CASE REPORT

Nephrotic Syndrome
Wahyu Tri Utomo
110170071
Konsulen:
dr. Irman Permana, Sp.A

Patient identity
Name
: An. Najwa
Age
: 6 years old
Sex
: Male
Adress
: Gegesik, Kuningan
Tribe
: Sunda
Religion
: moeslim
His father
: Mr. D
His Mother
: Mrs.S
Admission time : April 6 2015

Clinical Finding
Chieft Complaint :
A swelling on the eyelids; the belly, both hands
smrs the last two weeks
Additional Complaint :
dry cough

Current Illnes History :

Patient complaints waled taken to

hospital with swollen on the eyelids, the
stomach, both hands and second toes smrs
since two weeks. Originally swollen arising on
the eyelids and to stomach patients, hands
and legs. Mother patients sometimes dry
cough that the patient if the night. Patients as
much as ordinary urination clear yellow 2x per
day but the end of this urine with the amount
of water on little more, pain during a tub
refuted. Patient complaints fever refuted by
the mother .Before the puffy , 20 kg weight
patients .

History of Past Illness:

The patient ever suffer disease swelling in
his body in april 2014 .Swollen when it was not as
bad as now , not until patients treated in
hospital , the patients only go on with given
medicine to drink for two weeks and complaints
of swollen it has already reduced .

History of Family Illness:

No family member with the same symptoms
No history of hypertension (-), cough (-)
No history of diabetes mellitus (-), asthma (-),
and food allergy (-).
Medical history :
No drug use in long term

Physical Examination
General Condition : Moderate illnes
Consciousness
: Composmentis
Vital sign
TD : 100/80 mmHg S : 36,5C
HR : 88 breaths/min RR : 28 breaths/min
Antropometri
Body Weight : 21,5 kg
Body High : 114 cm
BMI = 16,15

Generalis status

Head
: Normocephale
Eye
: conjungtiva anemic ( - /- ), sclera
icteric ( - / - ), Edema palpebra (+/+)
Nose` : The breath of the nostrils ( - / - ),
secretions --/ ear
: a normal form , discharges ( - / - )
mouth : lips dry ( - ) , lips cyanosis ( - )
tonsils : t1-t1 quiet
Neck
: symmetrical , there is no
enlargement of lymph nodes

Thoraks
Retraction SS (-), IC -/-, Epi (-)
Slem +/+, Cr +/+, Wh -/Heart Sound 1-2 reguller, Mr (-), Gallop (-)

Abdomen
Peristaltic (+), timpani
Shiffting dullnes (+) Ascites sign (+)
Undulasi (+)

Ekstremitas :

Superio

Inferior

Akral

r
+/+

+/+

hangat
Akral

-/-

-/-

+/+
< 2 detik

+/+
< 2 detik

sianosis
Edema
Capillary
Refill

Laboratory finding
Initial laboratory results
(April 4nd, 2015)

Pemeriksaan

Nilai

Nilai Rujukan

11,7 g/dl

10,8 - 15,6 g/dl

17.420 /uL

4400 11000 /uL

32 %

33 45 %

Hematologi
Hemoglobin
Leukosit
Hematokrit
Trombosit
Netrofil

394.000 / uL

150.000 - 440.000
/uL

0%

36%

54 %

25 60 %

Limfosit

36 %

25-60 %

Monosit

4%

1-6%

Eosinofil

6%

15%

Basofil

0%

01%

30 mm/jam

0 15 mm/jam

batang
Netrofil
segmen

LED

nitial laboratory results (April 4nd, 2015)

Pemeriksaa

Nilai

Nilai Rujukan

Pemeriksa

n
Urine
Makroskopi

Kuning

Kuning

Kekeruhan

jernih

Jernih

Berat jenis

1,025

1,015 - 1,035

4,5 - 8

(+)

Negatif

Albumin

positif
Glukosa

Neg

Negatif

Keton

Neg

Negatif

Bilirubin

Neg

Negatif

Darah

Neg

Negatif

samar
Nitrit

Neg

Negatif

Normal

Normal

Urobilinoge
n

Nilai Rujukan

3,7 g/dl

6 8 g/dl

Albumin

1 g/dl

3,2 - 5,2 g/dl

Globulin

2,7 g/dl

2,5 5 g/dl

Ureum

58 mg/dl

6 46 mg/dl

Creatinin

0,6 mg/dl

0,6 - 1,5 mg/dl

Kimia Darah

s
Warna

ph

Nilai

an
Protein
total

Diagnosis

Differential diagnosis
- Nephrotic syndrome relaps + ARI
- Glomerulonephritis
- CKD
- UTI

Working diagnosis
- Nephrotic syndrome relaps +ARI

Treatments
IVFD D5% 6 tpm mikro
Ampicillin 4 x 500 mg iv
Furosemid 20 mg iv
Prednison 51 mg tab 4-3-3

Prognosis
Quo ad vitam
dubia ad bonam
Quo ad functionam
dubia ad malam
Quo ad sanationam
dubia ad malam