Presentasi Kasus Anak Akbar Fix

8/17/2019 Presentasi Kasus Anak Akbar Fix

1/57

Preceptor:

dr. Ulynar Marpaung, Sp.A

Presenter:

R.M.Affandi Akbar

(1102011216)Pediatric Department

Raden Said Soekanto Hospital

Yarsi Medical University

Periode Desember 2!" # $ebr%ari 2!&

Case Presentation

Acute

Glomerulonephritis


2/57

IdentityPatient

• Nae ! S"• #irt$ date ! %anuary 2 t$ 2011•

Age ! & years old• 'ender ! Male• Adresss ! apung Maassar • Nationality ! Indonesia• "eligion ! Mosle• *ate o+ adission ! %anuary t$ 2016

• *ate o+ e-aination! %anuary 10t$ 2016


3/57

Parents Identity$at'er Mot'er

Nae Mr. " Mrs. N

Age / years old years old

%o Cleaning Serie 3ouse4i+e

Nationality Indonesia Indonesia

"eligion Mosle Mosle

5duation 3ig$ s$ool

(graduate)

3ig$ s$ool

(graduate)

Address %l. 'g. 3.i$an "7.080& apung

Maassar


4/57

Ananesis

7$e ananesis 4as taen on (an%ary !t' 2!&, yalloananesis (+ro patient9s ot$er andgrandot$er).

S4ollen +ae sine & days e+ore adission to t$e $ospital.

:eer, s$ortness o+ reat$, reddis$ urine.

)'ief complain

Additional complain


5/57

3istory o+ Present Illness

A & years old oy ae to "aden Said SuantoPolie Center 3ospital su++ering +ro s*ollen face

since five days e+ore adission to t$e $ospital.

7$is oplains also +ollo4ed y interitten +eert$at eer rea$ noral teperature sine ; days

e+ore adission, patient also +eeling s$ortness o+

reat$ sine $e roug$t to t$e $ospital.


6/57

3istory o+ Present Illness (2)

Patient


7/57

3istory o+ Present Illness (/)

:or t$e lood test results in eergenyroo (t$ %anuary 2016) are Hb +,- /dl,

leuoytes .00 u8l, 'ematocrit 2&0 andtrombocytes "-./%l.=n t$e days o+ $ospital adission, patient

ondition 4as opos entis, s4ollen +ae

still e-ist, and $e got s$ortness o+ reat$.


8/57

3istory o+ Present Illness (6)

2 4ees

e+oreadission

S*allo*indiffic%lty

; days e+oreadission

1ntermittentfever

& dayse+ore

adission

Patient9sface *as

s*ollen and$is %rinet%rn reddis'

On

Admission

Swollenface,Breathless


9/57

3istory o+ Past Illness

P'arynitis

Bronchitis -

Pneumonia - Morbili +

Pertussis -

Varicella +

Diphteria - Malaria -

Polio -

Enteritis -

3acillary dysentry 4

Amoeba dysentry -

Diarrhea +Thyphoid -

Worms -

Surery -

Brain concussion -

!racture -

Dru reaction -


10/57

Allergi 3istory

• 7$e patient didn


11/57

3irt' History

Mot'er5s prenancy 'istory

7$e ot$er routinely $eed $er pregnany to t$e $ospital. S$e

denied any prole noted during pregnany.

)'ild5s birt' 'istory•aor ! Cipto Mangun usuo 3ospital•#irt$ attendants ! *otor •Mode o+ deliery ! Peragina•'estation ! > 4ee•In+ant state ! 3ealt$y

•#irt$ 4eig$t ! 200 gras•#ody lengt$ ! /0


12/57

Development History

:irst dentition ! 6 ont$s

Psycomotor development

? 3ead up ! 1 ont$ old? Sile ! 1 ont$? aug$ing ! 1@2 ont$ old? Slant ! 2,& ont$ old? Spee$ initiation ! & ont$ old

? Prone podition ! & ont$ old

? Prone position ! & ont$old? Sitting ! 6 ont$ old? Cra4ling ! > ont$ old? Standing ! 1 years old

? aling ! 1 years old


13/57


14/57

$amily History

7$ere are no signi+iantillness or $roni illness

in t$e +aily delared.

History of Disease

in

t'er $amilyMember

7$ere is no one liingaround t$eir $oe no4n

+or $aing sae

ondition as t$e patient.


15/57

Social and 6conomic History

• Patient lied at $ouse 4it$ siBe 20 - 10 toget$er 4it$

parents and a rot$er

• 7$ere 1 door at t$e +ront side,1 toilet near t$e it$en and

edroos, t$ere are / 4indo4s. 7$e 4indo4s are oasionally

opened during t$e day

• 3ygiene

✓ 7$e patient9s ot$er $anges $is lot$es eeryday 4it$ leanlot$es.

✓ #ed s$eets $anged eery t4o 4ees.


16/57

PHYS1)A; 6 (A=UARY !t' 2!&?

@eneral stat%s• 'eneral ondition ! Mild ill

• A4areness ! Copos entis• Pulse ! 112 -8in, regular, +ull,

strong

• #reat$ing rate ! 0 -8in

• 7eperature ! 6,6 0C


17/57

Antropometry Stat%seig$t ! 1; g

3eig$t ! 10&

=%tritional stat%s based =)HS

2

>=ational )enter for Healt'

Statistic? year 2

:A (eig$t +or Age)

1;81> - 100 D /

3:A (3eig$t +or Age)

10&8110 -100 D &

Conclusion: The patient has good

nutritional status.


18/57

Head 9oe 6amination

• HeadNoroep$aly, $air (la, noral distriution, noteasily reoed) sign o+ traua (@)

• 6yes

Iteri slera @8@, pale onEutia @8@, lariation @8@,s4ollen eyes F8F, pupils 8 isoor, diretand indiret lig$t response FF8FF.

• 6ars

Noral s$ape, no 4ound, no leeding, seretion orseruen @8@

• =oseNoral s$ape, idline septu, seretion @8@


19/57

Mo%t'

• ips ! Moist

• Muous ! Moist

• 7ongue ! Not dirty• 7onsils ! 71871, no $ypereia

• P$aryn- ! No $ypereia

=eck

• yp$ node enlargeent (@), sro+ulodera (@).

Head 9oe 6amination >2?


20/57

9'ora

• Inspetion ! syetri 4$en reat$ing, retration (F),

itus ordis is not isile.

• Palpation ! ass (@), tatile +reitus F8F

• Perussion ! sonor on ot$ lungs

• Ausultation

Cor ! regular S1@S2, urur (@), gallop (@)Pulo ! esiular F8F, 4$eeBing @8@, rony F8F

Head 9oe 6amination >B?


21/57

Abdomen

• Inspetion ! Cone-, epigastri retration (@), t$ere is

no 4idening o+ t$e eins, no spider nei.• Palpation! supple, lier and spleen not palpale, +luid

4ae (@), adoinal ass (@)

• Perussion! 7$e entire +ield o+ typani adoen,

s$i+ting dullness (@)

• Ausultation! noral o4el sound, ruit (@)

Head 9oe 6amination >C?


22/57

•ertebra

7$ere does not appear soliosis, yp$osis, and lordosis,

do not loo any ass along t$e line o+ t$e erteral•6tremities

ar,apillary re+ill tie G 2 seonds, edea(F)

•Skin

Noral turgor

Head 9oe 6amination >"?


23/57

=e%roloical 6amination

Meningeal sign

Nu$al rigidity @

ernig sign @

asegue sign @

#rudBinsi 1 @

#rudinsi 2 @


24/57

Motori 5-aination

Po4er

3and

:eet

& & & &8 & & & &

& & & &8 & & & &

7onus

3and

:eet

Norotonus 8 Norotonus

Norotonus 8 Norotonus

7rop$y

3and

:eet

Norotrop$y 8 Norotrop$y

Norotrop$y 8 Norotrop$y


25/57

P$ysiologi "e+le-

Upper e-triities

#ieps

7rieps

o4er e-triities

Patella

A$illes

F 8 F

F 8 F

F 8 F

F 8 F

Motoric 6amination >2?


26/57

Pat$ologi "e+le-

Upper e-triities

3o++an

7roer

o4er e-triities

#ainsy

C$addo

=ppen$ei

'ordon

S$ae++er

@ 8 @

@ 8 @

@ 8 @

@ 8 @

@ 8 @

@ 8 @

@ 8 @

Motori 5-aination ()

Clonus

Patella

A$illes

@ 8 @

@ 8 @


27/57

*e+eation

Urination S4eating

Noral ( 1@2 ties daily)

Noral ( /@& ties daily ) Noral

A%tonom 6amination


28/57

Laboratory Investigation


29/57


30/57

oring *iagnosis

• Suspet Aute 'loerulonep$ritis

*d8 Nep$roti syndroe


31/57

Manageent

•=2 1,& 8

• IH:* " ;dp

• InE. Ce+ota-ie 2 - ;&0 g i..

• InE. asi- 2 - ;,& g i..


32/57

• uo ad ita ! duia ad ona

•uo ad +untiona ! duia ad ona

• uo ad sanationa ! duia ad ona

Pronosis


33/57

$;;E UP

(A=UARY !9H

2!& #(A=UARY !"9H 2!&


34/57

$;;E UP >!4!4!&?


35/57

$;;E UP >!!4!4!&?


36/57

$;;E UP >!B4!4!&?


37/57

$;;E UP >!C4!4!&?


38/57

$;;E UP >!"4!4!&?


39/57

Acute Glomerulonephritis

iterature "eie4


40/57

*e+inition

Aute gloerulonep$ritis ('N) oprises a

spei+i set o+ renal diseases in 4$i$ an

iunologi e$anis triggers in+laation

and proli+eration o+ gloerular tissue t$at an

result in daage to t$e aseent erane,

esangiu, or apillary endot$eliu.

Aute poststreptooal gloerulonep$ritis

(PS'N) is t$e ar$etype o+ aute 'N.


41/57

5pideiology

In deeloping ountries APS'N, usually ours in c'ildren,

predoinately males and o+ten as epideis. Sporadi APS'N

follo*in %pper respiratory tract infection, p'arynitis, and

tonsillitis is ore oon in 4inter and spring in teperateareas, 4$ereas sin in+etions are oonly +ound to preede

APS'N in t$e ore tropial and sutropial areas, 4it$ a pea

inidene during suer and autun. Postin+etious 'N an

our at any age ut usually deelops in $ildren. Most ases

our in patients aged &@1& yearsJ only 10 our in patients older

t$an /0 years.


42/57

5tiology•

In+etious

Streptococcus speies (ie, group A, eta@$eolyti).

Usually deelops 1@ 4ees a+ter in+etion. 74o types

$ae een desried, inoling di++erent serotypes!? Serotype 12 @ due to an upper respiratory in+etion

? Serotype / @ due to a sin in+etion7$e inidene o+ 'N is appro-iately &@10 in persons 4it$

p$aryngitis and 2& in t$ose 4it$ sin in+etions

Nonstreptooal postin+etious 'N ay also result +ro

in+etion y ot$er ateria, iruses, parasites, or +ungi.

? Non@in+etious

Mig$t e primary renal diseases or systemic diseases


43/57

PA73='5N5SIS

• Glomerular injury may be result of : genetic, immunologic ,

perfusion, or coagulation disorder.

• Immunologic injury to the glomerulus results in

glomerulonephritis .• Evidence that glomerulonephritis is caused by immunologic

injury includes morphologic and immunopathologic

similarities to experimental immunemediated

glomerulonephritis! the demonstration of immune reactants"immunoglobulin, complement# in glomeruli! abnormalities in

serum complement! and the $nding of autoantibodies in

some of these diseases .


44/57


45/57

Clinial Mani+estation

5dea

3ypertension

3eaturia

%. &ematuria: the classicdescription of tea or colacolored urine occurs inapproximately '()*+ ofpatients

'. Edema: Edema usuallyappears abruptly and $rstinvolves the periorbital area,but it may be generali-ed

. &ypertension : &ypertension

occurs in approximately /+)0+ of cases . 1erebralcomplications of hypertensionincluding headaches, sei-ures,mental status changes, and

visual changes occur in +)

RIAD OF POST-STREPTOCOCCAL GN


46/57


47/57

*iagnosis

1. Ananesis2. P$ysial e-aination

. aoratory +indings

?. Urinalysis ! "#C asts, proteinuria, PMN leuoytes

?. ':" is o+ten dereased during aute p$ase o+ t$e

disease

?. Serologial arers ! AS= titer and depression o+

leel.?. "enal iopsy

*i++erential *iagnosis


48/57

*i++erential *iagnosis


49/57

7reatent

? 2reatment remains largely supportive and usually

addresses the most urgen problem hypertension.

? 2he importance of supportive therapies in acute

glomerulonephritis can not be over emphasised. 2ight

blood pressure control, appropriate use of diuretics, and

control hyper3alemia, uraemia, and 4uid overload, if

necessary by dialysis, are 5uite literally life saving.

? In most cases of poststreptococcal glomerulonephritis6here in4ammation does resolve spontaneously,

supportive therapies alone 6ill be su7cient 6ith

improved renal function being seen bet6een four and

%8 days after the initial acute failure in 0( of patient.


50/57

1. *iet and atiity

• 9 lo6sodium, lo6protein diet should be prescribed

during the acute phase, 6hen edema and

hypertension are in evidence.

•imitation of 4uid and salt inta3e is recommended inthe child 6ho has either oliguria or edema.

• ;otassium inta3e should be restricted to prevent

hyper3alemia.

• imited activity is probably indicated during the early

phase of the disease, particularly if hypertension is

present.


51/57

2. In Patient Manageent

• Severe Hypertension

Seere $ypertension, or t$at assoiated 4it$ signs o+ ereral

dys+untion, deands iediate attention. 7$ree drugs are

oonly ited as $aing a $ig$ ene+it@to@ris ratio!

1. aetalol (0.&@2 g8g8$ intraenously KIHL),

2. *iaBo-ide, and

. Adnitroprusside (0.&@2 g8g8in IH)

Seere $ypertension 4it$out enep$alopat$y

1. $ydralaBine or ni+edipin

• Mild4to4moderate 'ypertension


52/57

yp

1. #edrest, +luid restrition.

2. 7$e use o+ loop diuretis, su$ as +uroseide (1@ g8g8d oral KP=L,

ad+linistered 1@2 ties daily), ay $asten resolution o+ t$e

$ypertension.

•. 6dema

1. "estrition o+ +luids

2. oop diuretis (+uroseide).

. I+ ongestion is ared, adinister +uroseide parenterally (2

g8g).

•. An%ria or oli%ria

#eause t$ey ay e ototo-i, aoid large doses o+ +uroseide in$ildren 4it$ syptos o+ anuria or seere and persistent oliguria. In

addition, osoti diuretis, su$ as annitol, are ontraindiated, as

t$ey ig$t inrease asular olue.


53/57

. ong@7er Monitoring

• ong@ter +ollo4@up +or a patient +ollo4ing aute

poststreptooal gloerulonep$ritis (APS'N) priarily

onsists o+ lood pressure easureents and urine

e-ainations +or protein and lood


54/57

Copliation

• &ypertensive encephalopathy.

• ;rolonged hypertension can lead tointracranial bleeding.

• =ther potential complications include heartfailure, hyper3alemia, hyperphosphatemia,hypocalcemia, acidosis,sei-ures, and uremia.

• 9cute renal failure


55/57

GGG 7ae 3oe Messages

• Aute 'loerulonep$ritis is spei+i set o+ renal diseases in

4$i$ an iunologi e$anis triggers in+laation

and proli+eration o+ gloerular tissue t$at an result in

daage to t$e aseent erane, esangiu, or

apillary endot$eliu.

• 7$e ost oon in+etious ause o+ aute 'N is in+etion

y Streptococcus speies (group A, eta@$eolyti)

• 7riad o+ A'N ! 5dea, 3eaturia, and 3ypertension

• 7$e treatent is supportie. >upportive therapies alone

6ill be su7cient 6ith improved renal function being

seen bet6een 8 and %8 days after the initial acute

phase in 0( of patient.


56/57

7$an ou


57/57

"5:5"5NC5S

• liegan, ". and Nelson, . (200;). Nelson textbook of pediatrics. P$iladelp$ia! Saunders.

• 3all, %. and 'uyton, A. (2006). Guyton & Hall physiology review . P$iladelp$ia! 5lseier

Saunders.

• uar, H., Aas, A., :austo, N. and Aster, %. (201/). Robbins and Cotran Pathologic asis

of !isease" Professional #dition. ondon! 5lseier 3ealt$ Sienes.• 7ortora, '. and 'rao4si, S. (200). Principles of anato$y and physiology . Ne4 or!

iley.

• Han*eHoorde, ". (201&). Aute Poststreptooal 'loerulonep$ritis! 7$e Most Coon

Aute 'loerulonep$ritis. Pediatrics in Review , 6(1), pp.@1.

• 5ison, 7., Ault, #., %ones, *., C$esney, ". and yatt, ". (2010). Post@streptooal aute

gloerulonep$ritis in $ildren! linial +eatures and pat$ogenesis. Pediatric Nephrology ,

26(2), pp.16&@1>0.

• Martin, %., aul, A. and S$a$t, ". (2012). Aute Poststreptooal 'loerulonep$ritis! A

Mani+estation o+ Iune "eonstitution In+laatory Syndroe. P#!%'R%CS, 10(),

pp.e;10@e;1.

• Hinen, C. (201). Aute gloerulonep$ritis. Postgraduate (edical )ournal , ;(0), pp.206@

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