TUTORIAL SCENARIO B

GROUP 2
MEMBER:
M. Fadhiel Fajar 702017055
Harry Putra Kusuma 702017069
Fatinah Fairuz Qonitah 702017019
Chairunissa Alya Ananda 702017028
Fajar Alfarabi 702017031
Yusriyah 702017036
Najwa Anggraeni Kadir 702015075
Ghinaa Andariva Tanjung 702017050
Septi Fadhilah Sarabayan Pazka 702017053
Tri Fadia Ariani 702017043
Harum Pazadila Utami 702017059
 SCENARIO
“What Happened to My Eyes?”
Taro, a 7 years old boy, brought by his perents to pediatrician polyclinic with a chief
complain of swelled eyelids since 5 days ago. Swelledness first appear on the eyelids especially
right after waking up and diminishing by noon. Taro also complains of frequent headache. Taro
daily urine production is only one cups and red colored like a blood. Three weeks ago, before this
symptoms appear Taro experiencing cough and cold, but he never got any treatment. This is the
first time Taro experiencing this symptoms. Taro family never has this kind of symptom before.
Physical examination :
 General appearance :
 Conscious : compos mentis, looks moderately sick. BW : 28 kg, height : 123 cm.
 Vital sign : BP 140/90 mmHg, pulse 96 x/m, RR 24 x/m, temp 36,8°C.
Specific examination :
 Head : edema palpebral (+)/(+), pale conjungtiva (-)
 : hyperemic faring, normal tonsil
 Neck : no enlargement of the lymph nodes
 Thorax : lung : vesikuler (+) normal, ronchi (-), wheezing (-)
 Heart : normal heartsound I/II, murmur (-)
 Abdomen : flat, supple, shifting dullness (-), tenderness (-), hepar and lien not
palpable, bowel sound (+) normal
 Extremity : pitting edema -/-, edema dorsum pedis -/-
Additional examination :
 Blood exam : Hb 13,0 g/dl, leukocytes
18.500/mm³, thrombocytes 450.000/mm³, blood
sediment rate (BSR) 98 mm/hour.
 Urinalysis : gross hematuria (+), proteinuria (+2),
erithrocytes 30-50 cells/LPB, leukocytes 2-5 cells/LPB,
cylinder (+).
 Blood cham exam : total protein 5,3 g/dl, albumin 3
gr/dl, globulin 2,3 gr/dl, ureum 40 mg/dl, kreatinin 2,0
mg/dl, cholesterol 180 mg/dl, BUN : 25 mg/dl.
 Imuno-serologi : ASTO 420 IU, CRP (+), titer C3 :
60, titer C4 : normal
 Throat smear culture : streptococcus B hemolyticus is
found.
 CLARIFICATION OF TERM
Cough : A sudden expulsion of air from the lungs while making a loud
noise.
Cold : Low temperatures in physiological activity or in radioactivity.

Swelled eyelids : Temporary abnormal enlargement in certain parts or areas of the body is
not due to cell proliferation, especially in the eyelids.

Edema palpebra : Abnormal collection of fluid in the intercellular spaces of the body (eyelid).

Hyperemic faring : Inflammation of the pharynx.

Shifting dullness : Deafening sound that moves during percussion due to the presence of free
fluid in the abdominal cavity.

Bowel sound : The growling noises round the abdomen cause by the muscular
contraction of peristaltic.
Red colored urine : (Hematuria) blood or erythrocytes in the urine.
Daily urine production is : (Oligouria) reduced urine production / excretion in relation to fluid intake.
only one cup
 PROBLEM ANALYSYS
1. Taro, a 7 years old boy, brought by his perents to pediatrician polyclinic with
a chief complain of swelled eyelids since 5 days ago. Swelledness first appear
on the eyelids especially right after waking up and diminishing by noon.
A. What is the anatomy in this case?
 Answer :
 The kidneys are paired retroperitoneal structures that are normally
located between the transverse processes of T12-L3 vertebrae, with the
left kidney typically somewhat more superior in position than the right.
The upper poles are normally oriented more medially and posteriorly than
the lower poles (Chalouhy, 2017). Grossly, the kidneys are bean-shaped
structures and weigh about 150 g in the male and about 135 g in the
female. They are typically 10-12 cm in length, 5-7 cm in width, and 2-3 cm
in thickness (Chalouhy, 2017)
 Vasculature
The kidneys receive approximately 20% of
the cardiac output. The blood supply to the
kidneys arises from the paired renal arteries
at the level of L2. They enter into the renal
hilum, the passageway into the kidney, with
the renal vein anteriorly; the renal artery;
and the renal pelvis posteriorly
 Renal Lymphatics
The lymphatic drainage parallels the venous
drainage system. After leaving the renal
hilum, the left primary lymphatic drainage is
into the left lateral aortic lymph nodes,
including nodes anterior and posterior to
the aorta between the inferior mesenteric
artery and the diaphragm. On the right, it
drains into the right lateral caval lymph
nodes
B. What is the physiology in this case?
 Answer :
Maintaining H2O balance in the body.
 Maintain an appropriate plasma volume so that it is very
instrumental in the long-term regulation of arterial blood
pressure.
 Helps maintain acid-base balance in the body.
 Excreting metabolic waste products of the body.
 Excreting foreign compounds such as drugs.
C. What is the histology in this case?
Answer :
 Renalis Corpsus
Each renal corpuscular consists of a tuft of capillaries, the glomerulus
surrounded by a double-walled epithelial capsule called the bowman
capsule.
 Mesangial cells are contractile and have receptors for angiotensin II.
 Proximal Tubule Contus. At the urinary poles in the renal
corpuscles, the flat epithelium in the parietal layer of the bowman
capsule is directly related to the proximal tubular epithelial tubular
epithelium in a low cuboid or cylindrical shape.
 Ansa Henle is a U-shaped structure consisting of thick descending
segments, thin descending segments, ascending thin segments and
ascending thick segments
 Distal Tubule Contalus, The thick segment of the ascending ansa
henle breaks through the cortex, after traveling a certain distance.
D. What is the meaning Taro brought by his parents to pediatrician polyclinic
with a chief complain of swelled eyelids since 5 days ago?
 Answer :
The meaning is experience of palpebra edema that cause water and sodium
retention.

E. What is the possible disease with chief complain of swelled eyelids?

 Answer :
Possible causes puffiness / edema in general:
 Osmotic pressure drop
 glomerulonephritis
 nephrotic syndrome
 liver cirrhosis
Increased vascular permeability to protein
 angioneurotic edema
Increased hydrostatic pressure
 congestive heart failure
 liver cirrhosis
Lymph flow obstruction
 Congestive heart failure
Sodium and water retention
 glomerulonephritis
 nephrotic syndrome
 kidney failure
F. What is the etiology of swelled eyelids?
 Answer :
Increased capillary pressure
 Excessive salt and water retention in the kidney
 Acute or chronic renal failure
 Excess mineralocorticoids
Venous pressure height and venous constriction
 Heart failure
 Venous obstruction
 Venous pump failure
(a) Muscle paralysis
(b) Immobilization of body parts
(c) Venous valve failure
 Decreased arteriolar resistance
 Excessive body heat
 Sympathetic nervous system insufficiency
 Vasodilator drugs
 Decreased plasma protein
 Increased capillary permeability
 Barriers to lymphatic return

G. What is the meaning swelledness first appear on

the eyelids especially right after waking up and
diminishing by noon?
Answer :
The meaning is the retention of sodium and
water , so that during sleep the liquid goes to the
loose connective tissue that is the periorbital part,
and disappears during the day because of its gravity.
H. How is mechanism of swelled eyelids?
Answer :
Streptococcal Beta hemolytic infection → upper
respiratory tract infection → autoantiginetic (igG)
formation forms immune complexes in the blood
circulation to the kidneys → attaches to the basement
membrane and damages it → inflammation causes
glomerular filtration to decrease → reabsorbsi in the
proximal tubule increases, reabsorbsi in the distal tubule
increases → Na and water retention → fluid is pushed
from the intravascular space to the extravascular space
→ fluid goes to to transitional connective tissue →
palpebra edema.
I. What is the relation between age and
gender with the chief complain?
Answer :
◦ Age : although APSGN may occur at any age, it
is more commonly oncountered between the
age of 2-15 years. Occurrence of APSGN
below the age of 2 years is rare.
◦ Gender : more common in boys than girls in
the ratio of 2: 1.
2. Taro also complains of frequent headache. Taro
daily urine production is only one cups and red
colored like a blood.
A. What is the meaning Taro also complains of
frequent headache?
 Answer :
The meaning is that taro experiences cerebral
hypoxia which occurs as a result of vasoconstriction
which causes oxygen supply to the brain to
decrease, then stimulates free nerve endings to the
thalamus and arises the perception of pain in the
head. (Possibly due to bacterial infection in the
body).
B. What is the etiology of headache?
 Answer :
◦ Circulation: Intracerebral hemorrhage, subarachnoid hemorrhage
◦ Encephalomeningitis.
◦ Migraine.
◦ Eye: Glaucoma, inflammation, keratitis, anomaly refraction.
◦ Neoplasm (brain tumor).
◦ Traumatic capitis: Komusio, contusio, extradural bleeding, subdular bleeding.
◦ Ear and nose: Mastoiditis, otitis media, sinusitis, rhinitis.
◦ Dental: Teeth, gums.
◦ Cluster headache.
◦ Tension headache.
◦ hypertension
◦ Trigeminal neuralgia.
C. What is the meaning taro daily urine
production is only one cups and red colored
like a blood?
Answer :
 Urine production only one cups, called
oliguria
 Urine Colored Like Blood, called gross
hematuria or macroscopic Hematuria
D. What is the etiology of oligouria and hematuria?
Answer :
Etiology of oliguria :
 DehydrationDehydration is the most common cause of
decreased urine production.
 Infection or trauma Infection or trauma is a typical cause of
oliguria. This can cause the body to become shocked.
 Urinary Tract Obstruction Blockages in the urinary tract, or
blockages, occur when urine cannot be excreted
Etiologi hematuria:
 In acute glomerulonephritis after streptococci infection
(acute post-streptococcal glomerulonephritis / GNAPS), the
incidence of macroscopic hematuria reach
E. How is the mechanism of the additional complains?
Answer :
Hematuria
 Infection of Streptococcus beta hemolyticus antigens> Ag-Ab
complex crossing the glomerular basement membrane>
activation of the complement system> releasing substances
that attract neutrophils> lysosomal enzymes released by
neutrophils> damaging glomerulus> Vasoconstriction of
afferent arterioles and proliferation of endothelial cells,
mesangium, epithelium → decreased filtration surface area
→ increased glomerular membrane permeability → red
blood cells escape glomerular filtration → degradation of
hemoglobin to hematin acid, (mixed with urine) → red urine
such as washing water (gross hematuria)
Oligouria:
 Glomerular inflammation> Afferent arteriolar
vasoconstriction and proliferation of endothelial,
mesangium, epithelial cells → decreased filtration
surface area> decreased filtration rate> oligouria

Cough and cold:

 Streptococcus beta hemolithicus antigen
infection> Ag-Ab complex crossing the
glomerular basement membrane> entering the
respiratory circulation> secreting pro-
inflammatory cytokines> inflammatory response>
cough and cold
Headache:
 Glomerular inflammation>
juxtaglomerular response secretes renin>
angiotension I> angiotensin II> stimulates
the adrenal cortex> secretes
aldosterone> peripheral
vasoconstriction> headache
F. How much is the normal daily urine
production on kids?
 Answer :
Normal values for urinary solute excretion
aEquation 1: Urine uric acid (mg/dL) × Plasma creatinine (mg/dL)/Urine creatinine (mg/dL).

Metabolite Age Random 24-h (All Ages)

(mg/mg)
Calcium 0–6 mo <0.8 <4 mg/kg/d
7–12 mo <0.6
>24 mo <0.21
Oxalate 0–6 mo <0.26 <50 mg/1.73 m2
7–24 mo <0.11
2–5 y <0.08
5–14 y <0.06
>16 y <0.03
Citrate 0–5 y >0.2–0.42 >180 mg/gm Males, >300 mg/gm
>5 y Females
Cystine >6 mo <0.075 <50 mg/1.73 m2
Uric acid >2 y 0.56 mg/dL <815 mg/1.73 m2
GFRa
G. How is the process of formation of urine and micturition?
 Answer :
 Blood enters the kidneys (a. Renal) → into the afferent arterioles and
blood flow to the glomerulus → blood filtration in the glomerulus, the
component molecular such as proteins and erythrocytes are retained and
solute to the size of small molecules pass (urine primary) → blood
filtered, collected in the capsule of bowman → flowed into the proximal
tubule to reabsorbed back, substances that are useful to the body as
sugars, amino acids and other substances are absorbed back (urine
secondary) → brought into the loop of Henle (U) → pass juxtaglomerular
apparatus → entry to the distal tubule, here there is a process of
augmentation is the addition of urea into the tubular → kolingentes /
collecting → → ureter to the renal pelvis (peristalsis and gravity) into the
vesica urinary → after a full urinary vesica,→ impulses cause the kink
receptor brought to the spinal cord by afferent nerve stimulates the
parasympathetic nervous → open the internal sphincter and the external
sphincter followed by an open → second sphincter urinary vesica urinary
compelled due to contraction → urine is channeled through the urine out
of the urethra (urination).
Urine volume (300-400ml) mensitumlasi stretch
receptors / barroreceptors in vesica urinary > vesica
urinary distension with contraction. Detrussor >
stimulus is received, delivered afferent nerve fibers >
towards the spinal cord > delivery back through
efferent nerves > received stimulus m. spinkter
internus > m. Involunteer-relaxation of the internal
spinkter >Urinary about m. The external spinkter
(arising sensation want to urinate) > m. Spinkter
externus remain in a state of contraction of up to
be a volunteer individual wants micturition /
urination.
 If the urine want urinate, m. Spinkter
externus delivering stimulus through
afferents-hypothalamus (micturition center) -
efferent then relaxation occurs m. Spinkter
externus and occurs miksturisi.
 If the atmosphere is not yet possible,
then the external sphincter muscle will
consciously contract on the orders of the
central nervous system. In the right
atmosphere, the external spincter muscles
will consciously relax so that the process of
miksturisi occurs.
H. What is the composition and colour of urine?
Answer :
 Composision :
 Normal urine volume from 600-2500 ml / 24
hours, varies 24-hour urine volume is influenced
by: fluid intake, ambient temperature, humidity,
diet, mentality, weight gain, illnesses. The specific
gravity of urine 1,003-1,030 can be measured
with a urinometer. Total solid (dissolved
ingredients) 3-30 g / L (approximately 50 g / day).
Total solid urine = two digits after the decimal
point of density x 2.66. (2.66 is called the long’s
coefficient) Urine pH 4.7-8 (average 6)
Color :
 Color, clarity (transparency), odor (odor), pH
(acid-alkaline), and specific gravity (density). Color:
light yellow varies depending on the last diet and
the thickness of the urine. Drinking more water
will reduce the viscosity of urine so that the color
becomes clearer
 Compound in normal urine:
 "End-product" nitrogen metabolism: urea, uric
acid and creatinine
 Other components: sodium chloride (NaCl), and
over 100 other compounds in very small
amounts.
I. What is the relation between the
additioinal complains with the chief
complains?
Answer :
 The meaning is that both complaints
are clinical manifestations of GNAPS.
3. Three weeks ago, before this symptoms appear Taro
experiencing cough and cold, but he never got any
treatment. This is the first time Taro experiencing this
symptoms. Taro family never has this kind of symptom
before.
A. What is the meaning three weeks ago before this
symptoms appear Taro experiencing cough and cold, but
he never got any treatment?
 Answer :
 Having an average latent period of 10 to 21 days
after a throat infection followed by nonspecific
symptoms can be found fever, malaise, headache. In
GNAPS this occurs 2 weeks after a person
experiences ISPA by streptococcal germs
B. What is the relation between three weeks ago with the chief
complain?
Answer :
The relation is on three weeks ago Taro experiencing cough and
cold but never got treatment, because of respiratory infections
due to streptococcus infection which can be a trigger factor for
the complaints.

C. What is the meaning this is the first time Taro experiencing

this symptoms?
Answer :
The meaning of the symptoms of a new disease for the first time
shows that the disorder experienced by Bobby is an acute
disorder and the absence of further factors or recurrence of an
illness that has ever suffered.
D. What is the meaning Taro family never
has this kind of symptom before?
 Answer :
The meaning is a disease that is not taro
experienced from the family (hereditary)
and get rid of differential diagnosis from
alport syndrome
4. Physical examination :
 General appearance :
 Conscious : compos mentis, looks
moderately sick. BW : 28 kg, height : 123 cm.
 Vital sign : BP 140/90 mmHg, pulse 96 x/m,
RR 24 x/m, temp 36,8°C.

A. What is the interpretation of physical

examination?
 Answer :
 In Case Normal Value Explanation

Concious Compos mentis Compos mentis Normal

Blood Pressure 140/90mmHg Systolic& dyastolic <90% Hypertension

tile Grade II

Pulses 96x/m 60-100x/m Normal

Respiration Rate 24x/m 16-24x/m Normal

Temperature 36,8oC 36,5-37,5oC Normal

B. How is the abnormal mechanism of physical
examination?
 Answer :
 Pharyngitis -> antibody antigen reaction ->
antibody activation -> organism and host
reactivity -> tissue damage -> nephron
damage -> decrease in functional nephron
counts -> decreased renal filtration rate ->
renal hypoperfusion -> renin release ->
angiotension stimulation 1 & 2 ->
vasoconstriction -> hypertension
5. Specific examination :
 Head : edema palpebral (+)/(+), pale conjungtiva (-)
 : hyperemic faring, normal tonsil
 Neck : no enlargement of the lymph nodes
 Thorax : lung : vesikuler (+) normal, ronchi (-), wheezing (-
)
 Heart : normal heartsound I/II, murmur (-)
 Abdomen : flat, supple, shifting dullness (-), tenderness (-),
hepar and lien not palpable, bowel sound (+) normal
 Extremity : pitting edema -/-, edema dorsum pedis -/-

A. What is the interpretation of specific examination?

 Answer :
 Edema palpebral : abnormal
 Hyperemic faring : faringitis (inflammation of faring)
B. How is the abnormal mechanism of specific
examination?
 Answer :
 Acute nefritic syndrome → glomerulunefritis →
increased glomerular permeability → increase in
plasma protein filtration → proteinuria →
hipoalbuminea → Decrease immune respone → Risk
of infection → Hyperemic faring
 Acute nefritic syndrome → glomerulunefritis →
increased glomerular permeability → increase in
plasma protein filtration → proteinuria →
hipoalbuminea → Osmotic plasma decrease → active
renin angiotensin aldosterone (mechanism of renal
regulator) → Water and sodium retention → edem
6. Additional examination :
 Blood exam : Hb 13,0 g/dl, leukocytes 18.500/mm³,
thrombocytes 450.000/mm³, blood sediment rate (BSR) 98
mm/hour.
 Urinalysis : gross hematuria (+), proteinuria (+2), erithrocytes
30-50 cells/LPB, leukocytes 2-5 cells/LPB, cylinder (+).
 Blood cham exam : total protein 5,3 g/dl, albumin 3 gr/dl,
globulin 2,3 gr/dl, ureum 40 mg/dl, kreatinin 2,0 mg/dl,
cholesterol 180 mg/dl, BUN : 25 mg/dl.
 Imuno-serologi : ASTO 420 IU, CRP (+), titer C3 : 60, titer
C4 : normal
 Throat smear culture : streptococcus B hemolyticus is found.

A. What is the interpretation of additional examination?

 Answer :
 In case Normal Value Interpretation

blood exam Hb 13 gr/dl 13,5-18 gr/dl decrease of Hb

Leukosit 18.500/mm3 5000-15.000/mm3 Leukositosis

BSR 98 mm/jam 0-15 mmHg increase of BSR

Urinalisis Gross hematuria light yellow or Hematuria gross

dark yellow
Proteinuria +2 protein not found Proteinuria

Eritrosit 15-20 sel/LPB < 10 sel/LPB hematuria

Leukosit 2-5 sel/LPB < 5 sel/LPB leukosituria

Kimia darah protein total 5,3 gr/dl 6,2 – 8,0 gr/dl decrease
albumin 3 gr/dl 4,0 -5,8 gr/dl Hipoalbumin

globulin 2,3 gr/dl Normal

1,5 - 3,0 gr/dl
ureum 40 mg/dl anak-anak : 5-20 Uremia (penurunan fungsi ginjal)
mg/dl
Kreatinin 2 mg/dl kids 2-6 years : increase
0.3-0,6 mg/dL
kolesterol 180 mg/dl <200 Normal

imunoserolo ASTO 420 IU 5-12 th < 170 IU increase (streptococcus infection)

gi

C3 60 IU 50-140mg/dl abnormal
B. How is the mechanism abnormal of additional examination?
Answer:
 Hb decreases:
antigen infection Streptococcus> Ag-Ab complex crossing the
glomerular basement membrane> activation of the complement
system> releasing substances that attract neutrophils>
neutrophil-released lysosome enzymes> glomerular
inflammation> glomerular inflammation> Vasoconstriction of the
afferent arterioles and proliferation of endothelial cells,
mesangium, epithelium → decreasing the extent of the
lysosomes released by neutrophils> glomerular inflammation>
Vasoconstriction of the afferent arterioles and proliferation of
endothelial cells, mesangium, epithelium → decreasing the extent
of lysosomes released by neutrophils surface filtration →
increased glomerular membrane permeability → erythrocytes
escape filtration> hematuria> decreased Hb
 Leukocytosis and increased LED:
Possible antigen infection with
Streptococcus> Ag-Ab complex crossing
the glomerular basement membrane>
activation of the complement system>
releasing substances that attract
neutrophils> neutrophil-released lysosomal
enzymes> glomerular inflammation>
inflammatory response> leukocytosis and
increased LEDs
 Gross hematuria (+), erithrocytes 30-50
cell/LPB, cylinder (+):
Glomerular inflammation> Afferent arteriolar
vasoconstriction and proliferation of endothelial,
mesangium, epithelial cells → decreased filtration surface
area → increased glomerular membrane permeability →
red blood cells escape glomerular filtration →
degradation of hemoglobin into hematin acid, (mixed
with urine) → decreased red surface filtration →
increased glomerular membrane permeability → red
blood cells escape glomerular filtration → degradation
of hemoglobin to hematin acid, (mixed with urine) →
decreased red urine surface area such as meat washing
water (hematuria gross (+)), erithrocytes 30-50 cell /
LPB, cylinder (+)
 Proteinuria and decreased albumin:
ntigen infection Streptococcus> Ag-Ab complex crossing the
glomerular basement membrane> activation of the complement
system> releasing substances that attract neutrophils> neutrophil-
released lysosome enzymes> glomerular inflammation> glomerular
inflammation> Vasoconstriction of the afferent arterioles and
proliferation of endothelial cells, mesangium, epithelium → decreasing
the extent of the lysosomes released by neutrophils> glomerular
inflammation> Vasoconstriction of the afferent arterioles and
proliferation of endothelial cells, mesangium, epithelium → decreasing
the extent of lysosomes released by neutrophils surface filtration →
increased glomerular membrane permeability> some protein escapes>
proteinuria> decreased albumin

 ASTO 420 IU and culture (+):

Streptococcus beta hemolithicus antigen infection> ASTO 420 IU and
Culture (+).
7. How to diagnose?
Answer :
Anamnesis
 Chief complains : swelled eyelids since 5 days ago
 Additional complains : frequent headache, oligouria, hematuria,
cough and cold
Physical examination : looks moderately sick, hypertension
Specific examination : edema palpebral, hyperemic faring
Additional examination :
 Blood exam : decrease of Hb, leukocytosis, increase of BSR
 Urinalysis : gross hematuria (+), proteinuria (+2)
 Blood chem :hypoalbuminemia, increase of ureum and
kreatinin
 Imuno-serologi : ASTO increase
 Throat smear culture : Streptococcus B hemolyticus is found.
8. What is the differential diagnosis in the case?
Answer :
Diseses GNAPS Idopathic rapidly progressive iga nephrathy
glomerulonephritis

Clinical manifestations
Age and sex All ages M 7:F 1 Adults 2:1 male 10-35 yr 2: 1 male
Acute nephritic 90 % 90% 50%
syndrome
Asymptomatic Occasionally Rare 50%
hematuria
Nephrotic syndrome 10-20% 10-20% Rare
Hypertension 70% 25% 30-50%
Acute renal failure 50% transient 60% Very rare

Other Latent priode of 1-3 week None Follow viral syndromes

Laboratory findings Inc ASTO titer Postive ANCA in some -Inc serum ig A
Positive strepptozyme -iga IN DERMAL CAPILLARIES
Dec C3-C9
Normal C1,C4
Immunogenetics HLA-B12 ,D “EN” (9) None estabilish HLA-Bw 35 .DR4 (4)
Renal pathology
Light microscopy Diffuse prolifferation Crescentic GN Focal proliferation

Immunofluorescence Granular ig g ,c3 No immune deposite Diffuse mesangial ig a

Electron microscopy Subephitelial humps No deposite Mesangial deposite

Prognosis 95% resolve spontaneously 75% stabilize Low proggresson 25%

5% rpgn or slowy progressive
9. What is the additional examination in the
case?
 Answer :
Imaging (USG)

10. What is the working diagnosis in the case?

 Answer :
Acute post-streptococcal glomerulonephritis.
11. What is the therapy in the case?
 Answer :
 Bed rest
 Diet :
 Low salt 0,5 -1 gr/day
 Low protein 0,5 gr/kgBB/day
 Diuretic : furosemide 1-2 mg/kgBB/day for reduce
excess water and salt
 Antibiotic : erythromycin 40 mg/kgBB/day during
10 days
 Antihypertension : captopril 0,1-2 mg/kgBB/day
12. What is the complication in the case?
 Answer :
 EH is severe hypertension (emergency hypertension) .
 Acute kidney injury (AKI)
 Lung edema
 Posterior leukoencephalopathy syndrome
 Oliguria until anuria which can last 2-3 days. Occurs as a result of reduced
glomerular filtration. If oligouria lasts more than 2-3 days accompanied by
symptoms such as acute renal failure with uremia, hyperkalemia and
acidosis can be considered peritonial dialysis or hemodialysis
 Circulatory disorders in the form of dyspnea, orthopnea, the presence of
crackles, enlargement of the heart caused by increased plasma volume. The
heart can enlarge and develop heart failure due to persistent hypervolemia.
 Anemia that arises because of impaired formation of erythropoietin.
13. What is the prognosis in the case?
 Answer :
Dubia ad bonam

14. What is the SKDU in the case?

 Answer :
3A - General Doctors able to make a clinical
diagnosis based on a physical examination and
additional examinations requested by a doctor such
as a lab examination or x-ray. Doctors can decide
and give preliminary therapy, and refer to relevant
specialists (not emergency cases) (KKI, 2012).
15. What is the Islamic view in the case?
 Answer :
 O mankind, there has to come to you
instruction from your Lord and healing
for what is in the breasts and guidance
and mercy for the believers (QS.Yunus :
57)
Conclusion
Taro, a 7 years old boy, complains swelled
eyelids suffering acute post streptococcal
glomerulonephritis (APSGN).
 Conceptual framework
Streptococcus Beta
hemolitycus infection

Ag-Ab complex

Inflammation of
glomerulus

Hypertension GNAPS Oliguria

Edema palpebra Hematuria