/2016
Association. All rights reserved.
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 MEDICAL HISTORY
• faktor Yang Mempengaruhi Pemeriksaan Kreatinin
• Senyawa-senyawa yang dapat mengganggu pemeriksaan kadar
kreatinin darah hingga menyebabkan
• overestimasi
• nilai kreatinin sampai 20 persen adalah : Aseton, Asam askorbat,
Bilirubin, Asam urat, Asam aceto acetat, Piruvat, Barbiturat,
sefalosporin, metildopa. Senyawa-senyawa tersebut dapat
memberi reaksi terhadap reagen kreatinin dengan membentuk
warna yang serupa kreatinin sehingga dapat menyebabkan kadar
kreatinin tinggi palsu. Akurasi atau tidaknya hasil pemeriksaan
kadar kreatinin darah juga sangat tergantung dari ketepatan
perlakuan pada pengambilan sampel, ketepatan reagen, ketepatan
waktu dan suhu inkubasi, pencatatan hasil pemeriksaan dan
pelaporan hasi
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• Sukandar E, Sulaeman R. Ilmu Penyakit Dalam
Jilid II. Jaka
• rta: Balai
• Penerbit FKUI;1997. p. 282-305.

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• These are secondary to severe toxemia, perforation of
the bowel, toxic megacolon, rupture of the hepatic
abscess into pleura, lung, peritoneum, pericardium, skin
and subcutaneous tissue. Extraintestinal spread
metastasizing in the brain and bones is uncommon.
Formation of a granuloma in the bowel wall mimicking a
malignant growth, the amoeboma, is also not common.
Rarely, a large hepatic abscess producing obstructive
jaundice can occur. Fever, leukocytosis with elevated
polymorphs, rise in hepatic enzymes and serum bilirubin
are the accompaniments of the complications.
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• Most often, clinical manifestations are insidious and
intermittent, commencing as abdominal discomfort, bloating,
irregular bowel habits, intermittent dysentery with or without
blood/mucous, tenesmus with bloody mucoid diarrhea,
constitutional symptoms, abdominal tenderness, toxic
megacolon, and finally symptoms and signs of peritonitis
secondary to perforation.
• Extraintestinal manifestations are primarily those of hepatic
involvement. These include fever, pain in right lower chest,
which may be related to respiration, appetite disturbances,
breathlessness, cough with or without expectoration and
breathlessness, occasionally mild jaundice, rarely convulsions.
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,
• Urin basa menyebabkan negatif palsu karena
protein sukar mengendap
• Urin encer menyebabkan hasil negatif palsu
• Perbandingan urin dengan reagen tidak sesuai,
reagen kurang akan menjadi positif palsu,
reagen berlebih akan menjadi negatif palsu
• Pemanasan kurang dari 2 menit akan
menyebabkan hasil negatif palsu

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,
• Mikroalbumin atau
• Protein selain albumin yang stik tesnya tidak
sensitif terhadapnya (misalnya globulin)

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