Susp Nephritic Syndrome dd Nephrotic Syndrom

By :
Muhammad Sidiq, MD

Supervisor :
M. Diana Rahim, MD

Indonesian Doctor Internship Program

Guntur Hospital Garut
October 2021
Patient’s Identity

Name: JM
Age : 7 years old
Gender : Male
Medical Record Number: 171777
Admission Date : October,09 2021
Time : 13.30
GP : Pratama, MD
HISTORY TAKING

Chief complain : Swelling of the body

The patient was refered by Bethesda Clnic to the emergency departement at Guntur Hospital with his
family. His mother reported his complaint of swelling his body since 4days before. Swelling started from
his face then spreads to his belly and limb, especially lower limb. Patient also felt fever and sore throat 3
days before swelling common. Patient took medicine for relieving his fever and sore throat. Patient and
family don’t remember what kins of medicine was took by him.
Patient complains of his reddish yellow, lack urin. Sometimes patient felt stomache. Nausea -, vomitus –
Patient had check laboratory examination from Bethesda
HISTORY TAKING

History of past illness:

No h/o similar illness
No h/o allergy
No h/o TB, Asthma, Hypertension
No h/o rash and, neck swelling
Physical Examination

General Condition : Alert, swelling body

Awareness : Composmentis
GCS : E4M6V5
Blood Pressure : 80/60
Pulse Rate : 122x/menit
Respiratory Rate : 24x/menit
Temperature : 36.8 C
Oxygen Saturation : 96% free air
Weight : 28 kg
Physical Examination

Head : normochepal
Eyes : Anemic Conjungtiva -/-, Icteric Sclera - / -, edema periorbital +/+

Nose : nostring breathing ( - ), rhinorrhea -

Mouth: cyanosis ( - ), tonsil T1/T1, Pharyng hiperemis -

Neck : lymph node enlargment ( - )

Physical Examination

Head : normochepal
Eyes : Anemic Conjungtiva -/-, Icteric Sclera - / -, edema periorbital +/+

Nose : nostring breathing ( - ), rhinorrhea -

Mouth: cyanosis ( - ), tonsil T1/T1, Pharyng hiperemis -

Neck : lymph node enlargment ( - )

Thorax : symmetrical chest movements
Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : VBS right = left, crackle - / -, wheezing - / -

Abdomen : slightly distended, soepel, bowel sound ( + ) normal, epigastric tenderness -

Liver : within normal limits
Spleen : within normal limits

Extremities :
Warm, Edema (+), CRT < 2 second
Supporting Examination

• LABORATORY EXAMINATION RESULT

– Blood Routine: – Urine Routine:

• Hemoglobin : 9.9 gr % • Colour : red

• Leucocyte : 11.200 /mm2 • Protein : +3

• Hematocrite : 30.5 % • Erythrocyte : +++
• Thrombocyte :471.000/mm3 • Leucocyte :10-15
– Immunology :
• Rapid antigen Covid-19 : Negative
DIAGNOSE

• Nephritic Syndrom dd Nephrotic Syndrome

DIAGNOSE

• Nephritic Syndrom dd Nephrotic Syndrome

MANAGEMENT

• IVFD NaCl 8tpm

• Inj Furosemid 2x1/2 amp
• VIP Albumin 2x1