Scenario B Block 15 Class of 2015

Learning Objectives:
Students expected to be able to:
1. describe etiology of Acute Nephritic Syndrome
2. Describe corelation between infection by bacteria Streptococcus β hemolytic group B with the clinical
findings of Acute Nephritic Syndrome
3. Describe pathophysiology and clinical manifestations of Acute Post Streptococcal Glomerulonephritis
(APSGN)
4. Describe APSGN diagnostic criteria
5. Describe APSGN classification
6. Describe further investigation for APSGN diagnostic and the complication
7. Describe management of APSGN
8. Describe complications of APSGN
9. Describe prognosis of APSGN
10. Describe Islamic point of view of this case

"My eyes are swollen"

Ibnu, boy, 7 years old, brought to Pediactric Clinic RSMP with chief complaints is swollen of a whole
body. Swollen appeared since 5 days ago. Swollen first appears around the eyelids, especially after
awakening and testicles, then comes up in face, both the legs and back of foot. Ibnu also complained of
headaches, but no blurry vision and no dyspnue. Urine volume about one glass per days and red like water of
meat wash. Two weeks before the swollen, Ibnu suffered scabs in the area of legs. Ibnu didn’t seek
treatment and his scabs dry themselves. These symptoms are the first experienced. No family suffers the
same.

Physical Examination :
General Condition : compos mentis, moderate illnes , body weight 28 kg, height 113 cm.
Vital Signs : BP 140/90 mmHg, pulse 96 x/min, RR 28 x/min, body temperature 36.8OC.

Specific Circumstances:
Head : palpebrals edema, anemic conjunctivas
no hyperemic pharynx, tonsils are normal
Neck : no lymp gland enlargement
Chest : pulmo: sound vesicular ,no rhales, no wheezing
Heart: heart sound I / II normal, no murmur
Abdomen : buldging, tender, with shifting dullness,
liver and lien are not palpable, normal bowel sound
Extremities : pitting edema, dorsum pedis edema

(Given in 2nd session tutorial)

Supporting investigation:
labolatory findings:
Routin blood : Hb 8.0 g/dl, leucocytes count 18.500/mm3, platelets count450.000/mm3, LED 98
mm/hr
Urinalysis : Colors ( bahasa lab biasa nya cm bilang keruh), proteinuria (+3), erythrocyte
count 30-50 cells/hpf
leukocyte count 2-5 cells/ hpf, cylinders (+)
protein and renal functions : Total protein 5.2 g/dl, albumin 1.2 gr/dl, globulin 4 gr/dl, ureum 40 mg/dl,
creatinine 2.0 mg/dl, cholesterol 180 mg / dl.
Immunology : ASTO 420 IU, CRP (+), titer C3: 60, titer C4: within normal limit
skin scrapings Culture : Streptococcus B hemolytic is growd

I. Clarification of Terms  sesuaikan lg dgn teks

1. swollen
2. red like water meat wash urine
3. scabs
4. palpebra edema
5. pale conjunctiva
6. shifting dullness
7. pitting edema
8. proteinuria
9. cylinders of urinalysis
10. total protein
11. albumin
12. globulin
13. ureum
14. creatinine
15. cholesterol
16. immunology
17. ASTO
18. CRP
19. titer c3 and c4
 Problem Identification  copas sesuaikan lg dgn teks
20. swollen
II.
1. Ibnu, a boy, 7 year old, brought his parents to Pediactric Clinic RSMP with chief complaints of
swollen whole body. Swollen appeared since 5 days ago. Swollen first appears around the eyelids,
especially after awakening and testicles, then in face, both the legs and back of foot.
2. Ibnu also complained of headaches, but no blurry vision and no dyspnue.
3. Urine volume about one glass per days and red like water meat wash.
4. Two weeks before appears of swollen, Ibnu suffered from scabs in the area of legs. Ibnu didn’t seek
treatment and his scabs dry themselves. The symptoms of this disease first experienced. No family
suffers from this disease.
5. Physical Examination :
Vital Signs : BP 140/90 mmHg, weight 28 kg, height 113 cm.
Specific Circumstances:
Head : edema palpebra (+)/(+), pale conjunctiva (+)
Chest : Lung : vesicular (+) normal, ronki (-), wheeze (-)
Heart : heart sound I / II normal, noisy (-)
Abdomen : convex, limp, shifting dullness (+), tenderness (-),
Extremities : pitting (+)/(+) edema, edema dorsum pedis (+)/(+)
6. Supporting investigation:
Regular blood : Hb 8.0 g/dl, leucocytes 18.500/mm3, platelets 450.000/mm3,
LED 98 mm/hr
Urinalysis : Colors like meat wash water, proteinuria (+3), erythrocyte 30-50 cells/hpf
leukocyte 2-5 cells/ hpf, cylinders (+)
Blood chemistry : Total protein 5.2 g/dl, albumin 1.2 gr/dl, globulin 4 gr/dl, ureum 40 mg/dl,
creatinine 2.0 mg/dl, cholesterol 180 mg / dl.
Immunology : ASTO 420 IU, CRP (+), titer C3: 60, titer C4: normal
Cultured skin scrapings : found Streptococcus B hemolytic.

III. Problem Analysis

1. Ibnu, a boy, 7 year old, brought his parents to Pediactric Clinic RSMP with chief complaints of
swollen whole body. Swollen appeared since 5 days ago. Swollen first appears around the eyelids,
especially after awakening and testicles, then in face, both the legs and back of foot.
a. What are possible causes of Ibnu's complaints?
b. What is the mechanism of swollen around the eyelids, especially after awakening and testicles,
then in face, both the legs and back of foot?
c. Why does swollen first comes on the eyelids and the testicles? (untied tissue)
d. What are organs involved in this case? (kidney)
e. how is the anatomy, physiology and histology of organs involved in this case?

2. Ibnu also complained of headaches, but no blurry vision and no dyspnue.

a. What does the meaning of complaining headaches, but blurry vision does not exist? (hypertension,
possibly not hypertensive emergency)
b. What are possible causes of headaches?
c. What is mechanism of headache in the case?
d. What does the meaning of shortness of breath do not exist? (get rid of complications of pleural
effusion)

3. Urine volume about one glass per days and red like water of meat wash.
a. How does the physiology of urinate?
b. Why does the urine looked like water of meat wash?
c. how much is the normal urinary volume production in a day? (according to age and weight)
d. What does the meaning of urine volume about one glass per day? (oliguri)

4. Two weeks before appears of swollen, Ibnu suffered from scabs in the area of legs. Ibnu didn’t seek
treatment and his scabs dry themselves. The symptoms of this disease first experienced. No family
suffers from this disease.
a. what is the meaning of two weeks before the swollen, ibnu suffered scabs in the area of legs?
(possibly streptococcus B haemolytic infection)
b. What is meaning of These symptoms are the first experienced?
c. What is meaning of no family suffers the same?

5. Physical Examination : sda

Vital Signs : BP 140/90 mmHg, weight 28 kg, height 113 cm.
Specific Circumstances:
Head : edema palpebra (+)/(+), pale conjunctiva (+)
Chest : Lung : vesicular (+) normal, ronki (-), wheeze (-)
Heart : heart sound I / II normal, noisy (-)
Abdomen : convex, limp, shifting dullness (+), tenderness (-),
Extremities : pitting (+)/(+) edema, edema dorsum pedis (+)/(+)
 a. please explain the interpretations and mechanisms of physical general findings (must analyze why
weight more than ideal body weight, blood pressure increases)
b. How to determine hypertension in children, including the grades? (Students MUST discuss and
carry CDC table a weight-based on body length and carrying blood pressure classification table)
c. please explain the interpretations and mechanisms of the abnormal specific circumstances
d. What is meaning of lung and heart-specific examination results within normal limits? (get rid of
complications of pleural effusion)
e. What is the purpose to examine shifting dullness and how to perform it?

6. Supporting investigation: sda sesuaikan

Regular blood : Hb 8.0 g/dl, leucocytes 18.500/mm3, platelets 450.000/mm3,
LED 98 mm/hr
Urinalysis : Colors like meat wash water, proteinuria (+3), erythrocyte 30-50 cells/hpf
leukocyte 2-5 cells/ hpf, cylinders (+)
Blood chemistry : Total protein 5.2 g/dl, albumin 1.2 gr/dl, globulin 4 gr/dl, ureum 40 mg/dl,
creatinine 2.0 mg/dl, cholesterol 180 mg / dl.
Immunology : ASTO 420 IU, CRP (+), titer C3: 60, titer C4: normal
Cultured skin scrapings : found Streptococcus B hemolytic.
a. What are interpretations and mechanisms of abnormal findings?
b. How to determine kidney function based on glomerular filtration rate with Schwart formula?

5. When this set of symptoms is interconnected :

a. What disturbances might happen in this case? (students should discuss the different nephritic
syndromes and other nephrotic syndromes and different diagnosis)
b. What investigations are needed to diagnose this case?
c. What disturbances are most likely to occur in this case? (Acute Nephritic Syndrome)
d. how is the classification of Acute Nephritic Syndrome?
e. How does the comprehensive management (promotive, preventive, curative and rehabilitative)?
(antihypertensive, diuretic, antibiotic)
f. What will happen if these circumstances are not manage comprehensively?
g. Is this disorder can be overcome thoroughly, how the odds?

6. how does the competence of general practitioner for this case?

7. how does the Islamic point of view of this case?

Hypothesis And Concept Framework

Ibnu experiences a whole body swelling due to Acute Nephritic Syndrome caused by post-infection
Streptococcal beta hemolytic (Acute Post-Streptococcal Glomerulonephritis) with clinical manifestations
of grade II hypertension.

IV. Conceptual framework

Possible skin infections by beta hemolytic streptococcus immune complex or anti glomerular basement
membrane (GBM) antibodies deposited in glomeruli-activation of complementary classical or alternative
pathways and coagulation systems glomerular inflammation:
a. hematuria
b. renal flow ↓ glomerular filtration rate (LFG) ↓ oliguria water and salt retention edema,
hypervolemia, vascular congestion (hypertension) and azotemia.
c. hypoperfusion activation of renin angiotensin system peripheral vasoconstriction hypertension