BAB I

INTRODUCTION

1.1 Background

Urinary and Male Reproduction System is the 15th blok in the fifth
semester of Competency Based Curriculum of Medical Education Faculty of
Medicine, Muhammadiyah University of Palembang.
In this occasion already implemented tutorial with case Taro, a 7 years old
boy, brought by his parent to pediatrician polyclinic with a chief complain of
swelled eyelids since 5 day ago. Swelledness firest 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 symtoms appear
taro experience cough and cold, but he never got any treatment. This is the
first time taro exprience this symtoms. Taro family never has this kind of
symtom before.

Physical examination:

General appearance:
Counscious: Compos mentis, looks moderately sick. BW: 28 kg, Height:
123 cm.
Vital Sign: BP 140/90 mmHg, Pulse 96x/m, RR 24x/m, Temp: 36,8oC
Specific Examination:

Head : Edema palpebra (+)/(+), pale conjungtiva (-)

: hiperemic Faring, normal tonsil
Neck : no enlargement of the lympth nodes
Thorax : lung: vesikuler (+) normal, ronchi (-), wheezing (-)
Heart: normal heartsound I/II, tenderness (-)

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 Abdomen : flat, supple, shifting dullness (-), tenderness (-), hepar and
lien not palpable, bowel sound (+) normal
Ekstremity : pitting edema -/-, edema dorsum pedis -/-

1.2 Purposes and objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 BAB II
DISCUSSION

2.1. Data Tutorial

Tutor : dr. Putri Rizki
Moderator : Chairunisa
Board secretary : Arika shafa nabila
Desk secretary : Wina
Time : Day 1: Tuesday, October 28 2019
At 08.00 – 10.00 WIB
Day 2: Thursday, November 30 2018
At 08.00 – 10.00 WIB

The Rule of Tutorial : 1. Gadget should be nonactive or in silent mode.

2. Everyone in the group should express their
opinion.
3. Ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2. Scenario
‘’ what happened to my eyes’’
Taro, a 7 years old boy, brought by his parent to pediatrician polyclinic with
a chief complain of swelled eyelids since 5 day ago. Swelledness firest 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 symtoms
appear taro experience cough and cold, but he never got any treatment. This is
the first time taro exprience this symtoms. Taro family never has this kind of
symtom before.

Physical examination:

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 General appearance:
Counscious: Compos mentis, looks moderately sick. BW: 28 kg, Height:
123 cm.
Vital Sign: BP 140/90 mmHg, Pulse 96x/m, RR 24x/m, Temp: 36,8oC

Specific Examination:
Head : Edema palpebra (+)/(+), pale conjungtiva (-)
: hiperemic Faring, normal tonsil
Neck : no enlargement of the lympth nodes
Thorax : lung: vesikuler (+) normal, ronchi (-), wheezing (-)
Heart: normal heartsound I/II, tenderness (-)
Abdomen : flat, supple, shifting dullness (-), tenderness (-), hepar and
lien not palpable, bowel sound (+) normal
Ekstremity : 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), erythrocytes 30-50
cell/LPB, cylinder (+)
Blood Chem exam: total protein 5,3 g/dl, albumin 3gr/dl, globulin 2,3
gr/dl, ureum 40 mg/dl, kreatinin 2,0 mg/dl, cholesterol 180 mg/dl, BUN:
25 mg/dl
Imunoserologi: ASTO 420 IU, CRP (+), Titer c3: 60, Titer c4: normal
Throat smear culture: streptococcus B hemolyticus is found

2.3. Terms Clarification

No. Term Term Clarification

1. Headache Patological clinic with sign severe pain

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 attack on unilateral location

2. Pitting Palpebra Edema refers to visible swelling cause by

a build of fluid with in periorbital tissues

3. Cough A response from body as immune system

to remove substance or particle from the
respiratory track

4. Hiperemic Faring When excess blood build up inside the

vascular system which is the system of
blood vessel in the faring

5. Pitting Edema Edema refers to visible swelling cause by

a build of fluid withing tissue when an
indentation remain after the swallen skill
is pressed

6. Urine like a blood Is a blood eritrocyte in urine ( hematuria)

2.4. Problem Identification

1. Taro, a 7 years old boy, brought by his parent to pediatrician polyclinic
with a chief complain of swelled eyelids since 5 day ago. Swelledness
first appear on the eyelids especially right after waking up and
diminishing by noon.
2. Taro also complains of frequent headache. Taro daily urine production is
only one cups and red colored like a blood.
3. Three weeks ago, before this symtoms appear taro experience cough and
cold, but he never got any treatment. This is the first time taro exprience
this symtoms. Taro family never has this kind of symtom before.
4. Physical examination:
General appearance:
Counscious: Compos mentis, looks moderately sick. BW: 28 kg, Height:
123 cm.

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 Vital Sign: BP 140/90 mmHg, Pulse 96x/m, RR 24x/m, Temp: 36,8oC
5. Specific Examination:
Head : Edema palpebra (+)/(+), pale conjungtiva (-)
: hiperemic Faring, normal tonsil
Neck : no enlargement of the lympth nodes
Thorax : lung: vesikuler (+) normal, ronchi (-), wheezing (-)
Heart: normal heartsound I/II, tenderness (-)
Abdomen : flat, supple, shifting dullness (-), tenderness (-), hepar and
lien not palpable, bowel sound (+) normal
Ekstremity : pitting edema -/-, edema dorsum pedis -/-

2.5. Problem Analyze

1. Taro, a 7 years old boy, brought by his parent to pediatrician polyclinic
with a chief complain of swelled eyelids since 5 day 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.
The kidneys serve important functions, including filtration and excretion of
metabolic waste products (urea and ammonium); regulation of necessary
electrolytes, fluid, and acid-base balance; and stimulation of red blood cell
production. They also serve to regulate blood pressure via the renin-
angiotensin-aldosterone system, controlling reabsorption of water and
maintaining intravascular volume. The kidneys also reabsorb glucose and
amino acids and have hormonal functions via erythropoietin, calcitriol, and
vitamin D activation.

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 Picture 1: Anatomy of kidney
1. Gross Anatomy
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.
The relationship of neighboring organs to the kidneys is important, as
described below:
- Superiorly, the suprarenal (adrenal) glands sit adjacent to the upper
pole of each kidney
- On the right side, the second part of the duodenum (descending
portion) abuts the medial aspect of the kidney
- On the left side, the greater curvature of the stomach can drape
over the superomedial aspect of the kidney, and the tail of the pancreas
may extend to overlie the renal hilum
- The spleen is located anterior to the upper pole and is connected by
the splenorenal (lienorenal) ligaments
- Inferiorly to these organs, the colon typically rests anteriorly to the
kidneys on both sides
- Posteriorly, the diaphragm covers the upper third of each kidney,
with the 12th rib most commonly crossing the upper pole
- The kidneys sit over the psoas (medially) and the quadratus
lumborum muscles (laterally)

b. what is the physiology in this case ?

Answer :
Each human kidney consists of about one million nephrons, each of
which has the task to form urine. The kidneys cannot form new

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nephrons, therefore, in trauma, kidney disease, or normal kidney aging
there will be a gradual decrease in the number of nephrons. After the
age of 40, the number of nephrons usually decreases every 10 years.
This reduction in function should not be life-threatening due to the
body's adaptive processes to reduce kidney function (Sherwood, 2001).
The kidneys are supplied with blood via the renal arteries, which arise
directly from the abdominal aorta, immediately distal to the origin of
the superior mesenteric artery. Due to the anatomical position of the
abdominal aorta (slightly to the left of the midline), the right renal
artery is longer, and crosses the vena cava posteriorly. Each renal artery
enters the kidney via the renal hilum, dividing into segmental branches.
These branches undergo further divisions to supply the renal
parenchyma:
Each segmental artery divides to form interlobar arteries. They are
situated either side every renal pyramid. These interlobar arteries
undergo further division to form the arcuate arteries. At 90 degrees to
the arcuate arteries, the interlobular arteries arise.
The interlobular arteries pass through the cortex, dividing one last time
to form afferent arterioles.
The afferent arterioles form a capillary network, the glomerulus, where
filtration takes place. The capillaries come together to form the efferent
arterioles. In the outer two-thirds of the cortex, the efferent arterioles
form what is a known as a peritubular network, supplying the nephron
tubules with oxygen and nutrients. The inner third of the cortex and the
medulla are supplied by long, straight arteries called vasa recta.
Venous Drainage
The kidneys are drained of venous blood by the left and right renal
veins. They leave the renal hilum anteriorly to the renal arteries, and
empty directly into the inferior vena cava.
As the vena cava lies slightly to the right, the left renal vein is longer,
and travels anteriorly to the abdominal aorta below the origin of the

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superior mesenteric artery. The right renal artery lies posterior to the
inferior vena cava.
Lymphatics
Lymph from the kidney drains into the lateral aortic (or para-aortic)
lymph nodes, which are located at the origin of the renal arteries.

Figure 3. Left Kidney.

Renal Hilum
The renal hilum is the entry and exit site for structures servicing the
kidneys: vessels, nerves, lymphatics, and ureters. The medial-facing
hila are tucked into the sweeping convex outline of the cortex.
Emerging from the hilum is the renal pelvis, which is formed from the
major and minor calyxes in the kidney. The smooth muscle in the renal
pelvis funnels urine via peristalsis into the ureter. The renal arteries
form directly from the descending aorta, whereas the renal veins return

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cleansed blood directly to the inferior vena cava. The artery, vein, and
renal pelvis are arranged in an anterior-to-posterior order.
Nephrons and Vessels
a) Artery – brings waste-filled blood from the aorta to the kidney
for filtering in the nephron.
b) Glomerulus – each glomerulus is a cluster of blood capillaries
surrounded by a Bowman’s capsule. It looks similar to a ball of
tangled yarn.
c) Proximal convoluted tubule (PCT)
d) Thin descending limb of the loop of Henle
e) Thin Ascending limb of the loop of Henle
f) Thick Ascending limb of the loop of Henle
g) Distal convoluted tubule
h) Renal Vein – when filtration is complete, blood leaves the
nephron to join the renal vein, which removes the filtered blood
from the kidney
i) Arterioles – blood is brought to and carried away from the
glomerular capillaries by two very small blood vessels—the
afferent and efferent arterioles.
Nephron Function
a) Bowman’s Capsule – Surrounds the glomerulus
b) Glomerulus – consist of a the cluster of capillaries
c) Proximal Convoluted Tubule – nearest the glomerulus; have
permeable cell membranes that reabsorb glucose, amino acids,
metabolites and electrolytes into nearby capillaries and allow for
circulation of water
d) Loop of Henle – has an ascending and descending limb, these
loops along with their blood vessels and collecting tubes for the
pyramids in the medulla. When the filtrate reaches the
descending limb of the loop, water content has been reduced by
70%. The filtrate contains high levels of salts (mostly sodium).

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 As the filtrate moves further through the loop, more water is
removed which further concentrates the filtrate.
e) Distal Convoluted Tubule – farthest from the glomerulus; helps
regular potassium excretion.
f) Collecting Duct – collects the filtrate
Individual nephrons cannot be seen by the naked eye.The nephron is the
basic structural and functional unit of the kidney. Each kidney has
about 1 million nephrons. The walls of the nephron are made of a single
layer of epithelial cells. Blood containing urea and metabolic waste
products enters the kidney from the liver. The blood is mechanically
filtered to remove fluids, wastes, electrolytes, acids and bases into the
tubular system while leaving blood cells, proteins and chemicals in the
bloodstream. The nephrons also reabsorb and secrete ions that control
fluids and electrolyte balance.
The blood enters the kidney and goes to the glomerulus. Pressure forces
fluid out of the blood through membrane filtration slits creating a cell-
free fluid (plasma) of water and small molecules that enters into the
renal tubule. Large cells and proteins stay in the blood. This plasma is
taken to the nearest (proximal) convoluted tubule. This runs down into
the medulla into the loop of Henle and then back to the farthest (distal)
convoluted tubule to join with other tubules. In the distal tubule most of
the salts are reabsorbed. What is left is further modified until it becomes
concentrated urine which contains urea and other waste products at the
end of the collecting duct. (See Anatomy Terms to understand proximal
and distal.)
The kidneys collect and get rid of waste from the body in 3 steps:
a) Glomerular filtration – Filtrate is made as the blood is filtered
through a collection of capillaries in the nephron called
glomeruli.
b) Tubular reabsorption – The tubules in the nephrons reabsorb the
filtered blood in nearby blood vessels.

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 c) Tubular secretion – The filtrate passes through the tubules to the
collecting ducts and then taken to the bladder.
d) The glomerular filtration rate (GFR) is the rate at which the
glomeruli filter the blood. The normal GFR is 120 ml/minute.
The most accurate measure of the GFR is done by measuring
creatinine clearance. Clearance is the complete removal of a
substance from the blood. Creatinine is a good measure because
it is filtered by the blood but not reabsorbed by the tubules.
The renal artery first divides into segmental arteries, followed by
further branching to form interlobar arteries that pass through the renal
columns to reach the cortex (Figure 3). The interlobar arteries, in turn,
branch into arcuate arteries, cortical radiate arteries, and then into
afferent arterioles. The afferent arterioles service about 1.3 million
nephrons in each kidney.
This figure shows the network of blood vessels and the blood flow in
the kidneys.

c. what is the histology in this case ?

Answer :
1) Kidney: Cortex, Medulla, Pyramid, and Minor Calix (Comprehensive
View)
In sagittal fragments, the kidneys are divided into a dark-black cortex on
the outside and a brightly-litmedulla on the inside. The cortex is protected by
renal capsules (1) in the form of irregular solid connective tissue.
The cortex contains proximal tubules (4, 11) and distal, glomeruli (2),
and medullary radius (3). The interlobularis artery (12) and the
interlobularis vein (13) are also present in the cortex. The medullaris radius
(3) is formed by straight nephrons, blood vessels, and collagen tubules that
fuse in the medulla to form the larger ductuscoligens (6). The medullary
radius does not extend to the renal capsule (1) because of the presence of
subcapsular tubular consortions (10).

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 The medulla consists of renal pyramids. The base of each pyramid (5)
borders the cortex and apex to form the renal papilla (7) which protrudes into
the funnel-shaped structure, minor calix (16), which represents the wide
ureteric portion. The cribrosa area (9) is penetrated by a small opening,
which is the mouth of the collagen duct (6) into the minor calix (16).
The tip of the renal papilla (7) is usually coated with a cylindrical layer
of epithelium (8). As the cylindrical epithelium of the renal papilla (7)
continues into the outer wall of the minor calix (16), this epithelium becomes
a transitional epithelium (16). The thin layer of connective tissue and smooth
muscle (not visible) under this epithelium is subsequently fused with the renal
sinus connective tissue (15).
In the renal sinus (15) there are branches of the arteries and renal veins
namely the interlobaris artery (17) and the interlobaris vein (18).
Interlobaris vessels (17, 18) enter the kidney and curve at the base of the
pyramid (5) in the corticomedular link as an artery and venous arcuate (14).
The arcuate vessels (14) form interlobularis arteries (12) and interlobularis
veins (13) which are smaller and travel radially into the renal cortex and form
afferent glomerular arteries which form glomerular capillaries (3)

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2) Ureter
The ureter is a muscular duct that delivers urine from the kidneys to the
bladder through the contraction of a thick layer of smooth muscle in the wall.
This weak-magnification photomicrograph shows the ureter in cross section.
The ureteral mucosa is very multi-folded and covered with thick transitional
epithelium (1).Under the transitional epithelium (1), the connective tissue of
lamina propria (2). The ureteral musculature contains two layers of smooth
muscle, a deep longitudinal layer (3) and a middle circular muscle layer
(4). The third layer, the outer longitudinal layer (not visible), there is a lower
third-ureteral wall, near the bladder. The ureter is surrounded by connective
tissue adventisia (6) with blood vessels (5) and adipose tissue (7).

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3) VesicaUrinaria
The bladder (vesicaurinaria) has thick muscular walls. This wall is similar
to that found in the lower third of the ureter, except for its thickness. On the
wall three layers of smooth muscle are found loosely arranged, namely the
inner longitudinal, middle circular, and outer longitudinal layers. However,
similar to the ureter, muscle layers are difficult to distinguish. These three
layers form an anastomosis of smooth muscle bundles (1) with interstitial
connective tissue (2) found in between. In this figure, smooth muscle bundles
are cut in various fields (1) and all three layers of muscle are difficult to
distinguish. Interstitial connective tissue (2) merges with serous connective
tissue (3). Mesothelium (3b) covers the serous connective tissue (3a) and is
the outermost layer. Serosa (3) coats the superior surface of the bladder, while
the inferior surface is covered by the adventitic connective tissue, which
blends with the surrounding connective tissue structures.
Empty bladder mucosa shows many folds of mucosa (5) that disappear
when the bladder is dilated. Transitional epithelium (6) is thicker than in the
ureter and contains about six layers of cells. The lamina propria (7), under
the epithelium, is wider than in the ureter. Loose connective tissue in the
deeper part contains more elastic fibers. Many blood vessels (4, 8) of various
sizes are found in the serosa (3), between the smooth muscle bundles (1), and
in the lamina propria (8).

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 (Eroschenko, 2014)

d. what is the possible cause swelled eyelids ?

Answer:
Localized Edema (RepresentDistinctive Areas of Involvement)
 Increased Capillary Permeability
Allergic reaction (insect bites,contact dermatitis, drug orfood
allergy),Local trauma,Angioedema (hereditary, ACEinhibitor
induced),Dermatomyositis ,Kawasaki disease ,Hypothyroidism,
Epstein–Barr virus.
Generalized Edema
 Increased Capillary Permeability
Sepsis, Burns, Hypothyroidism (myxedema),Other infections
(Scarlet Fever,Rocky Mountain Spotted Fever,Roseola).
 Decreased Plasma OncoticPressure (Hypoproteinemia)
Nephrotic syndrome,Hepatic failure (hepatitis,congenital fibrosis,
cysticfibrosis, metabolic disorders),Protein-losing enteropathy(milk
protein allergy, Celiacdisease, Menetrier’s disease,inflammatory
bowel disease,Fontan physiology),Protein-calorie
malnutrition(kwashiorkor),Severe anemia (hemolytic
anemia),Beriberi.
 Increased Hydrostatic Pressure
Congestive heart failure, Cirrhosis, Renal failure,
Glomerulonephritis (Postinfectious, hereditary,IgA
Nephropathy,Henoch–Schönlein,Membranoproliferative),

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 Medications (vasodilators,corticosteroids), Excessive iatrogenic
intravenousfluid.

e. what is the meaning taro with a chief complain with swelled eyelids
since 5 day ago?
Answer :
taro suffered acute palpebral edema due to fluid and sodium retention due to
acute nephritic syndrome. Edema occurs in the palpebral because palpebral
tissue is loose connective tissue.

f. what is the meaning swelledness first apppear on the eyelides especially

right after waking up and diminishing by noon?
Answer :
The meaning is there are retention of natrium and fluid and its make
fluids shift from intravascular to intertisium tissues. Its happen after
waking up and diminishing by nood cause of the gravitation and loose
connective tissuesin the eyes

g. how is the patofisiology of swelled eyelids?

Answer:
Infection Streptococcus → Inflamation reaction at glomerulus →
Disturbance in glomerular basement membrane → Retensi natrium and
fluid → Increase volume hidrostatik preassure → Edema move to low
intertisial pressure which preorbital → Swelled eyelid.

h. what is the relation between age and gender in this case?

Answer :
One form of acute glomerulonephritis (GNA) that is commonly found
in children is acute glomerulonephritis post streptococcus (GNAPS).
GNAPS can occur at any age, but most often occurs at the age of 6-7
years. Multicenter research in Indonesia shows the age distribution of

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 2.5-15 years with the highest average age of 8.46 years and the ratio
♂(male) : ♀( female) = 1, 34: 1. So, in this case, GNAPS most often in
children age of 6-7 years and for gender, male is most often than
female.

i. why swelling occur in the eye?

Answer :
because in the eye area is a loose connective tissue when they has retention
of fluid that can accumulates easily cause edema.

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 the frequent headache?
Answer :
Increase of intracranial pressure due to hypertension
Classification of Hypertension in Children Age 1 Year or More and
Teenagers.
Classification
Normal Blood Pressure Systolic and diastolic limits less
than the 90 percentile

Prehypertension Systolic or diastolic is greater or

equal to the 90 percentile but
smaller than the 95 percentile

Hypertension Systolic or diastolic is greater or

equal to the 95 percentile

Level 1 hypertension Systolic and diastolic between 95

and 99 percentages plus 5 mmHg
Level 2 hypertension Systolic or diastolic above the 99
percentile plus 5 mmHg

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b. what is the meaning of daily urine production is only on cups and red
colored like a blood ?
Answer :
Urine production only one cups is oliguria and urine red like colored
like blood is hematuria.

c. what is the pathofisiology of headache in this case?

Answer :

Homeostasis →Na and water retention → hypervolemia →hypertension →

vasoconstriction of blood vessels in the brain → intracranial pressure
increases → headache.

d. what is the characteristic of urine?

Answer:
The normal amount of urine is an average of 1 to 2 liters a day, but
varies according to the amount of fluid being inserted. Much is added
too if too much protein is eaten, there is enough liquid needed to
dissolve urea. urine is usually clear yellow or yellow. Turbidity may
indicate the presence of bacteria, cells or high solute concentration.
Urine pH values range from 4.6 to 8.0, but usually tend to be acidic to
provide protection against bacteria. Specific gravity ranges from 1,001-
1,035. Normal urine does not contain glucose or blood cells and only
occasionally contains a trace protein, especially associated with heavy
exercise.

e. what is the pathofisiology of urine like a blood and 1 cup?

Answer :
With complaints experienced by Taro, it is strongly suspected that
Acute Glomerulonephritis Post Streptococcus (GNAPS) has occurred.
the mechanism that occurs in GNAPS is an immune complex process in
which antibodies from the body will react with antigens circulating in

19
 the blood and complement to form an immune complex. Immune
complexes circulating in the blood in large quantities and short periods
are attached to glomerular capillaries and mechanical damage occurs
through activation of the complement system, inflammatory reactions
and microcoagulation. The latent period between streptococcal infection
and glomerular abnormalities shows that immunological processes play
an important role in the mechanism of disease. Allegedly the excessive
response of the host immune system to the antigen stimulus with
excessive antibody production causes the formation of Ag-Ab complex
which will later cross the glomerular basement membrane.
Furthermore, the complement will be fixed resulting in lesions and
inflammation that attract polymorphonuclear leukocytes (PMN) and
platelets to the lesion site. Phagocytosis and release of the lysosome
enzyme also damage the endothel and glomerular basement membrane
(IGBM). In response to the lesions that occur, proliferation of
endothelial cells followed by mesangium cells and then epithelial cells.
Increased leakage of gromelurus capillaries causes proteins and red
blood cells to escape into the urine that is being formed by the kidneys,
this is what causes proteinuria and hematuria.

f. what is the etiology of urine like blood?

Answer:
Glomerular Abnormalities
1. Acute glomerulonephritis (GNAPS)
2. Nefropathy IgA
3. Membranoproliferative glomerulonephritis
4. Alport's Syndrome
5. Benign familial hematuria
Systemic Abnormalities
1. Henoch-Schonlein Purpura
2. Systemic Lupus Erythematosus

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 3. Uremic Hemolytic Syndrome
4. Polyarteritisnodosa
5. Subacute bacterial endocarditis
6. Hemophilia
7. Idiopathic puropathic thrombocytopenia
8. Sickle cell anemia
9. Leukemia
Interstitial abnormalities
1. Pyelonephritis
2. Polycystic kidney disease
3. Renal trauma
4. Kidney stones
5. Renal vein thrombosis
6. Kidney tumors
7. Hydronephrosis
8. Idiopathic hypercalciuria
9. Papillary necrosis
Abnormalities from outside the kidney
1. Urinary tract infections
2. Trauma in the urinary tract
3. Tumors in the urinary tract
4. Stones in the urinary tract
5. Foreign objects in the urinary tract
6. Congenital urinary abnormalities
7. Fimosis
8. Meatus stenosis
9. Periuretritis

g. what the relation of additional complain and a chief complain?

Answer:

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 The relation between swelled eyelids ad headache is causes there are
retention of natrium and fluids, its make activate of renin-angiotensin
systemm so it cause hypertension, hypertension will makes
vasocontriction of blood vessel and cause headache. Retention of
natrium and fluids also makes fluid shift from intravascular to
intertisium tissues and cause swelled eyelids.

h. what is the ingredients normal of urine?

Answer:
Urineconsist 95% water. Other compotition in normal urine is solid
part that consist in water.It can divided by size or electrolit, such as :
OrganicMolecul : It has non electrolit characteristic that have relative
big size in urine: UreaCON2H4 atau (NH2)2CO, Kreatin, Asam Urat
C5H4N403, and other substance which is hormone. lon: Sodium (Na+),
Potassium (K+), Chloride (Cl-), Magnesium(Mg2+), Calcium (Ca2+).
Small amount : Ammonium(NH4+), Sulphates (S042-), Phosphates
(H2PO4-, HPO42-PO43-). Glucose negative, protein < 30 mg/dl,
urobilinogen <1,0 EU/dl, nitrit negative, blood negative, leukosit
negative. In urine sediment : epitel cell negative, eritrosit <5 LPB,
leukosit <5 LPB, silinder negative.

3. Three weeks ago, before this symtoms appear taro experience cough and
cold, but he never got any treatment. This is the first time taro exprience
this symtoms. Taro family never has this kind of symtom before.
a. what is the relations between complaints 3 weeks ago and 5 days ago ?
Answer:
Relationship with complaints 3 months ago which is cough and
cold(upper respiratory tract infections) are a symptom of streptococcus
beta hemolithicus infection which progresses to acute
glomerulonephritis after streptococcus in which one of the symptoms is
palpebral edema.

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b. what is the meaning before this symtoms appear taro experiencing
cough and cold, but he never got any treatment?
Answer :
there had infection from 3 weeks ago (ISPA). The target of type A beta
hemolytic streptococcal is kidney, faring, skin. When Taro had
inadequate treatment it can allow the spread of streptococcal bacteria to
the kidned causing acute glomerulonephritis post streptococcal
infection.

Karakteristik Streptococcus pyogenes, also known as group

A Streptococcus (GAS), is a common human pathogen that can induce
a wide spectrum of diseases, ranging from noninvasive diseases, such
as pharyngitis, scarlet fever, and impetigo, to invasive diseases, such as
erysipelas, cellulitis, pneumonia, bacteremia, necrotizing fasciitis, and
toxic shock syndrome. Moreover, GAS can cause rheumatic fever and
acute poststreptococcal glomerulonephritis. Group A beta-hemolytic
streptococci (GABHS) are gram-positive bacteria that grow in culture
as pairs or chains of variable length. On sheep blood agar they appear as
transparent to opaque, round, small colonies surrounded by a zone of
complete hemolysis (beta) of red cells. The beta-hemolytic streptococci
include the pathogens of Lancefield groups A, C, and G. In contrast,
viridans streptococci produce partial (alpha) or no (gamma) hemolysis.

c. what is the patophysiology cough and cold in this case ?

Answer :

infection streptococcus in tractus respiration secretion

mucustoeliminating patogen cold
infection streptococcus in tractus respiration mechanisme eliminate
patogen stimulated central of cough in opioid (medula oblongata)

23
 cough

d. what is the meaning of the first time taro experience this symtom?
Answer :
This symptom are the first experience means there is suggest that the
disease is acute phase not a recurrence or exarcebation of another
disease.

e. what is the etiology of cough and cold?

Answer :
 Virus
The virus that usually causes coughs and colds are Human rhinovirus
(HRV), coronavirus, adenovirus, human parainfluenza virus (HPIV)
and respiratory syncytial virus (RSV).
 Bacteria
The bacteria that usually cause cough and colds are bacteria
streptococcus.
 Allergen
The disease caused by an allergy that has complaints of cough and
colds is allergic rhinitis.

f. what is the meaning taro family never has this kind of symtoms before ?
Answer:
To eliminate the diagnos eof neritis herediter

4. Physical examination:
General appearance:
Counscious: Compos mentis, looks moderately sick. BW: 28 kg, Height:
123 cm.
Vital Sign: BP 140/90 mmHg, Pulse 96x/m, RR 24x/m, Temp: 36,8oC
a. what is the interpretation of physical examination?

24
 Answer:
BP 140/90 : Hypertension

b. what is the pathofisiology of physical examination?

Answer:
hypertension
infection streptococcus in tractus respiration (latent period) ) the
body's defense mechanisms (coughing and flu) ) failing in
eliminating )  circulating in the bloodstream ) complexes forming
antigenic antibodies ) circulating in the blood circulation)  buildup
in the glomerular capillary ) activation of the complement and
phagocytic system )  protease secretion, oxidants and mediators of
inflammation )  glomerulonephritis disturb filtration in glomerular)
 hypoproteinemia )  CES volume  ) hypovolemia ) renin
angiotensin aldosteron system water and sodium retension and
systemic vasocontrictionhypertension grade II

5. Specific Examination:
Head : Edema palpebra (+)/(+), pale conjungtiva (-)
: hiperemic Faring, normal tonsil
Neck : no enlargement of the lympth nodes
Thorax : lung: vesikuler (+) normal, ronchi (-), wheezing (-)
Heart: normal heartsound I/II, tenderness (-)
Abdomen : flat, supple, shifting dullness (-), tenderness (-), hepar and
lien not palpable, bowel sound (+) normal
Ekstremity : pitting edema -/-, edema dorsum pedis -/-
a. what is the interpretation of specific examination?
Answer :

25
 Table 3. Specific Circumstances Interpretation
Spesific
Interpretati
Circumstanc Case Normal
on
es
Head palpebra palpebra Abnormal
edema +/+, edema -/-,  palpebra
pale pale edema
conjungtivas conjungtivas because
-/ -/- edema
hiperemic moves to
faring low
normal tonsil interstitial
pressure as
in preorbital
area

Neck No lymp No lymp gland Normal

gland enlargement
enlargement
Chest Pulmo: pulmo and Normal
sound heart within
vesicular, no normal limits
rhales, no
wheezing
Heart: heart
sound I/II
normal no
murmur
Abdomen Flat, supple, Flat, shifting Normal
with shifting dullness (-)
dullness,
hepar and
lien are not
palpable,
normal
bowel sound
Exstremity pitting pitting edema normal
26
edema -/-, -/-, dorsum
dorsum pedis pedis edema
-/-
b. wb. what

b. what is pathophysiology of spesific examination?

Answer :
Infection Streptococcus → Inflamation reaction at glomerulus →
Disturbance in glomerular basement membrane → Retensi natrium and
fluid → Increase volume hidrostatik preassure → Edema move to low
intertisial pressure which preorbital → edema palpebral

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), erythrocytes 30-50
cell/LPB, cylinder (+)
Blood Chem exam: total protein 5,3 g/dl, albumin 3gr/dl, globulin 2,3
gr/dl, ureum 40 mg/dl, kreatinin 2,0 mg/dl, cholesterol 180 mg/dl, BUN:
25 mg/dl
Imunoserologi: ASTO 420 IU, CRP (+), Titer c3: 60, Titer c4: normal
Throat smear culture: streptococcus B hemolyticus is found
a. what is the interpretation of specific examination?
Answer :

No. Normal Range Interpretation

1. Regular Hb 13,0 g/dl 13 -17,5 g/dl Normal
blood Leucocytes 4.500-11.000/mm3 Leucocytes
18.500/mm3 (Infection)
Platelets 150.000- Normal
450.000/mm3 450.000/mm3
BSR 98 mm/hr 0-22 mm/hr Increased
2. Urinalysis Gross hematuria (-) Hematuria

27
 (+)
proteinuria (+2) (-) Proteinuria
erythrocyte 30- < 2/hpf Increased
50 cells/hpf
leukocyte 2-5 < 2-5/hpf Normal
cells/ hpf
cylinders (+) (-) Hematuria
3. Blood Total protein 5.3 Normal
chemistry g/dl,
Albumin 3 gr/dl Normal
Globulin 2,3 2,5-3,5 gr/dl Decreased
gr/dl
Ureum 40 mg/dl 15-40 mg/dl Normal
Creatinine 2.0 0,7-1,3 mg/dl Increased
mg/dl
Cholesterol 180 < 200 Normal
mg / dl.
BUN : 25 mg/dl 7-20 mg/dl Increased
4. Immuno ASTO 420 IU < 200 Increased
serology CRP (+) CRP (-) Abnormal
Titer C3: 60 83-177 mg/dl Decreased
Titer C4: normal Normal
5. Throat Smear Streptococcus B Abnormal
Culture hemolyticus is
(+) Infection
found.
Streptococcus

glomerular filtration rate (GFR) with the Schwartz formula :

(0.413 x height (cm) / serum creatinine (mg / dL) for creatinine and
filler (66.22 x (1 / cystatin C (mg / L) ) 0.777 for cystatin C.
= 0,413 x 123 : 2,0
=25,3995

28
 b. what is pathophysiology additional examination ?
Answer :
infection streptococcus in tractus respiration (latent period) ) the
body's defense mechanisms (coughing and flu) ) failing in
eliminating )  circulating in the blood stream ) complexes
forming antigenic antibodies ) circulating in the blood circulation)
 buildup in the glomerular capillary ) activation of the
complement and phagocytic system )  protease secretion, oxidants
and mediators of inflammation )  glomerulonephritis ( leucocytes,
BSR increased, titerc3 decreased, CRP(+), ASTO increased, BUN
increased, infection streptoccous beta hemolitycus(+).

7. How to diagnose of this disease by this case ?

Answer:
Chief complaint : swelled eyelids since 5 days ago, sweldness first
appear on the eyelids especially right after waking up and diminishing by
noon.
Additional complaint : frequent headache, daily urine production is only
one cups (oliguria) and red colored like a blood (hematuria).
Case history ( disease ) : 3 weeks ago, taro experiencing cough & cold
before chief complaint & additional complaint appear. This is the first
time taro experience this symptomp.
Family History : taro family never has this kind symptom before.
Physical examination :
Concscious : looks moderately sick
Vital sign : Blood Pressure : 140/90 mmHg ( Hypertension stage II)
Specific examination :
Head : Edema palpebra (+)(+) & hiperemic faring.
Additional examination :

29
 Blood Exam :
Leukocytes : 18.500/mm3 (Leukositosis) & Blood Sediment Rate (BSR) :
98mm/hour (increasing = abnormal)
Urinalysis : gross hematuria (+), proteinuria (+2) (increasing = abnormal)
, erithrocytes 30-50 cell/LPB = erithrocytosis, leukocytes 2-5 cell/LPB =
leukocythosis, cylinder (+)
Blood chem exam : Kreatinin 2,0 mg/dl (increasing = abnormal), BUN
(Blood Urea Nitrogen): 25mg/dl (increasing = abnormal)
Imuno-serologi : ASTO 420 IU (increasing = abnormal), Titer C3 : 60
(decreasing = abnormal)

Throat smear culture : Streptococcus B hemolyticus is found

8. What is the differential diagnose of the disease ?

Answer :

GNAPS NefrotikSindrom

Hematuria (+) (-)

Edema Palpebra Anasarka

Hypertention (+) (-)

Etiology type A beta Autoimun

hemolytic
streptococcal

Hiperalbumin (-) (+)

Hiperkolestro (-) (+)

l

Proteinemia (+) (+)

ASTO (+) (-)

30
 Karakteristik Streptococcus pyogenes, also known as group
A Streptococcus (GAS), is a common human pathogen that can induce a
wide spectrum of diseases, ranging from noninvasive diseases, such as
pharyngitis, scarlet fever, and impetigo, to invasive diseases, such as
erysipelas, cellulitis, pneumonia, bacteremia, necrotizing fasciitis, and
toxic shock syndrome. Moreover, GAS can cause rheumatic fever and
acute poststreptococcal glomerulonephritis. Group A beta-hemolytic
streptococci (GABHS) are gram-positive bacteria that grow in culture as
pairs or chains of variable length. On sheep blood agar they appear as
transparent to opaque, round, small colonies surrounded by a zone of
complete hemolysis (beta) of red cells. The beta-hemolytic streptococci
include the pathogens of Lancefield groups A, C, and G. In contrast,
viridans streptococci produce partial (alpha) or no (gamma) hemolysis.

9. What are the supporting examination of the disease ?

Answer:
No supporting examination

10. a. What is the working diagnose of the disease ?

Answer :
GNAPS

b. definition ?
Answer:
GNAPS is a histopatological form of glomerular inflammation which
shows proliferation and inflammation that is preceded by group A β-
hemolytic streptococci (GABHS) and characterized by nephritic
symptoms (IDAI, 2012)

c. etiology ?

31
 Answer
 Post-infectious acute glomerulonephritis (Group A B-hemolytic
streptococcus or staphylococci),Occurs due to primary infection of the
throat or skin untreated.
 Representative or progressive glomerulonephritis in situ formation of
glomerular basement anti-membrane antibodies or immune complex
desposition. Nonspecific response to glomerular injury; can occur in
any severe glomerular disease. Can be related to goodpasture
syndrome
 Glomerulonephritis proliferative mesangial
 Nephropathy IgA

d. epidemiology?
Answer:
In Indonesia in 2007, there were 270 patients admitted to a teaching
hospital in 12 months. the majority of patients treated were treated in
Surabaya (26.5%), followed by consecutively in Jakarta (24.7%),
Bandung (17.6%) and Palembang (8.2%)

e. patogenesis?
Answer:
infection streptococcus in tractus respiration (latent period) ) the
body's defense mechanisms (coughing and flu) ) failing in
eliminating )  circulating in the blood stream ) complexes forming
antigenic antibodies ) circulating in the blood circulation)  build up
in the glomerular capillary ) activation of the complement and
phagocytic system )  protease secretion, oxidants and mediators of
inflammation )  glomerulonephritis

f. manifestation clinis?

32
 Answer:
1. Latent period
In a typicals GNAPS there must be a latent period that is the period
between streptococcal infection and the onset of clinical symptoms.
GNAPS period that is preceded by ispa is 1-2 weeks.
2. Edema
Edema most often occurs in the preorbital region followed by leg
area. If there is severe retention, it arises in the abdominal region
(asites) and external genitalia (scrotal edema)
3. Hematuria
Urine looks reddish brown or like thick tea, washing water or
colored like colas.
4. Hypertension
The presence of severe hypertension causes cerebral symptoms such
as headaches, decreased conciousness, vomiting and convulsions
5. Oliguria
Oliguria occurs when kidney function decreases or acute renal
failure develops
6. Other symptoms
Symptoms can also be found such as pale, malaise, lethargy and
anorexia

11. How to manage the patient in this case ?

Answer:
Antibiotik : Amoksisilin 50 mg/ kgbb divided 3 dose for 10 days
Diuretik : Furosemid
Hipertention : Captropil 0,3-2mg/kgbb/day

12. What is the complication of the disease ?

Answer :
1. Encephalopathy hypertension (EH)

33
 EH is severe hypertension (hypertensive emergency) which in
children> 6 years can pass the blood pressure of 180/120 mmHg. EH
can be overcome by giving nifedipine (0.25 - 0.5 mg / kg / dose) orally
or sublingually in children with decreased awareness. If the blood
pressure has not dropped, it can be repeated every 15 minutes for up to
3 times. The drop in blood pressure must be done gradually. When
blood pressure has dropped to 25%, captopril (0.3 - 2 mg / kg / day) is
added and then monitored to normal.
2. Acute kidney disorders
 (Acute kidney injury / AKI) Conservative treatment:
1) Diet arrangements are made to prevent catabolism by providing
enough calories, i.e. 120 kcal / kg / day.
2) Regulate electrolytes:
A. If hyponatremia occurs, hypertonic 3% NaCl is given.
B. If hypokalemia occurs, give:
a) Calcium Gluconas 10% 0.5 ml / kg / day
b) NaHCO37,5% 3 ml / kg / day
c) K + exchange resin 1 g / kg / day
d) Insulin 0.1 unit / kg & 0.5-1 g glucose 0.5 g / kg
3. Lung edema
Children usually look crowded and sound loud crackles, so often
mistaken for bronchopneumoni.
4. Posterior leukoencephalopathy syndrome
Is a rare complication and is often confused with hypertensive
encephalopathy, because it shows the same symptoms as headaches,
seizures, visual hallucinations, but blood pressure is still normal

13. What is the prognose of the disease ?

Answer:
vitam :dubia at bonam
sanationam :dubia at bonam
fungsionam :dubia at malam

14. What is the competency level for general practitioner of the disease ?
Answer:

3A

34
 Doctor graduates can make clinical diagnoses and treatments introduction
to non-emergency situations. Graduate doctor able to determine the most
appropriate referrals for patients next. Doctor graduates are also able to
follow up the return fromreference.
(SKDI, 2012)

15. What is the Islamic value based on the case ?

Answer :
“Manfaatkanlah lima perkara sebelum lima perkara :
1. Waktu mudamu sebelum masa tuamu
2. Waktu sehatmu sebelum waktu sakitmu
3. Waktu kayamu sebelum waktu fakirmu
4. Waktu luangmu sebelum waktu sibukmu, dan
5. Waktu hidupmu sebelum matimu.”
(HR. Al-Hakim dalam Al-Mustadrok, 4: 341. Hadits ini shahih sesuai
syarat Bukhari-Muslim

35
2.7 Conclusion
Taro, a 7 years old boy, experiencing edema palpebra, gross hematuria, ,
hipertension due to GNAPS

2.8 Conceptual Framework

infection

Reaction of antibody antigen

Inflamation of glomerulus

Disturbance of glomerulus
filtration

Gross hematuria Retension of natrium and fluid

36
 hypertension edema oligouria

GNAPS

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