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CASE

History of Present Disease

A 5 month old boy (MSP/ MR 55 86 73) was admitted at May 9th, 2013 to hospitalization
Haji Adam Malik with chief complained history shortness of breath since three months and
getting worse for the last one and half months. The shortness of breath is not related to the
weather, but it getting worse by the activity. Dyspnea usually occur after he cried or
sneezing and blue appearance showed but it disappear immediately. History of
discontinuity while suckle found. History sweating while suckle was not found. History of
fever, loss of appetite, and weight loss was not found. Those patient come to RSUP HAM
as a referral from the Sufina Azis Hospital and already diagnosed as a Moderate PDA with
good LV function examined by echocardiography and planned to get Transcatheter PDA
Closure.

He was born in hospital through caesarean section assisted by obstetrician and
gynaecologist, birth body weight was 3000 gram and the birth body length was 46 cm but
the APGAR score was not recorded. Mother’s age 39 years old and history of previous
hypertension was found.

History of Development

- Following object direction : 1 month
- Smile : 2 months
- Laughing : 3 months
- Head lifting : 4 months
- Turning away : 4 months

History of Feeding

- Breast feeding : was given from birth until now

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Isochoric pupil.3 kg. Ear. Light reflex (+/+). Corneal ulcer (-). Head circumference: 40 cm BW/BL : 2<Z<1 BW/age : -2 < Z < 0 BL/age : -3 < Z < -2 Presens status Consciousness: Alert Heart Rate: 104 x/i Body temperature: 36. Icteric sclera (-). Body length: 59 cm. 2.History of Immunization . Upper arm circumference: 12 cm. Icteric (-). Localized status Head : Inferior palpebra conjunctiva pale (-/-). DPT : 2. 4 months . nose. HBV : 0. Anemic (-). 2 . Cyanosis (-).2°C Respiratory Rate: 32x/i General condition was moderate and nutrition condition was good. Polio : 0. Dyspnea (-). BCG : 2 month . 1. 6 months History of previous illness : unclear History of previous medications : unclear Physical Examination Generalized status Body weight: 6. Edema (-). 4 months . Bitot’s spot (-). mouth were within normal limit.

warm. grade III/VI ICR II/III LMCS continous murmur (+). Abdomen: Soepel. JVP R-2 cmH2O. CRT < 3”. adequate pressure/volume. Lower extremities: oedem (-/-) Urogenital: Male.Neck : Lymph node enlargement (-). Thorax: Symmetrical fusiformis. within normal limit Chest X-Ray on RS Sufina Azis (May 6th 2013) Echocardiography Result (May 7th 2013) : Moderate PDA with Good LV Function 3 . HR: 104 bpm. reguler. RR: 32x/i. peristaltic (+) N. reguler. Rales (-/-). Breath sound: vesicular. Hepar/Lien: not palpable Extremities: Upper extremities Pols: 104 x/i. Chest retraction (-). regular.

25 mg Diagnostic Planning: Transcatheter PDA closure 4 .Differential Diagnosis: Moderate PDA + Left sided Hypertrophi with Good LV Function Working Diagnosis: Moderate PDA + Left sided Hypertrophi with Good LV Function Management: Furosemid 2 x 6 mg Aldacton 2 x 6.

CRT Extremities : pulse 100 bpm.5 cc Nebule / 6 hr with NaCl 0. peristaltic (+) normal.Follow up on May 9th-10th 2013 May 9th 2013 May 10th 2013 S Shortness of breath (+) Shortness of breath (+) O Sensorium: compos mentis Sensorium: compos mentis Temperature: 37. conjunctiva palpebra palpebra was not pale was not pale Ear. no rales RR : 30 breathes/minute. warm acral.25 mg Nebule / 6 hr with NaCl 0. CRT <3” A Working Diagnosis : Working Diagnosis : Moderate PDA with good LV function Moderate PDA with good LV function P O2 ½ L/I nasal canule O2 ½ L/I nasal canule Furosemide 2 x 6 mg Furosemide 2 x 6 mg Aldactone 2 x 6. warm acral. reguler. normal. no retraction retraction HR : 98 bpm.7°C BW: 6. no rales liver and spleen unpalpable Abdomen : Soepel.2°C Temperature: 36. liver and spleen pressure and volume were unpalpable adequate.3 kg BW: 6. reguler. reguler.3 kg BL: 59 cm BL: 59 cm Head : Eyes : Light reflexes : +/+. no Chest : Simmetrical fusiformis.9% 2. Abdomen : Soepel. grade HR : 100 bpm. pressure and volume were adequate. reguler. and mouth : normal Ear and mouth : normal Nose : nasal canule Nose : nasal canule fixed Neck : lymph node was not Neck : lymph node was not palpable palpable Chest : Simmetrical fusiformis. peristaltic (+) Extremities : pulse 98 bpm. reguler. (+) reguler. III/VI ICR II/III LMCS grade III/VI ICR II/III continous murmur (+) LMCS continous murmur RR : 26 breathes/minute. Head : Eyes : Light reflexes : +/+. isocoric. <3”.25 mg Aldactone 2 x 6. conjunctiva isocoric.9% 2.5 cc Diet MII 630 kkal + 12 gr protein 5 .

20-0.40 fL (93-115) fL MCH 21.5) x 103 /mm3 Hematocrite 33.3-0.76 x 103/µL (1.4) x 103/µL Limfosit absolute 8.1) x 103/µL 6 .90 % (20-40) % Monosit 10.90 fL (7.42 x 103/µL (0.0) fL PCT 0.35 x 103 /mm3 (6.0-17.1) gr% Erithrocyte 4.7-10.10 % (1-6) % Basofil 0.7) x 103/µL Monosit absolute 1.10 % (38-52) % Trombocyte 649 x 103 /mm3 (217-497) x 103 /mm3 MCV 68.7) % MPV 7.05 x 103/µL (0-0.8) x 103/µL Eosinofil absolute 0.400 % (0-1) % Neutrofil absolute 2.95) x 106 /mm3 Leucocyte 13.7 – 17.50) x 103/µL Basofil absolute 0.90 % (14.3 fL Diftel Neutrofil 20.90 pg (29-35) pg MCHC 32.9-18.9-5.2-10.70 % (37-80) % Limfosit 64.51% PDW 8.Laboratory result : May 10th 2013 Parameters Value Normal Value Complete Blood Count Hemoglobin 10.75-4.66 x 103/µL (3.84 x 106 /mm3 (3.60 gr% (10.46 x 103/µL (0.90 % (2-8) % Eosinofil 3.00 g% (28-34) % RDW 14.

39 mg/dL <1 Direct bilirubin 0.40 mg/dL < 50 mg/dL Creatinine 0.30 minute < 5 minute PT + INR Protrombine Time Control 13.9 sec Patient 39.20 sec Patient 15.00 mg/dL < 200 mg/dL Renal Ureum 26.Faal Hemostatic Bleeding Time 3.2 Fosfatase alkali (ALP) 338 U/L < 449 U/L AST/SGOT 45 U/L < 38 U/L ALT/SGPT 17 U/L < 41 Carbohydrate Metabolism Blood glucose (at the time) 106.2 sec Patient 13.37 mg/dL 0.4 sec Clinic Chemistry Hepar Total bilirubin 0.0 mg/dL Electrolyte 7 .17-0.42 mg/dL Uric acid 5.6 sec INR 1.33 mg/dL 0 – 0.6 sec Trombine time Control 13.20 APTT Control 29.1 mg/dL < 7.

8) mEq/L Chlor (Cl) 96 mEq/L (96-106) mEq/L Magnesium (Mg) 2.5) mEq/L Phospor 6.Natrium (Na) 132 mEq/L (135-155) mEq/L Kalium (K) 4.58 mEq/L (1.9 mEq/L (3.3 mEq/L (5.0-10.4-1.6-5.00 Negative (Negative < 20 Positive >= 20) Hepatitis C Anti HCV Negative Negative 8 .9) mEq/L Immunoserology Hepatitis HBsAg Negative Negative Hepatitis A Profile Anti HAV Total 60.

Abdomen : Soepel.3 kg BW: 6.9% 2. CRT <3” A Working Diagnosis : Working Diagnosis : Moderate PDA with good LV function Moderate PDA with good LV function P O2 ½ L/I nasal canule O2 ½ L/I nasal canule Furosemide 2 x 6 mg Furosemide 2 x 6 mg Aldactone 2 x 6. LMCS continous murmur reguler. liver and spleen unpalpable reguler. conjunctiva isocoric.2 kg BL: 59 cm BL: 59 cm Head : Eyes : Light reflexes : +/+. peristaltic (+) normal. reguler. Chest : Simmetrical fusiformis. grade epigastrial III/VI ICR II/III LMCS HR : 100 bpm. conjunctiva palpebra palpebra was not pale was not pale Ear and mouth : normal Ear and mouth : normal Nose : nasal canule fixed Nose : nasal canule fixed Neck : lymph node was not Neck : lymph node was not palpable palpable Chest : Simmetrical fusiformis. Head : Eyes : Light reflexes : +/+. reguler. Extremities : pulse 100 bpm.25 mg Nebule / 8 hr with NaCl 0.5 cc Diet MII 630 kkal + 12 gr protein Diet MII 630 kkal + 12 gr protein R/ ADO R/ ADO 9 . CRT unpalpable <3”. pressure and volume were adequate. reguler. warm acral. isocoric. retraction (+) epigastrial retraction (+) in HR : 90 bpm. continous murmur (+) grade III/VI ICR II/III RR : 40 breathes/minute. reguler.5 cc Nebule / 8 hr with NaCl 0. liver and spleen adequate. warm acral.25 mg Aldactone 2 x 6. RR : 25 breathes/minute. no rales (+) Abdomen : Soepel. May 11st 2013 May 12th 2013 S Shortness of breath (+) Shortness of breath (-) O Sensorium: compos mentis Sensorium: compos mentis Temperature: 37°C Temperature: 37°C BW: 6. no rales Extremities : pulse 90 bpm.9% 2. peristaltic (+) pressure and volume were normal.

isocoric. reguler. LMCS continous murmur reguler.8°C BW: 6. peristaltic (+) pressure and volume were normal. no rales Extremities : pulse 108 bpm. May 13th 2013 May 14th 2013 S Shortness of breath (-) Shortness of breath (+) O Sensorium: compos mentis Sensorium: compos mentis Temperature: 37°C Temperature: 36. liver and spleen adequate.2 kg BW: 6. reguler. Extremities : pulse 100 bpm. reguler. warm acral.2 kg BL: 59 cm BL: 59 cm Head : Eyes : Light reflexes : +/+. Head : Eyes : Light reflexes : +/+. grade epigastrial III/VI ICR II/III LMCS HR : 100 bpm. conjunctiva palpebra palpebra was not pale was not pale Ear and mouth : normal Ear and mouth : normal Nose : nasal canule fixed Nose : nasal canule fixed Neck : lymph node was not Neck : lymph node was not palpable palpable Chest : Simmetrical fusiformis.5 cc Nebule / 8 hr with NaCl 0. Chest : Simmetrical fusiformis. peristaltic (+) normal.25 mg Nebule / 8 hr with NaCl 0. CRT <3” A Working Diagnosis : Working Diagnosis : Moderate PDA with good LV function Moderate PDA with good LV function P O2 ½ L/I nasal canule O2 ½ L/I nasal canule Furosemide 2 x 6 mg Furosemide 2 x 6 mg Aldactone 2 x 6.25 mg Spinorolactone 2 x 6. CRT unpalpable <3”. no rales (+) Abdomen : Soepel.9% 2. pressure and volume were adequate. warm acral. reguler. liver and spleen unpalpable reguler.5 cc Diet MII 630 kkal + 12 gr protein Diet MII 630 kkal + 12 gr protein R/ ADO R/ ADO 10 . conjunctiva isocoric. Abdomen : Soepel.9% 2. retraction (+) epigastrial retraction (+) in HR : 108 bpm. RR : 38 breathes/minute. continous murmur (+) grade III/VI ICR II/III RR : 30 breathes/minute.

epigastrial murmur (-) HR : 110 bpm. reguler. warm acral.9°C BW: 6. Extremities : pulse 128 bpm. peristaltic (+) adequate. no rales LMCS continous murmur Abdomen : Soepel. reguler. liver and spleen <3”.25 mg Nebule / 8 hr with NaCl 0. retraction (+) epigastrial retraction (+) in HR : 128 bpm. pressure and volume were adequate. conjunctiva isocoric. reguler.2 kg BL: 59 cm BL: 59 cm Head : Eyes : Light reflexes : +/+. reguler. conjunctiva palpebra palpebra was not pale was not pale Ear and mouth : normal Ear and mouth : normal Nose : nasal canule fixed Nose : nasal canule fixed Neck : lymph node was not Neck : lymph node was not palpable palpable Chest : Simmetrical fusiformis.2 kg BW: 6.5 cc Diet MII 630 kkal + 12 gr protein R/ ADO (15/5/2013) 11 . CRT <3” A Working Diagnosis : Working Diagnosis : Moderate PDA with good LV function Post transcatheter PDA closure (H-1) P O2 ½ L/I nasal canule Inj Ceftriaxone 300 mg/12 hr/IV (2x) Furosemide 2 x 6 mg Diet MB 620 kkal + 12 gr protein Spironolactone 2 x 6. Chest : Simmetrical fusiformis. warm acral. Head : Eyes : Light reflexes : +/+. grade III/VI ICR II/III reguler.9% 2. reguler. no rales pressure and volume were Abdomen : Soepel. RR : 30 breathes/minute. unpalpable Extremities : pulse 110 bpm. isocoric. (+) liver and spleen unpalpable RR : 36 breathes/minute. May 15th 2013 May 15th 2013 (follow up post trancatheter closure) S Shortness of breath (-) Bleeding (-) O Sensorium: compos mentis Sensorium: compos mentis Temperature: 37.1°C Temperature: 36. CRT normal. peristaltic (+) normal.

Cath and Transcatheter PDA Closure (May 15th 2013) Conclusion : Succesful Transcatheter PDA Closure with Heart 4/6 No residual PDA and no Coarctation Advice : Keep NBM till fully aware Guidance IV ceftriaxone 250 mg 2x Watch bleeding at puncture site and pulsation Plan for tomorrow : Chest X-Ray (AP and lateral) and Echocardiography 12 .

pressure and volume were adequate. no rales liver and spleen unpalpable Abdomen : Soepel. reguler. <3”. liver and spleen pressure and volume were unpalpable adequate. CRT <3” A Working Diagnosis : Working Diagnosis : Post Transcatheter PDA Closure Post Transcatheter PDA Closure P Inj. Abdomen : Soepel.2 kg BL: 59 cm BL: 59 cm Head : Eyes : Light reflexes : +/+. reguler. grade epigastrial murmur (-) HR : 100 bpm. nose. and mouth : normal normal Neck : lymph node was not Neck : lymph node was not palpable palpable Chest : Simmetrical fusiformis. reguler. May 16th 2013 May 17th 2013 S Shortness of breath (-). reguler.7°C Temperature: 36. warm acral. no rales RR : 36 breathes/minute. peristaltic (+) Extremities : pulse 96 bpm. retraction (+) epigastrial retraction (+) in HR : 96 bpm. RR : 30 breathes/minute. CRT Extremities : pulse 100 bpm. Cough (+) Cold (-). peristaltic (+) normal. Ceftriaxone 300 mg/12 hr/IV (H1) Inj. and mouth : Ear. Head : Eyes : Light reflexes : +/+. Ceftriaxone 300 mg/12 hr/IV (H1) Diet MB 620 kkal + 12 gr protein Diet MB 620 kkal R/ Echocardiography R/ Foto Thorax PA Chest X-Ray PA Patient may came home and have to control on schedule Echocardiography 1 week later 13 . isocoric. conjunctiva palpebra palpebra was pale (+/+) was pale (+/+) Ear. normal. conjunctiva isocoric. murmur (-) reguler. reguler. fever (-). warm acral.2 kg BW: 6. Chest : Simmetrical fusiformis. nose. Fever (-) weakness (+) O Sensorium: compos mentis Sensorium: compos mentis Temperature: 36.8°C BW: 6.

essentially a disease of child hood that accounts for 90% of renal disorders in children. no residual PDA No LPA stenosis No coarctation Chest X-Ray (May 17th 2013) Chest X-Ray (May 17th 2013) Bronchopneumonia dextra Dilatation aorta DISCUSSION Acute glomerulonephritis. Acute glomerulonephritis (AGN) is a disease characterized by the sudden appearance of edema. and hypertension. proteinuria.Echocardiography (May 16th 2013) Device in situ. hematuria.7 14 .

face. 150/90 mmHg.1 In this case. large immune complexes) in the serum.8 APSGN has latent period for 1- 2 weeks in upper respiratory tract infection and 3 weeks in pyoderma. a decline in C3 complement. the patient had high level of ASO (400) and hypocomplementemia (33mg/dL) . Possible (subclinical cases) are often found when screening individuals for APSGN but do not present with more than 1 clinical symptom.e. but 10% of cases are patients older than 40. confirm. Important laboratory findings include an elevated streptococcal exoenzyme (antistreptolysin O) titer.7 Not all types of streptococcus cause kidney problems but only those caused by ‘nephritogenic’ strains.3 The patient in this case is 14 years old. History of dysphagia was experienced for this two years. and both of legs for six days. otitis media or skin infections like pyoderma. and possible case. They do not have oedema or hypertension but on 15 . and the familial or cohabitant incidence is as high as 40%. laboratory definitive evidence OR b. 2. and cryoglobulins (i.In this case. The blood pressure is found hypertension. The group A beta-haemolytic streptococcus (GAS) is a common infective agent in children that causes the widest range of clinical disease in humans of any bacterium. laboratory suggestive evidence AND clinical evidence. It is more common in males. the chief complained are oedema in eyelids. APSGN case can be classified in three part. Confirmed case A confirmed case requires either: a. Possible case A possible case requires laboratory suggestive evidence only. Acute poststreptococcal glomerulonephritis typically affects children between the ages of 2 and 14 years. Probable case A probable case requires clinical evidence only. 3.. protein is +3 and blood is +2 which mean he had proteinuria and hematuria. It shows the possibility of streptococcal infection. 1. impetigo or infected scabies. From urine dipstick.2 In this case. the patient had history of fever not too high three weeks ago. Infection can be that of respiratory tract in the form of pharyngitis. probable. Redness spotting was found on the skin.

If microscopy is not available then moderate haematuria on dipstick fulfils this criteria. or elevated ASO titre or Anti-DNase B). Reduced C3 level Clinical evidence At least 2 of the following − facial oedema − ≥ moderate haematuria on dipstick − Hypertension (Hypertension as defined in CARPA Standard Treatment Manual) − peripheral oedema8 Simplified Classification of Hypertension for use in the CARPA STM 9 Systolic Diastolic Action (mmHg) (mmHg) <130 <85 ‘normal’ BP. this could be notified as a confirmed case after discussion with infectious disease physician. Laboratory definitive evidence Renal biopsy suggestive of APSGN. recheck in 1 year. 140-159 90-99 confirm within 2 months – lifestyle advice 160-179 100-109 evaluate or refer within 1 month – lifestyle advice ≥180 ≥110 evaluate and refer within 1 week (or immediately depending on 16 . evidence of a streptococcal infection and a reduced C3. Laboratory suggestive evidence a. recheck in 1–2 years 130-139 85-89 ‘high-normal’ BP. laboratory investigation are found to have haematuria. If all other criteria have been fulfilled but the only evidence of recent streptococcal infection is isolation of Group C or Group G Streptococci from skin or throat. AND b. Haematuria on microscopy (RBC >10/μl). AND c. Evidence of recent streptococcal infection (positive Group A Streptococcal culture from skin or throat. Offer lifestyle advice.

the patient can be included to the confirmed case. hypertension. Evidence of APSGN is obtained from clinically and laboratoric result. APSGN can completely recover for 1-2 weeks if there’s no complication. Generally. Alternations in The Urinary System. However . In: Essentials of Pathophysiology: Concepts of Altered Health States. Lewis. REFFERENCES 1. 425-427. 85-95% of APSGN case recover completely and 5-10% can be chronic glomerulonephritis. or hypertension ensefalophaty. followed by disappear of laboratory sign escpecially microscopic hematuria and proteinuria for 1-12 months. Rauf. 2008. diuretics. the prognosis is good. but not in prolong time. and hypocomplentemia. n. 2. supportive. and low salt nutrition. & Aras. J. Murphy. high titre of ASO. The acute phase should be treated with antihypertensives. Hallingstad. 3. diuretics. hypocomplementemia. If recovery is slow.. B.d. corticosteroids may be helpful. In child.1 In this case.. the course of this disease is marked by acute phase for 1-2 weeks. Glomerular Disease. J. usually 10-14 day. 2012. hematurian and hypertension. In this case. acute pulmonary oedema. New York: McGraw-Hill. M. A.1 In this case. It obtained from laboratory suggestive results which shows high titre of ASO. & Neilson. In: Jakarta: Badan Penerbit Ikatan Dokter Anak Indonesia.. antihypertension. rarely APSGN can be relapse. Albar. Konsensus Glomerulonefritis Akut Pasca Streptokokus. furosemide and aldactone as diuretics. H. Branch. G.. the pastient has discharge on the fouteenth days of hospitalized. pp. dead can occur in the acute phase as acute kidney injury. hematuria. the patient was given nifedipine as antihypertension. In: Harrison's Principles of Internal Medicine 17th Edition. and had low salt nutrition. S. 1786-1790. salt restriction and dialysis as necessary. D. Although. then it is often clasified as self limiting disease. 17 ..So. SUMMARY It has been reported a case of acute post streptococcal glomerulonephritis in a boy. J. E. proteinuria. 1-21. Philadelpia: Lippincott. Treatment were only bed rest. that is oedema. pp. patient had dyspnoe which may shows symptom of pulmonary oedema. pp. G. K. face and legs. & Strauch.4 Bed rest also useful in acute phase treatment. The patient showed clinically improvement in 14 days treatment and has discharged on the fourteenth days hospitalizing. and hematuria from dipstick and from clinical evidence that is oedema on the both of eyelids..

4.. O.. S. 9. A.. 7.au 18 .d. eds. GV. K. Glomerulopathies. 2006. P. 2011. Clinical Study of Post Streptococcal Acute Glomerulonephritis in Children with Special Refeerence to Presentation. Volume 11. 522-523. n. A. Download from: www. Northern Territory Guidelines for Acute Post- Streptococcal Glomerulonephritis 2010. Centre for Disease Control. Pardede. 56-65. Healthy Territory. In: E. Tanagho & J. Struktur Sel Streptokokus dan Patogenesis Glomerulonefritis Akut Pascastreptokokus. Boyden. 5. London: Saunders. F. Curr Pediatr Res. 89- 92. 2009. Smith's General Urology 17th Edition. et al. pp. pp. & Amend. C. Vincenti. pp. G.. High Blood Pressure (Hypertension).. & Clark. New York: McGraw-Hill. J.org. Kumar. 6. 8. Sari Pediatri. 2008. M. W. 2010. W.carpa. 11(2). McAninch. In: Kumar and Clark Clinical Medicine 6th Edition. Diagnosis of Mediacal Renal Disease.