1. Mr.

Rahmad, a 39 years old, came to the emergency departement of RSMP with

a chief complain of inability to urinate since 1 hours ago.
a. What is the meaning a chief complain of inability to urinate since 1 hours ago ?
zhafira, lisa, ridho, yuliana, irvan
Jawab:
Anuria e.c maybe he suffers urolithiasis (urinary tract obstruction)
b. What are the etiology of inability to urinate? Amar, zafira,nisa, rega, zhafira
Jawab:
Pre-renal : syok hipovolemik, penurunan curah jantung
Intra-renal: glomerulonefritis, kelainan pembuluh darah
Post-renal: obstruksi saluran kemih (BPH, urolithiasis)

PRERENAL CAUSES
Approximately 70 percent of community-acquired cases of acute kidney injury are attributed to
prerenal causes.10 In these cases, underlying kidney function may be normal, but decreased
renal perfusion associated with intravascular volume depletion (e.g., from vomiting or diarrhea) or
decreased arterial pressure (e.g., from heart failure or sepsis) results in a reduced glomerular
filtration rate. Autoregulatory mechanisms often can compensate for some degree of reduced
renal perfusion in an attempt to maintain the glomerular filtration rate. In patients with preexisting
chronic kidney disease, however, these mechanisms are impaired, and the susceptibility to
develop acute-on-chronic renal failure is higher. 11

Several medications can cause prerenal acute kidney injury. Notably, angiotensin-converting
enzyme inhibitors and angiotensin receptor blockers can impair renal perfusion by causing
dilation of the efferent arteriole and reduce intraglomerular pressure. Nonsteroidal anti-
inflammatory drugs also can decrease the glomerular filtration rate by changing the balance of
vasodilatory/vasoconstrictive agents in the renal microcirculation. These drugs and others limit
the normal homeostatic responses to volume depletion and can be associated with a decline in
renal function. In patients with prerenal acute kidney injury, kidney function typically returns to
baseline after adequate volume status is established, the underlying cause is treated, or the
offending drug is discontinued.

INTRINSIC RENAL CAUSES

Intrinsic renal causes are also important sources of acute kidney injury and can be categorized
by the component of the kidney that is primarily affected (i.e., tubular, glomerular, interstitial, or
vascular).

Acute tubular necrosis is the most common type of intrinsic acute kidney injury in hospitalized
patients. The cause is usually ischemic (from prolonged hypotension) or nephrotoxic (from an
agent that is toxic to the tubular cells). In contrast to a prerenal etiology, acute kidney injury
caused by acute tubular necrosis does not improve with adequate repletion of intravascular
volume and blood flow to the kidneys. Both ischemic and nephrotoxic acute tubular necrosis can
resolve over time, although temporary renal replacement therapy may be required, depending on
the degree of renal injury and the presence of preexisting chronic kidney disease.
Glomerular causes of acute kidney injury are the result of acute inflammation of blood vessels
and glomeruli. Glomerulonephritis is usually a manifestation of a systemic illness (e.g., systemic
lupus erythematosus) or pulmonary renal syndromes (e.g., Goodpasture syndrome, Wegener
granulomatosis). History, physical examination, and urinalysis are crucial for diagnosing
glomerulonephritis (Table 39 and Figure 112). Because management often involves administration
of immunosuppressive or cytotoxic medications with potentially severe adverse effects, renal
biopsy is often required to confirm the diagnosis before initiating therapy.

POSTRENAL CAUSES
Postrenal causes typically result from obstruction of urinary flow, and prostatic hypertrophy is the
most common cause of obstruction in older men. Prompt diagnosis followed by early relief of
obstruction is associated with improvement in renal function in most patients.

d. What is the impact if someone have inability to urinate? Zafira, nisa, yuliana,
zhafira, alifa
Jawab:

2. 6 hours before coming to the hospital, patient also experiencing a colic pain on
his left and right waist. The pain was left spreading to the stomach followed with
nausea without vomiting and peeing with a smells of jengkol. The patient wants
to urinate, but the urine excreted were not much, painful, and also followed with
blood and some white stuff.
a. What is the meaning 6 hours before coming to the hospital, patient also experiencing
a colic pain on his left and right waist? Ridho, zhafira, irvan, lisa, nisa
Jawab:
The meaning is he suffers urinary tract obstruction ec djenkolic acid
Maknanya adalah telah terjadi obstruksi traktus urinarius e.c keracunan jengkol
(kristal asam jengkolat).

b. What is the possibility of disease colic pain on left & right waist? Rega, alifa, zhafira,
ridho, irvan
Jawab:
Urolithiasis, pielonefritis akut, tumor ginjal, cholelithiasis, apendisitis akut.
c. What are the possible causes of colic pain (general & case)? Irvan, amar, zafira, nisa,
zhafira

e. What is the meaning of patient wants to urinate, but the urine excreted were not
much, painful, and also followed with blood and some white stuff? Zhafira, nisa,
ridho, rega, amar
Jawab:
 Ingin BAK dan BAK sedikit-sedikit = polakisuria
Keluar benda putih + tetesan darah = kristal asam jengkolat melukai dinding traktus
urinarius.

Adanya darah dalam urin disebabkan oleh adanya luka pada lambung, saluran
kemih, bahkan ginjal akibat terkena kristal asam jengkolat yang tajam.

h. How is the patophysiology of urine excreted were not much, painful, and also followed with
blood and some white stuff? Lisa, yuliana, rega, zhafira, alifa
Jawab:
Ingin BAK dan BAK sedikit-sedikit
Konsumsi jengkol → absorbsi asam jengkolat oleh traktus digestivus → asam
jengkolat masuk dalam aliran darah → asam jengkolat bebas melewati membran
glomerulus → proses reabsorbsi air di ansa henle → oversaturated asam jengkolat →
pembentukan endapan kristal-kristal berbentuk jarum yang tajam → obstruksi traktus
urinarius (ureter) → aktivitas peristaltik ureter untuk mengeluarkan kristal asam
jengkolat yang tajam ↑ → peregangan dinding ureter → sebagian urin yang terbentuk
keluar melalui celah peregangan → BAK sedikit-sedikit.

Urin keluar diikuti keluarnya benda putih + tetesan darah

Konsumsi jengkol → absorbsi asam jengkolat oleh traktus digestivus → asam
jengkolat masuk dalam aliran darah → asam jengkolat bebas melewati membran
glomerulus → proses reabsorbsi air di ansa henle → oversaturated asam jengkolat →
pembentukan endapan kristal-kristal berbentuk jarum yang tajam → obstruksi traktus
urinarius (ureter) → aktivitas peristaltik ureter untuk mengeluarkan kristal asam
jengkolat yang tajam ↑ → ↑ tekanan intraluminal → kristal asam jengkolat yang
berukuran kecil keluar, selain itu kristal tajam melukai dinding traktus urinarius →
urin keluar diikuti keluarnya benda putih + tetesan darah.

3. 12 hours ago, the patient claimed that he was consuming 5 raw jengkol
fuit.
b.What are the subtances contain in jengkol? Nisa, zhafira, amar, zafira, ridho
jawab:
Karbohidrat, protein, vitamin A, vitamin B, fosfor, kalsium, dan besi. Namun,
selain kandungan nutrisi tersebut terdapat kandungan senyawa dalam jengkol
yang berisiko dapat menimbulkan keracunan yaitu asam jengkolat.
Hasil penelitian menunjukkan bahwa dalam biji jengkol terkandung nutrisi yang
diperlukan oleh tubuh antara lain karbohidrat, protein, vitamin A, vitamin B, fosfor,
kalsium, dan besi. Kadar protein dalam biji jengkol (23,3 gram per 100 gram bahan)
melebihi kadar protein dalam tempe (18,3 gram per 100 gram bahan) sehingga
jengkol dapat menjadi sumber protein nabati.

c. What is the relation between consuming jengkol & chief complain? Yuliana,
irvan, zhafira, lisa, rega
Jawab:
Konsumsi jengkol → absorbsi asam jengkolat oleh traktus digestivus → asam
jengkolat masuk dalam aliran darah → asam jengkolat bebas melewati membran
glomerulus → proses reabsorbsi air di ansa henle → oversaturated asam jengkolat →
pembentukan endapan kristal-kristal berbentuk jarum yang tajam → obstruksi traktus
urinarius (ureter) → urin tidak bisa keluar → tidak BAK.

4. Physical Examination:

General Appearance: composmenstis, looks midly sick

Vital sign: BP: 130/180 mmHg, HR: 118 x/m, regular, RR: 22X/m, T: 37,4 C
Specific Examination:
Head: Anemic Conjungtive (-), Icteric sclera (-), mouth and breat smells like
jengkol.
Neck: JVP 5-2 cmH2O, there is no enlargement of the lymph nodes.
Thoraks: Normal shape, simetry.
Heart: heart sound I-II (+) normal, mur mur (-), gallop (-)
Lung: Vesicular (+) normal, ronchi (-), wheezing (-)
Abdomen: normal bowel sound, suprapubic tenderness (+), CVA pain when
being hit (+), ballotement (-), hepar and lien were not palpable.
Extremity: CRT lest than 2 second, warm acral.
Urogenital: urine catether were inserted: 750 cc red colored urine were
produced.
a. How is the interpretation of physical examination? Zhafira, alifah, lisa, ridho, nisa
Jawab:
Tampak sakit sedang
TD 130/80 mmHg = pre-hipertensi.
HR 118 x/menit = takikardi
Mulut dan napas berbau jengkol = efek kandungan sulfur yang ada dalam asam
jengkolat.
Nyeri tekan suprapubik (+) = iritasi pada vesika urinaria
Nyeri ketok CVA (+) = iritasi pada ginjal
Urin 750 cc = poliuria (250-300 cc)
 Urin berwarna kemerahan = hematuri (lecet pada traktus urinarius)

5. Laboratorium
Blood test: Hb 13,4 g/dl; Ureum 85 mg/dl; Creatinin 2,0 mg/dl; Natrium 135
mmol/l; Kalium 3,9 mmol/l;
Urinalysis: pH urine 5,8; urine erythrocytes 100/LPB
a. How is the interpretation of laboratorium examination? Amar, lisa, zhafira, rega,
zafira
Jawab:
indikasi gagal ginjal akut
Ureum ↑ (5-35 mg/dl)
Creatinin ↑ (0,5-1,5 mg/dl)

6. How to diagnose? Zafira, nisa, yuliana, zhafira, irvan, alifa

9. Wd? Ridho, irvan, zhafira, lisa, rega
Jawab: GGA et causa keracunan jengkol.
11.Complication? Rega, zhafira, amar, ridho, alifa
Jawab: Infeksi saluran kemih (ISK)
Gagal ginjal kronis
12.Prognostic? Zhafira, amar, zafira, nisa, lisa
Jawab:
Quo ad vitam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam