Local Board Examination Ade

LONG CASE REPORT
INFREQUENT RELAPSE NEPHROTIC SYNDROME
Name of candidate
Ade Nur Prihadi S
Local Board Examination

Makassar , November 9 th 2021
INDONESIAN COLLEGE OF PEDIATRI

TIMELINE DIAGRAM
Observation by
candidate
November, 2021 October 19th, 2021 October 26th, 2021 November 9th, 2021
Patient was diagnosed as Patient was admitted to

Nephrotic syndrome at pediatric ward of “W” hospital End of observation by Report
“W” hospital and began candidate
To observation by candidate
1
PATIENT’S IDENTITY
Name : MI
Gender : Male
Age : 10 years 5 months old
Date of birth : May 18th 2011
Medical record : 925xxx
Address : Bone, Sulawesi Selatan.
Admission date : October 19th 2021
Hospital length of stay : 7 days
PARENT’S IDENTITIES : Father Mother

Name : Mr. D Mrs. AR
Age : 43 years old 43 years’ old
Last education : Junior High School Junior High School
Occupation : Farmer Housewife
Address : Bone Bone
Initial observation by the candidate began on 19th October 2021
PATIENT’S HISTORY (Alloanamnesis from the mother and autoanamnesis)

Chief complain
Swelling all over the body
History of present illness
A boy, 10 years 5 months old ,was admitted to the hospital with swelling
all over his body since 1 week and getting worse since 3 days prior to admission.
Initially, swelling was noticed on the face and then spread to the abdomen, legs
and scrotal. No history of cough, fever, headache, vomiting, seizure, arthralgia
or loss of consciousness. Good appetite. Defecation within normal limits.
Micturition within normal limit. No history of dysuria and discontinuous micturition.
There was no history of heart disease, liver disease, allergic disease or another
systemic disease.
2
History of previos illnes
The swelling was first noticed on eyelid, face, abdomen, exteremities and
genetalia on 11 months ago (November 2020) at W hospital with complaints of
swelling all over the body since 1 month.
On physical examination, the general condition was found: weak,
conscious, vital signs within normal limits. There is palpebral edema, there is
facial edema. Lungs and heart within normal limits. Abdomen has ascites present
with positive undulation. There is edema of the scrotum, pretibial and dorsum
pedis edema.
On laboratory examination November 2020: WBC 14,810/mm3, Hb 15.1
gr/dl, platelet 627,000/mm3. Blood glucose 91 mg/dl, urea 15 mg/dl, Creatinine
0.40 mg/dl, SGOT 29 U/L, SGPT 13 U/L, Albumin 1.6 gr/dl, total cholesterol 579
mg/dl, Magnesium 1.80 mg/dl, Calcium 5.1 mg/dl, Sodium 138 mmol/l,
Potassium 3.7 mmol/l, Chloride 107 mmol/l
On November 2020 urinalysis, protein +++ / 300 mg/dl was found, Blood
++.
The patient was diagnosed with nephrotic syndrome and then hospitalized
for 2 weeks and received calcium supplementation, albumin and prednisone
therapy. Then the patient did routine control at the pediatric polyclinic at W
hospital. On December 2020 urinalysis, protein negative, Blood negative. The
patient received prednisone therapy for 3 months.
There is no history of anemia or decreased urine volume since the first
attack of swelling. The kidney function value has always been within normal limit
until now. History of dysuria was denied. History of allergies was also
denied.There was no history of jaundice, dyspnea or cyanosis on activities. There
was no history of previous skin infections.
Conclusion: There is a history nephrotic syndrome
3
History of illness in the family
The mother explained that there were no family members or relatives with
the same symptoms as the patient. A family history of hypertension or kidney
disease was denied.
Patient’s family pedigree
Note: : Male
: Female
: Patient
Conclusion : Unremarkable history of illness in the family
Patient’s personal and social history

a) Prenatal history
During pregnancy, the mother routine control at the midwives, and
given vitamin and iron supplementation, she never had any herbal nor drugs
other than prescribed from a medical professional. She felt healthy with
aterm pregnancy and never experienced any trauma or other problems
during her pregnancy.
Conclusion : A mother had a normal prenatal history
b) History of delivery
The patient was born at a hospital. It was aterm, spontaneous vaginal
delivery, assisted by a doctor. The baby cried immediately with no cyanosis.
Birth weight was 3000 grams, birth length was forgotten. Head circumference
was forgotten
Conclusion: Patient was born aterm, normal birth weight, with normal
history of delivery.
4
c) Post natal history
The patient received vitamin K1 injection. Hepatitis B vaccination was

given the first day and oral polio at the discharge time. No history of
cyanosis,jaundice, seizure nor bleeding. The mother stayed at the hospital
for two more days after delivery.
Conclusion : post- natal history was unremarkable
d) Feeding history
The patient was exclusively breastfed since born up to 6 months old.

Complementary food introduced at 6 months of age in form of milk porridge,
followed by steamed rice by the age of 9 months old and had family meal
since 1-year-old. At the moment patient consumed rice, fish, chicken/meat,
eggs, tofu/temph, vegetales and fruits.
Conclusion: patient had adequate quality and quantity of intake
e) Growth and developmental history

Growth
Until the patient was 1 year old, the mother routinely took him to
posyandu, and based on Kartu Menuju Sehat (KMS), the patient’s growth
was always above the green line, hence normal growth
Developmental
The patient was able to show responsive smile at the age of 2 months
old, rollover at 4 months old, stand without support at 7 months old, stand
alone at 12 months old, was able to walk by the age of 14 months old and
was able to speak at 12 months old.
Conclusion: Growth and developmental history were within normal
limit.
5
f) History of immunization
The immunization that has been obtained were hepatitis B 4 times (age
0 day, 2, 3, 4 months), oral polio 4 times (age 2 days, 2, 4, 6 months), BCG
at 1 month, DPT 3 times (at 2,3,4 months), measles 1 time (at 9-months-old).
A booster vaccination has been given at 18 months of age. History of
immunization at the time of grade 1 elementary school.
Conclusion: basic vaccination was complete and booster has been
given.
g) Basic need
Physical-bio medic needs
Patien’s main caregiver was his mother. The patient got adequately
breastfed. Complimentary food was introduced after 6 monthss old, and
since the age of 1 year, she had a family meal. Clothing needs were also
fulfilled. The patient had received complete basic vaccination.
Conclusion : Patient’s parent is able to fulfill all of the patiens
physisical-bio medic needs adequately.
Emotional needs
Parents child relationship seems close and lovingly. Both the mother
and father love the patient very much. The mother is patient enough and tries
to give more attention to her child illness.
Conclusion : Adequate emotional needs from both parents
Mental stimulation needs

Early stimulation were given by both parents and siblings since aerly
age that includes touch and hug, playing together and talking
Conclusion : Mental stimulation needs are fulfilled
6
h) Family Socio-economy/environmental/housing
The father is a 43 years old, his daily activity is as a farmer. He does
not have any fixed income (ranged from IDR 1.500.000 to 2.500.000). The
mother is a 43 years old housewife. Both are from Bone and both are
Moslem. The patient lives with both his parent, brother in a permanent house
7x10 m2 with 1 living room, 1 kitchen, 1 bathroom, 2 bedrooms.
Drinking water source is from refill water product water for daily
activities such as for washing and bath is from boreholes. Electricity sources
is coming from the national electricity company (PLN). Ventilation and light
at the house is sufficient. The nearest health facility from the patient’s house
are primary health center (Puskesmas) ± 1 km away. The hospital bill is
covered by national health insurance.
Conclusion: patient comes from a low middle economic class. Health
facility is easly accessible and health care fees are covered by
government.
PHYSICAL EXAMINATION (pediatric ward, 19th October 2021)

General condition : Severely ill
Consciousness : Glass Coma Scale 15 (E4M6V5)
Vital sign
Blood pressure : 105/70 mmHg (between P50-90)
P50 96/58 mmHg
P90 109/72 mmHg
P95 113/75 mmHg
P95+12 125/87 mmHg
Heart rate : 92 beats per minute, regular, adequate volume
Respiratory rate : 20 beats per minute, regular
Temperature : 36,8 0C
Pain scale : 0 NRS
7
Anthropometric status
Actual Body weight : 32 kg (with edema)
Dry Body weight : 28 kg
Ideal Body weight : 27 kg
Body Height : 130 cm (P10-P25 CDC-NCHS 2000 Chart,
appendix)
Head circumference : 52 cm (normocephaly : 50 cm-56 cm)
Mid upper arm circ. : 21 cm
(MUAC)
MUAC for age : 95,2 % (good nourished)
Head circumference : 53 cm (normocephaly : 50 cm-56 cm)
Weight for height : 103,7 % (good nourished, CDC NCHS 2000 chart)
(Appendix 3)
: 92,8 % (Normal Stature, CDC NCHS 2000 chart)
Height for age
(Appendix 3)
: 84,8% (Normal body weight, CDC NCHS 2000
Weight for age
chart) (Appendix 3)
: 8 years old and 5 month
Height for Age
: 162 cm
Father’s height
: 156 cm
Mother’s height
: 157cm–174 cm (<P3 – P25, CDC-NCHS 2000 chart)
Genetic Potential height
: 165,5 cm
Mid parental height
Conclusion : well nourished, normal stature
8
Table 1. General examination
Organ Description
Skin No erythema, no purpura, good turgor, no striae, no
jaundice, no pale
Head Normocephal, closed fontanella, no deformities
Hair Black, evenly distributed, not easily pluckable.
Face Swelling, not dysmorphic, no cranial nerve palsy
Eye Swelling on both eyelids. No icteric sclera, no
strabismus conjunctiva no anemic, no conjunctivitis,
pupil round isocor diameter 2,5 mm/2,5 mm, light
reflex normal.
Nose Nasal septum in the middle, no secret
Ear No secret, intact tympanic membrane.
Mouth No oral ulcer, no stomatitis
Teeth No caries dentis
Throat Pharynx not hyperemic, no tonsiliar enlargement
Neck No thyroid glands enlargement. Normal jugular vein
pressure, no nuchal rigidity. No neck stiffness.
Chest Shape and movement are symmetric, no
deformities, no piano sign, subcostal chest
retraction
Lung Vocal fremitus symmetrical, percussion sonor,
vesicular breath sound, no additional breath sound
(wheezing and rales).
Heart Ictus cordis was not visible, heart sound I-II normal,
no murmur or gallop.
Abdominal Normal peristaltic. No Palpable liver and spleen.
Ascites were found (by undulation test). Abdominal
circumference 70 cm.
Genitalia Boy, there is scrotal edema, 2 testes palpable
inside the scrotum, with size 2x2x1 cm, pubertal
status A2G2P2
Lymph node No enlargement
Extremities Warm extremities,capillary refill time less than 2
seconds, pitting edema was noted at pretibial and
dorsum pedis. BCG scar on deltoid region right
upper arm. Motoric : muscle strength and tonus are
within normal limit, normal physiological reflexes, no
pathological reflexes, no wasting
9
LABORATORY EXAMINATION
Table 2. Complete blood count
Hospital W
CBC
October 19th 2021
Hb (g/dL) 12,3
MCV (fL) 82
MCH (pg) 27,7
MCHC (g/dL) 33,8
Ht (%) 36,3
Leukocyte (/uL) 11.100
Neutrophil (%) 57,8
Lymphocyte (%) 25,6
Monocyte (%) 12,9
Eosinophil (%) 2,1
Basophil (%) 1,6
Platelets (mm3) 421.000
Table 3. Blood chemistry and electrolyte

Hospital W
October,19th2021
AST (u/L) 34
ALT (u/L) 8
Ureum (mg/dL) 30
Ceatinine (mg/dL) 0,58
Albumin (g/dL) 1,1
Sodium (mEq/L) 148
Potassium (mEq/L) 4,0
Chlorida (mEq/L) 91
Glucose (mg/dL) 125
10
Table 4. Urinalysis
Hospital W
October 19 th2021
Color Yellow
Clarity Clear
Glucose Negative
Bilirubin Negative
Ketones Negative
Ph 7,0
Specific gravity 1.015
Protein urine +4
Nitrites Negative
Blood +1
Leukocyte esterase Negative
Resume
A boy, 10 years 5 months old ,was admitted to the hospital with swelling
all over his body since 1 week and getting worse since 3 days prior to admission.
Initially swelling was noticed on the face then spread to the abdomen, legs and
pubic. Patient no cough, no fever, headache, vomiting, seizures, arthralgia nor
decrease of consciousness. Micturation within normal limits. There was no
history of dysuria. Defecation within normal limits. His appetite was good. There
was no history of fever of unknown origin for more than 2 weeks. There was no
history of heart disease, liver disease, allergic disease or another systemic
disease.There are no signs of symptoms of TB disease. History was hospitalized
at W hospital on 11 months ago and diagnosed with nephrotic syndrome and
received prednisone therapy then outpatient treatment at W hospital with
prednisone therapy for 3 months.
Physical examination revealed a severe ill, normal body weight, conscious
child , vital signs blood pressure 105/70 mmHg (P50-90th), heart rate 92
x/minutes, respiratory rate 20 x/minutes, temperature 36.8 0C. Actual body
weight (BW) 32 kg, body height (BH) 130 cm. Swelling in eyelids and face.
Ascites were found by undulation test. With an abdominal circumference of 70
cm. There is edema at pretibial et dorsum pedis and scrotum.
11
Laboratory examination revealed leucocytosis and hypoalbuminemia.
Urinalysis showed proteinuria massive and microscopic hematuria.
Based on the patient’s history, physical examination, and supporting
examination, patient was diagnosed as having Infrequent relapses nephrotic
syndrome.
The patient was treated with steroids prednisone 60 mg/m2 BSA/day,
plasbumin 25% transfusion 1gr/kgBW (28 grams) followed by furosemide 28
mg/intravenous, vitamin D 800 IU/day, Calcium 700 mg/day. Fluid requirements
are Holiday segar-50% (820ml) consisting of enteral 140 ml and parenteral 680
ml (Nacl 0.9%). Monitoring of vital blood pressure, fluid balance and abdominal
circumference. Patient was suggested to have a bed rest.
The observation was started on the first day of hospitalization
Diagnosis
1. Infrequent relapse nephrotic syndrome
2. Leucocytoses
Problems
1. Infrequent relapse nephrotic syndrome
2. Edema
3. Massive proteinuria
4. Hypoalbuminemia
5. Microscopic hematuria
6. Leukocytoses
7. Prone to infection
Management Planning
1. Infrequent relapse nephrotic syndrome with bilateral eyelids, edema
scrotalis, pretibial, doreum pedis ascites with moon face,
hypoalbuminemia and microscopic hematuria.
Diagnostic - 24 hours’ urine collecting and daily urinalysis
- Qualitative protein urine measurement (dipstick)
- Quantitative protein urine measurement (esbach)
12
- Albumin & cholesterol serum
Therapeutic - Bed rest
- Prednison 60 mg/m2 BSA/day (60 mg/days). (Full
dose)
- Furosemide 1mg/kgBW/12 hours ( 27 mg)
- Plasbumin 25% transfusion 1gr/kgBW (27 grams)
Nutrition care - Diet according to RDA based on height age, solid
food 3 times/day and snack 2 times/day, consist
of:
Energy = RDA height age x IBW = 70 x 27 =
1890 kcal/day
Carbohydrate 300 gr/day
protein 1 g/kgBW/day ≈ 27 gram/day
fat 30% of total calorie ≈ 588 kcal ≈ 65
gram/day
low salt diet 2 gr/day
Monitoring - Fluid balance
- Complications
- Adverse effects from treatment
- Blood pressure
- Body weight
- Abdominal circumference
- Adherence to treatment
Education - Parents were informed about the patient’s current
condition, drugs schedule, possible adverse
effects due to treatment, blood pressure, daily
urine volume follow up/monitoring.
- Therapy given is not for short time and depends
on patient’s adherence.
- Adherence and routine checkup after being
discharge are influencing
prognosis.
2. Infection prevention and leucocytosis

Diagnostic • If signs of infection are found, laboratory
evaluation of infection markers
• Complete blood count
Therapeutic • Prompt treatment if an infection is proven
Monitoring • Signs of infection
13
Education • The importance to prevent infection by personal
hygiene and keep environment sanitation
OBSERVATION IN PEDIATRIC WARD, 20th-26th of October 2021
20th October 2021 (2 days of hospitalization)

S - Swelling on eyelids, face and both legs
- There are no fever, cough and difficulty of breathing
- Good appetite
O Compos mentis
Blood pressure : 100/70 mmHg
Pulse : 88 x/minute, regular
Respiratory rate : 24 x/minute, regular
Temperature : 36,8 OC
Pain scale : 0 NRS
Urine output : 4,1 ml/kgBW/hr
Actual BW : 31 kg
N Swelling eyelids, face decreased. Normal peristaltic. No Palpable liver
and spleen. Ascites was found (undulation test). Abdominal
circumference 68 cm. Edema scrotal, pretibal and dorsum pedis.
A Infrequent relapse nephrotic syndrome
Leucocytosis
P - Bed rest
- Monitoring of fluid balance, blood pressure, body weight, and
abdominal circumference.
- Fluid requirements are Holiday segar (-50%) (820ml) consisting
of parenteral 140 ml (Nacl 0,9%) and enteral 680 ml.
- 2/ Prednison 60 mg/24 hour/day. (Full dose)
- Calcium 700 mg / day, Vitamin D 800 IU / day
- Nutrition: Regular food 3 times/ day, snack 3 times/day, consist
of: energy 1890 kcal/day, carbohydrate 300 gr/day, protein 1
14
g/kgBW/day ≈ 27 gram/day, fat 30% of total calorie = 65
gram/day, low salt diet 2 gr/day.
- Education :
o The importance to prevent infection by personal
o Parents were informed about patient’s current
condition, drugs schedule, the importance of
compliance prednisone treatment, and possible
adverse effects due to the treatment.
o The importance of patient to eat or drink in
compliance with his nutritional role
21st – 22nd October 2021 (3th – 4 thday of hospitalization)

S - Minimal edema eyelids, edema pretibial, dorsum pedis, scrotal
and ascites had decreased
- There were no fever, cough, and difficulty of breathing.
O Compos mentis
Temperature : 36,7OC
Pain scale : 0 NRS
Actual BW : 30,5 kg
Urine output : 1,9 ml/kg/hour, fluid balance negative (470 ml)
Swelling eyelids and moon face, Ascites was found (shifting dullness
test). Abdominal circumference 66 cm. Edema scrotal, pretibal and
dorsum pedis decreased. .
Laboratory examination 21st October 2021:
Blood examination
15
Hemoglobin 12,9 mg/dl, MCV 78,9 fl, MCH 26,7 pg, MCHC 33,9
g/dl, leucocyte 14.700/uL, platelet 470.000/uL, albumin 1,3 gr/dl,
blood glucose 123 mg/dl, ureum 79 mg/dl, creatinine 0,57 mg/dl,
SGOT 48 U/L, SGPT 43 U/L, sodium 130 mmol/l, potassium 3,5
mmol/l, chloride 103 mmol/L, total cholesterol 528 mg/dl.
Urinalysis: yellow, qualitative protein +++, blood negative, leucocyte
sediment and epithelium cell negative
Leucocytosis
P - Bed rest
of enteral 820 ml
- 4/ Prednison 60 mg/24 hour/day (Full dose)
- Calcium 700 mg / day
- Vitamin D 800 IU / day
- Albumin syrup 5ml/24 jam/oral
- Education :
16
23rd - 24th October 2021 (5th-6th day of hospitalization)

S - Edema pretibial, dorsum pedis, scrotal and ascites had decreased
O Compos mentis
Pain scale : 0 NRS
Actual BW : 30 kg
Ascites (undulation test). Abdominal circumference: 65 cm. Edema
scrotal, pretibal and dorsum pedis decreased. .
Leucocytosis
P - Bed rest
of enteral 820 ml
17
- Education :
25th October 2021 (7th day of hospitalization)

S - Edema pretibial, dorsum pedis and ascites had decreased
O Compos mentis
Pain scale : 0 NRS
Actual BW : 29 kg
Ascites (shifting dulness). Abdominal circumference: 63 cm. Edema
pretibal and dorsum pedis decreased. .
Urinalysis: yellow, qualitative protein negative quantitative protein
blood negative, leucocyte sediment and epithelium cell negative
18
Leucocytosis
P - Bed rest
of enteral 820 ml
- Education :
o The importance to prevent infection by personal hygiene
and keep environment sanitation
o Parents were informed about patient’s current condition,
drugs schedule, the importance of compliance prednisone
treatment, and possible adverse effects due to the
treatment.
o The importance of patient to eat or drink in compliance with
his nutritional role
PROGNOSIS
Quo ad vitam : dubious
Quo ad sanationam : dubious
Qua ad functionam : dubious
19
SUMMARY OF HISTORY OF ILLNESS AND HOSPITALIZATION
Prior to observation by candidate
“W” Hospital “W” Hospital “W” Hospital

November 2020 December 2020 19 th October 2021
• Initial onset of NS • Generalize edema.

• Generalize edema. • No edema. • BP 100/70
• Albumin 1.6 gr/dl, total • Proteinuria negative. • Hb 12,3 gr/dl, wbc 11.100/
cholesterol 579 mg/dl, mm3, plt 421.000/ mm3,
proteinuria +3. ureum 30 mg/dL, creatinine
0,58 mg/dL, albumin 1,1
gr/dL, Urinalysis urine,
• Diagnosis: Nephrotic
• Diagnosis :Nephrotic qualitative protein +++, blood
syndrome syndrome
+, leucocyte sediment and
erythrocyte sediment
negative.
Therapy Therapy
• Bed rest • Bed rest
• Prednisone 60 mg/m BSA/ 2
• Prednisone 40 mg/m2 BSA/ Diagnosis: Infrequent relapse
Days continued for 1 Days alternating days and nephrotic syndrome
months) tapering off Leucocytosis
• Bed rest
• Prednison 60 mg/24
hour/day, full dose day
• Fursemide 27 mg/12hours/
day
• Calcium 700 mg / day,
Vitamin D 800 IU / day
• Plasbumin transfusion
• Diet solid 1890 kcal,

carbohydrate 300 gr/day,
protein 28 gram/day, fat 65
gram/day, salt 2 gr/day diet
1 gr/day.
• Nutrition: solid food 3
times/ day, snack
20 3
times/day, consist of:
energy 1740 kcal/day,
During observation by candidate
“W” Hospital “W” Hospital

“W” Hospital
20th October 2021 23-25th Ocotber 2021
21st -22 nd October 2021
Day 2 of Day 4-7 of
Day 3-4 of hospitalization hospitalization
hospitalization
• Pretibial and
• Minimal edema eyelids, pretibial and
• Generalized dorsum pedis,
dorsum pedis, scrotal, ascites had
edema scrotal, ascites had
decreased.
• BP :100/70 mmhg decreased
• BP : 100/70 mmhg
• Actual BW : 31 kg • Actual BW : 30,5 kg • BP : 100/70 mmhg
• AC : 68 cm • AC : 66 cm • Actual BW : 29 kg
• Urine output : 1,9 ml/kg/hour
• Urine output : 4,1 • AC : 63 cm
• Hemoglobin 12,9 mg/dl, leucocyte
ml/kg/hour 14.700/uL, platelet 470.000/uL, • Urine output : 1,69
albumin 1,3 gr/dl, blood glucose 123
mg/dl, ureum 79 mg/dl, creatinine ml/kg/hour
0,57 mg/dl, SGOT 48 U/L, SGPT 43
U/L, sodium 130 mmol/l, potassium
3,5 mmol/l, chloride 103 mmol/L, total
cholesterol 528 mg/dl.
• Urinalysis : protein +++,
Diagnosis : Infrequent relapse nephrotic syndrome + Leucocytosis
• Bed rest
• Monitoring of fluid balance, blood pressure, body weight, and abdominal
circumference.
• Prednison 60 mg/24 hour/day, full dose.
• Furosemide 28 mg/kgbW/12 Hours
• Calcium 700 mg / day, Vitamin D 700 IU / day
• Albumin syr 5 ml/ 24 jam/orally
• Diet solid 1890 kcal/day, carbohydrate 300 gr/day, protein 28 gram/day, fat 65
• Education
21
CASE ANALYSIS
P
A 10- years -5 months boy
R
O
Hypoalbuminemia Proteinuria Edema
B
Hypercholesterolemi
L Actual Body Weight: 32 kg
a Ideal Body Weight: 28 kg
E Body Height: 130 cm
History taking
Head circumference: 52 cm (normocephaly)
M Physical examination Mid-upper-arm-circumference-for-height: 95,2%
Laboratory finding (good nourished)
D Height-for-age: 92,8 %
I
Infrequent relapse nephrotic syndrome
A Risk factor and Length of use of
G steroids at the first attack
N
O Gebrehiwot M et al. Time to Relapse
Corticosteroid Adequate nutrition & Calcium &Vitamin D and Its Predictors among Children
S with Nephrotic Syndrome in
Observation Comprehensive Specialized
I
Hospitals, Tigray, Ethiopia, 2019.
Hahn D, Hodson EM, Willis NS, Aljebab F, Choonara I, Conroy S
S Polderman, et al. (2021). (LoE3B)
Craig JC. Corticosteroid therapy (2017) Systematic Review of
Dietary intakes of children Schijvens, A.M., et al. Steroid
T for children with nephritic the Toxicity of Long-Course
with nephrotic syndrome. treatment for the first episode of
syndrome. Cochrane Database of Oral Corticosteroids in
H Pediatric Nephrology.. (LoE childhood nephrotic syndrome:
Systematic Reviews 2015, Issue Children. PLoS ONE 12(1):
3B) comparison of the 8 and 12 weeks
E 3. Art. No.: CD001533. (LoE1A) e0170259. (LoE 1A)
regimen using an individual patient
R data meta-analysis. Eur J Pediatr
180, 2849–2859 (2021). (LoE1A)
A
P
Y Response to treatment and complication Prognosis :
Quo ad vitam : dubious
P Quo ad sanationem : dubious
Welegerima Y et al. Treatment Outcomes of Pediatric Nephrotic Syndrome
R Patients Treated in Ayder Comprehensive Specialized and Mekelle General Quo ad functionam : dubious
O Hospitals, Ethiopia. Int J Nephrol Renovasc Dis. 2021;14:149-156. 11 (LOE 3B)
G
N
O
S
22
I
S
DISCUSSION
A boy, 10-years-5-months hospitalized with swelling in eyelids, face, both
legs, scrotum and abdomen since 1 weeks and getting worse since 3 days prior
to admission. 11 months earlier the patient complained of the same thing and
was treated for nephrotic syndrome by receiving steroid therapy and was
declared cured after outpatient treatment. Diagnosed as having infrequent
relapse nephrotic syndrome. The problem in this case are about the
determination of diagnosis, the type of nephrotic syndrome, how to treat the
infrequent relapse nephrotic syndrome condition, the complication, and the
prognosis.
In general, the causes of edema formation were based on five
mechanisms which are an increase of intravascular hydrostatic pressure, a
decrease of plasma oncotic pressure, an increase of capillary permeability, the
obstruction of lymphatic flow, and the disturbance of sodium and fluid regulation
of the body. Therefore, edema can be found in diseases that involve the kidney,
heart, liver, or in malnutrition. In such children with nefrotic syndrome, the
selective loss of large amounts of albumin in the urine leads to hypoalbuminemia
and decreased plasma oncotic pressure favoring fluid sequestration in the
interstitial fluid compartment, and secondarily triggers renal Na+ and fluid
retention so as to preserve intravascular volume and blood pressure, hence
preventing an “underfill” state.1,2 In this case, a history of disease, physical
examination and laboratory examination, the cause of edema is due to a
decrease in oncotic pressure due to protein leakage in the kidneys resulting in
hypoalbuminemia which causes a decrease in oncotic pressure which retains
fluid in the blood resulting in extravasation of fluid that causes edema.
Relapse in children with nephrotic syndrome leads to a variety of
complications due to prolonged treatment and potential dependency on steroids.
More than half of children with nephrotic syndrome suffer one or more relapses
and most of them occur within the first six months. Around 80% of children with
steroid-sensitive nephrotic syndrome experience relapse in developed countries.
Having undernutrition, high triglyceride at initiation, baseline low serum albumin
23
level, and rural residence were found to be independent predictors of relapse. 3
(Level of evidence 3B). The duration of steroid treatment in the first attack of
nephrotic syndrome can be a risk factor for relapse. The results of meta-analysis
suggest that the International Study of Kidney Disease in Children (ISKDC)
steroid regimen using 8 weeks of steroid treatment for a first episode of steroid-
sensitive nephrotic syndrome may not be equally effective as the 12 weeks
Arbeitsgemeinschaft für Pädiatrische Nephrologie (APN) steroid regimen in terms
of time to first relapse and relapse rates at 12 months and at total follow-up.
Relapse rate ratios during total follow-up were 51% higher for the 8 weeks
regimen.4 (Level of evidence 1A).
The cause of the idiopathic nephrotic syndrome remains unknown, but
some observations provide important clues to the primary pathogenesis of
idiopathic nephrotic syndrome such as mutations in genes that encode important
podocyte proteins; a plasma factor that alters glomerular permeability, especially
among patients with steroid-resistant nephrotic syndrome; and the altered of T-
lymphocyte responses which result in the production of a permeability factor that
interferes with the expression, function, or both, of key podocyte proteins to cause
proteinuria. A Recent study shows increased systemic production of
representative cytokines, chiefly IL-4 in NS patients. In vitro studies suggest that
podocytes express receptors for IL-4 and IL-13. Activation of these receptors, by
respective cytokines, might disrupt glomerular permeability resulting in
proteinuria.5
The most common etiology of nephrotic syndrome is idiopathic nephrotic
syndrome. Cases with corticosteroids treatment failure, showing underlying
pathology and age more than 8 years indications for renal biopsy to detect and
assess tubular atrophy, interstitial fibrosis and glomerulosclerosis as prognostic
markers. Therefore, once a child is defined because of having steroid resistance
nephrotic syndrome, a kidney biopsy should be performed according to current
standards to determine the underlying pathology.6 In this case the patient was
not indicated for a kidney biopsy because the patient was still sensitive to steroid
treatment and experienced 1 relapse in the span of 11 months.
24
The classic nephrotic syndrome presentation is edema, in the early phase
is located in the face in the morning on waking with puffiness of the eyelids and
the impression of the folds of sheets on the skin and ankles at the end of the day.
Without measure corrective, they become more pronounced, diffuse and lead to
anasarca with ascites, hydrocele or pleural effusion, may also be revealed by a
complication such as hypovolemia, infection (pneumonia and peritonitis due to
Streptococcus pneumoniae), deep-vein or arterial thromboses, and pulmonary
embolism. Moderate arterial hypertension is present in 25% cases, and
hypotension may reveal a state of effective hypovolemia. Functional renal failure
is possible. Microscopic hematuria is noted in about 20% of cases, macroscopic
hematuria being exceptional and having to make look for thrombosis of the renal
veins.7 This patient experienced clinical signs of edema in both eyes and face
that spread to both legs, abdomen and scrotum. This patient also had
microscopic hematuria.
Important finding in laboratory test were massive proteinuria (40 ≥
mg/h/m2 or dipstick urine >+2) + hypoalbuminemia (serum albumin ≤ 2.5 g/dL)
or edema and hyper-lipidemia with total cholesterol of 170- 200 mg/dL.8,9 In this
case, the level of protein in urine was +3 and serum albumin level was 1,1 gr/dL.
The majority of children who present with idiopathic nephrotic syndrome
have minimal change disease (MCD), which is generally responsive to steroid
therapy (85 - 90 %). Steroid-responsive nephrotic syndrome was defined as
patients achieving complete remission with steroid therapy for four weeks.
Steroid-resistant nephrotic syndrome was defined as failure to achieve remission
following four weeks of treatment with prednisone 60 mg/m2. Based on the
frequency of relapses, nephrotic syndrome can be divided into 2, infrequent
relapses with less than two relapses within six months of the initial response or
less than four relapses for any year thereafter. Frequent relapses with two or
more relapses within six months of initial response or four or more relapses within
a period of one year.9 This patient was diagnosed as infrequent relapses
nephrotic syndrome because eleven months before the patient was diagnosed
with nephrotic syndrome based on history, physical examination and laboratory
25
findings. Initially swelling all over the body, starting from the eyelids and followed
by swelling in the abdomen, extremities and scrotum . He received prednisone
treatment and after the treatment was completed, the patient was declared
achieve remission. Then the patient again experienced edema all over the body
since 1 week before entering the hospital and the patient had proteinuria and
hypoalbuminemia so that the diagnosis of nephrotic syndrome was declared.
Current recommendations on the treatment of a first episode of nephrotic
syndrome are based on empirical experience and small randomized controlled
trials. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical
Practice Guideline for Glomerulonephritis recommends that corticosteroid
therapy should be given for at least 12 weeks. Moreover, it is stated that daily
oral prednisone is given for 4–6 weeks followed by alternate day medication for
2–5 months with tapering off the dose.4 Daily prednisone is given for relapses
and is reduced to alternate day dosing once the urine is negative or trace for
protein for 3 days. For patients with frequent relapses, especially if there are
significant steroid side effects, a variety of agents are used to prevent relapses:
alkylating agents, calcineurin inhibitors, mycophenolate mofetil, and rituximab.
Home urine monitoring for relapses is a critical component of management.10
High dose oral methylprednisolone showed no significant difference in the time
to relapse and the relapse rate at one year in patients receiving high dose oral
methylprednisolone given over two weeks versus six months of prednisone
therapy. Prednisone in relapsing sensitive steroid nephrotic syndrome Daily
prednisone with alternate-day prednisone therapy reduced the rate of relapse.11
(Level of evidence 1A). This patient was given daily prednisone therapy and on
the 7th day of treatment, routine urine examination showed negative proteinuria
and was planned to be continued as an alternate day if then he continued to show
negative proteinuria for 3 consecutive days.
The complication of NS are divided into two categories: disease-
associated and drug-related complications. Disease-associated complications
include infections (e.g., peritonitis, sepsis, cellulitis, and chicken pox),
thromboembolism, hypovolemic crisis (e.g., abdominal pain, tachycardia, and
26
hypotension), cardiovascular problems (e.g., hyperlipidemia), acute renal failure,
anemia, and others (e.g., hypothyroidism, hypocalcemia, and bone disease). The
main pathomechanism of disease-associated complications originates from the
large loss of plasma proteins in the urine of nephrotic children. Infection is one of
major complication related to the underlying NS in children. Some factors that
may contribute to this problem are: reduced serum concentrations of
immunoglobulin G (IgG), impaired ability to make specific antibodies, depressed
T-cell function, decreased levels of the alternative complement pathway,
immunosuppressive therapy, and physiological factors such as fluid collection in
cavities and dilution of local humoral defenses by edema that may play a major
role in the susceptibility of nephrotic patients to infection. Side effects include
bone marrow suppression with leucopenia and, rarely, malignant transformation,
hemorrhagic cystitis and, among many others, gonadal toxicity.12,13
The other drug-related complications that can occur in this patient is
related with the use of corticosteroid. Clinical effects predominantly by
upregulating the transcription of anti-inflammatory genes (transactivation) or by
downregulating the transcription of inflammatory genes (trans repression) to
affect the downstream production of a number of pro-inflammatory cytokine and
chemokine proteins, cell adhesion molecules and other key enzymes involved in
the initiation and/or maintenance of the host inflammatory response
Corticosteroids are synthetic analogs of the natural steroid hormones produced
by the adrenal cortex. However, corticosteroids have known adverse effects such
as obesity, poor growth, hypertension, diabetes mellitus, osteoporosis and
adrenal suppression.14,15 The things that should be monitored include the
physical and laboratory progress, and that is not less important is the side effects
of corticosteroids. A dose of >7.5 mg/m2/day of prednisolone or its equivalent will
suppress growth. Thus, all patients on long-term steroids regardless of route of
administration should have a growth monitoring by measurement of weight and
length/height.16
Calcium levels should then be maintained with oral calcium supplements.
In addition to calcium supplements, calcitriol may be necessary in doses of 20 to
27
100 ng/kg per day in 2 to 3 divided doses until calcium levels normalize. 6 Once
vitamin D supplementation has been reduced to 400 IU/day with normal PTH and
25(OH)-D levels. Prednisolone in the dose of 7.5 mg/day for 6 months more, or
a cumulative dose of >10 g leads to bone loss. This patient has a normal value
of calcium level, but the level of vitamin D has not been performed yet because
of the high cost. In addition, they should also receive prophylactic calcium and
vitamin D supplements.15 The three adverse drug reactions of long courses of
oral corticosteroids experienced by the highest number of patients were weight
gain, growth retardation and Cushingoid features with respective incidence rates
of 21.1%, 18.1% and 19.4% of patients assessed for these adverse drug
reactions of long courses of oral corticosteroids. 21.5% of patients measured
showed decreased bone density and 0.8% of patients showed osteoporosis. 17
(Level of evidence 1A) During monitoring, the patient does not experience
complications due to drug complications, therapy to prevent drug complications,
especially growth problems, is given vitamin D and calcium supplementation.
To determine the nutritional state of this patient, we used body Mid upper
arm circumference -for-Age (MUAC/A). According to MUAC/A, the nutritional
state of the patient was good-nourished. Caloric and protein needs were
calculated based on RDA (recommended daily allowance) and ideal body weight,
which was 100 kcal/kg/day for calories, and diets required in nephrotic syndrome
in children protein 0.8 mg/kg/day is the most effective diet in nephrotic patients.
Low-fat diets (calorie intake <30% and cholesterol ≤200mg/day) can improve
hyperlipidemia. Salt should be restricted in the range of less than 2 gr/day was
18,19
suggested if the patient had edema and hypertension Regulating dietary
sodium intake can minimize edema associated with the condition, regulating
energy intake may limit excessive weight gain associated with corticosteroid
therapy and, optimizing calcium and vitamin D intakes can mitigate adverse bone
effects of high dose and prolonged corticosteroid therapy.20 (Level of evidence
3B)
Over 80–90% of minimal change nephrotic syndrome patients are steroid-
sensitive and respond to standard prednisolone therapy with complete resolution
28
of proteinuria. However, most patients tend to relapse, and around 50% become
frequent relapsing and/or steroid-dependent. Patients developing frequent
relapsing and/or steroid-dependent nephrotic syndrome require prolonged
treatment that leads to toxicity, systemic infections, and other complications. The
predictors for quent relapsing and/or steroid-dependent nephrotic syndrome with
steroid therapy were younger age (≤6 years) at initial diagnosis (p=0.00),
presence of hematuria (p=0.00), infection (p=0.01), acute renal failure (p=0.01),
serum albumin below 1.5g/dl (p=0.01) at diagnosis and lack of remission within
2 weeks (p=0.0) of therapy. Patients that encounter frequent relapses and/or
steroid dependence indicate unfavorable features suggesting poor prognosis.
Steroid-resistant NS is difficult to treat with 36–50% of the patients progress to
end-stage renal disease.21 (Level of evidence 3B) Quo ad vitam prognosis is
dubious because this patient received long-term steroid therapy which can lead
to complications such as infection and growth disorders Quo ad functionam and
qua ad sanationam prognosis is dubious because In this patient there are factors
of low albumin levels and hematuria that can increase the occurrence of relapse
and steroid-dependent nephrotic syndrome which has a poor outcome.
The family has the right to know about the symptoms, progressivity of the
disease, treatment and its side effects, complications, prognosis, and the factors
that trigger the disease. Families need to understand that the illness requires a
long regular treatment, because inadequate treatment will prevent remission,
easy to relapse, and eventually leads to chronic kidney disease.
29
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1. Halim, H. Edema. In: Noer MS., et al, editor. Kompendium Nefrologi Anak.
Jakarta: UKK Nefrologi IDAI 2011. p 15-8.
2. Ellis D. Pathophysiology, Evaluation, and Management of Edema in
Childhood Nephrotic Syndrome. Front Pediatr. 2016;3:111. Published 2016
Jan 11. doi:10.3389/fped.2015.00111
3. Gebrehiwot M, Kassa M, Gebrehiwot H, Sibhat M. Time to Relapse and Its
Predictors among Children with Nephrotic Syndrome in Comprehensive
Specialized Hospitals, Tigray, Ethiopia, 2019. Int J Pediatr.
2020;2020:8818953. Published 2020 Nov 22. doi:10.1155/2020/8818953
4. Schijvens, A.M., Teeninga, N., Dorresteijn, E.M. et al. Steroid treatment for
the first episode of childhood nephrotic syndrome: comparison of the 8 and
12 weeks regimen using an individual patient data meta-analysis. Eur J
Pediatr 180, 2849–2859 (2021). https://doi.org/10.1007/s00431-021-04035-
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5. Chen CP., Cheung W., Heng CK., Jordan SC., Yap HK. 2003. Childhood
nephrotic syndrome in relapse is associated with down-regulation of
monocyte CD14 expression and lipopolysaccharide-induced tumour
necrosis factor-α production. Clin Exp Immunol 2003; 134 :111–119
6. Agnes T.,Marina V., Susan S., Debbie G, et al. IPNA clinical practice
recommendations for the diagnosis and management of children with
steroid-resistant nephrotic syndrome. Guidelines Pediatric Nephrology.
https://doi.org/10-1007/s00467-020-04519-1Alatas H., Trihono PP.,
Tambunan T., Pardede SO., EL Hidayati. Pengobatan terkini sindrom
nefrotik (SN) pada anak. Sari Pediatri Vol. 17 2015. p 155-162.
7. Tapia C, Bashir K. Nephrotic Syndrome. [Updated 2021 Aug 10]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470444/
8. Nishi S, Ubara Y, Utsunomiya Y, et al. Evidence-based clinical practice
guidelines for nephrotic syndrome 2014. Clin Exp Nephrol. 2016;20(3):342-
370. doi:10.1007/s10157-015-1216-x
9. Ali SH, Ali AM, Najim AH. The predictive factors for relapses in children with
steroid-sensitive nephrotic syndrome. Saudi J Kidney Dis Transpl. 2016
Jan;27(1):67-72. doi: 10.4103/1319-2442.174075. PMID: 26787569.
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10. Wang, Chia-shi; Greenbaum, Larry A. (2019). Nephrotic Syndrome.
Pediatric Clinics of North America, 66(1), 73–85.
doi:10.1016/j.pcl.2018.08.006
11. Hahn D, Hodson EM, Willis NS, Craig JC. Corticosteroid therapy for
nephrotic syndrome in children. Cochrane Database Syst Rev. 2015 Mar
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25785660; PMCID: PMC7025788.
12. Park SJ., Shin JI. Complications of nephrotic syndrome. Korean J Pediatr
2011; 54: 322-328.
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target of immunosuppressive agents. Nephrol Dial Transplant (2011) 26:
18–24
14. Anju S., Anu A. 2004. Monitoring Adverse Reactions to Steroid Therapy in
Children. Indian pediatrics volume 41__april17, 2004
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Vitamin D in incident nephrotic syndrome: a Midwest Pediatric Nephrology
Consortium study. Pediatr Nephrol. 2016 March ; 31(3): 465–472.
16. Anne MS., Rob H., Saskia NWildt., Michiel FS. 2017. Pharmacology and
pharmacogenetics of prednisone and prednisolone in patients with
nephrotic syndrome. https://doi.org/10.1007/s00467-018-3929-z
17. Aljebab F, Choonara I, Conroy S (2017) Systematic Review of the Toxicity
of Long-Course Oral Corticosteroids in Children. PLoS ONE 12(1):
e0170259. https://doi.org/10.1371/journal.pone.0170259
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19. Eskandarifar A, Fotoohi A, Mojtahedi Y. Nutrition in Pediatric Nephrotic
Syndrome. J Ped. Nephrology 2017;5(3)
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31
Appendix 1. List of Abbreviations
- AC : abdominal circumference
- BCG : bacillus calmette-guerin
- BH : body height
- BSA : body surface area
- BW : body weight
- CBC : complete blood count
- CD : continuous day
- CDC : center of disease control
- CsA : cyclosporin A
- DPT : diphtheria pertussis tetanus
- ESRD : end stage renal disease
- FSGS : focal segmental glomerulonephritis
- GCS : glasgow coma scale
- GFR : glomerular filtration rate
- GH : growth hormone
- Gr : gram
- HA : height age
- Hb : hemoglobin
- Hct : hematocrit
- Hib : haemophilus influenza type b
- IPS : indonesian Pediatric Society
- IPNA : international Pediatric Nephrology Association
- ISKDC : international study for kidney disease in
children
- IV : intravenous
- IVFD : intravenous Fluid Drips
- KDIGO : kidney disease improving global outcomes
- KMS : kartu menuju sehat
- MCH : mean corpuscular hemoglobin
- MCHC : mean corpuscular hemoglobin concentration
32
- MCNS : minimal change nephrotic syndrome
- MCV : mean corpuscular volume
- mg : milligram
- mg/dl : milligram per desiliter
- mg/kg : milligram per kilogram of body weigh
- mmHg : millimetres of mercury
- mmol/L : millimoles per liter
- MMR : mumps, measles, rubella
- MUAC/A : mid-upper arm circumference for age
- NCHS : national center for health statistics
- NMCNS : non-minimal change nephrotic syndrome
- NRS : numeric rating scale
- NS : nephrotic syndrome
- PO : per oral
- PRC : packed red cell
- RDA : recommended daily allowance
- SGOT : serum glutamic oxaloacetic transaminase
- SGPT : serum glutamic pyruvic transaminase
- SRNS : steroid-resistant nephrotic syndrome
33
Appendix 2. Head Circumference (Nellhaus Curve)
Examination date : October, 19 th 2021

Name : MI
Age : 10 years 5 months
Head circumference : 52 cm (normal: 50-56,5 cm)
34
Appendix 3. Genetic potential height
Name : MI
Age :10 year 5 months
Name : MI
Age : 10 years 5 months
Weight : 28 kg
Height : 130 cm
Weight for height : 28/27 x 100% = 103,7 % (good nourished)
Height for age : 130/140 x 100% = 92,8 % (Normal Stature)
Weight for age : 28/33 x 100% = 84,8 % (normal weight)
Father’s body height 162 cm, mother’s body height 156 cm.
midparental height 165,5 cm. Genetic potential height: 157 -174 cm (<P3- P25)
35
Appendix 4. MUAC/A
Name : MI
Age : 10 year 5 months
MUAC : 20/21 x 100%= 95,2% (good nourished)
36
Appendix 5. Relapsing nephrotic syndrome protocol
(Reference: Nephrology Working Group of Indonesian Pediatric Society)
Description: Treatment of relapsed NS: daily full dose of prednisone (FD) until
remission (maximum 4 weeks) then followed by intermittent or alternating (AD)
prednisone 40 mg/m2 BSA/day for 4 weeks.
37
A Appendix 6. Blood Pressure Table for boy Based on Age and
Height
38
Appendix 7. Pediatric Symptom Checklist
Pediatric Symptom Checklist (PSC) adalah sekumpulan kondisi-kondisi perilaku yang digunakan sebagai
alat untuk mendeteksi secara dini kelainan psikososial pada anak berusia 4 – 16 tahun.
Cara Menilai :
1. Tentukan apakah tingkah laku ini tidak pernah, kadang-kadang atau sering pada anak yang diperiksa
2. Berikan nilai untuk setiap jawaban sesuai dengan data perilaku anak :
Tidak pernah : bernilai 0
Kadang-kadang : bernilai 1
Sering : bernilai 2
3. Penilaianya itu jumlahkan nilai jawaban dari data perilaku anak :
a. Untuk anak yang berusia 4-6 tahun, jumlah nilai kurang dari 24 tidak ditemukan masalah
psikososial, anak tak perlu dirujuk
b. Bila jumlah nilai adalah 24 atau lebih terdapat masalah psikososial, anak perlu dirujuk
(Psikolog/Psikiater)
c. Untuk anak yang berusia > 6 tahun, jumlah nilai kurang dari 28 tidak ditemukan masalah
psikososial, anak tak perlu dirujuk
d. Bila jumlah nilai adalah 28 atau lebih terdapat masalah psikososial, anak perlu dirujuk
(Psikolog/Psikiater)
TIDAK KADANG- SERING
PERILAKU ANAK
PERNAH KADANG
1. Sering mengeluh nyeri atau sakit √
2. Menyendiri √
3. Mudah lelah, kurang energik √
4. Gelisah, sulit untuk duduk tenang √
5. Bermasalah dengan guru di sekolah √
6. Kurang perhatian pada pelajaran di sekolah √
7. Berperilaku seolah-olah dikendalikan oleh mesin √
8 Terlalu banyak melamun √
9. Mudah teralih perhatiannya √
10. Takut pada situasi baru √
11. Sedih dan murung √
12. Mudah marah √
13. Cepat putus asa √
14. Susah berkonsentrasi √
15. Tidak suka berteman √
16. Berkelahi dengan anak lain √
17. Membolos di sekolah √
18. Penurunan prestasi di sekolah √
19. Memandang rendah diri sendiri √
20. Kedokter, tetapi ternyata tidak ditemukan kelainan √
21. Gangguan tidur √
22. Kecemasan yang berlebihan √
23. Ingin bersama Ibul ebih lama √
24. Merasa dirinya buruk √
25. Mengambil risiko berlebihan yang tidak perlu √
26. Ceroboh √
27. Kurang gembira √
28. Kekanak-kanakan bila dibanding anak sebayanya √
29. Tidak mengikuti peraturan √
30. Tidak menunjukkan perasaan √
31. Tidak memahami perasaan orang lain √
32. Mengganggu orang lain √
33. Menyalahkan diri sendiri √
34. Mengambil barang yang bukan kepunyaannya √
35. Menolak untuk berbagi √
Examination date : October, 20th 2021

Name : MI
Age : 10 years and 5 month 39
Total Score : 4
Appendix 8. PedsQL Version 4.0 Examination date : October, 20th 2021
Name : MI
Child report Age : 10 years and 5 month
Parent report score Teen report score

Physical function 75 Physical function 84
Emotion function 75 Emotion function 80
Social function 80 Social function 80
School function 60 School function 60
40

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LONG CASE REPORT

INFREQUENT RELAPSE NEPHROTIC SYNDROME

Local Board Examination

INDONESIAN COLLEGE OF PEDIATRI

Patient was diagnosed as Patient was admitted to

PARENT’S IDENTITIES : Father Mother

Initial observation by the candidate began on 19th October 2021

PATIENT’S HISTORY (Alloanamnesis from the mother and autoanamnesis)

Conclusion: There is a history nephrotic syndrome

Conclusion : Unremarkable history of illness in the family

Patient’s personal and social history

The patient received vitamin K1 injection. Hepatitis B vaccination was

Conclusion : post- natal history was unremarkable

The patient was exclusively breastfed since born up to 6 months old.

e) Growth and developmental history

Mental stimulation needs

PHYSICAL EXAMINATION (pediatric ward, 19th October 2021)

Table 3. Blood chemistry and electrolyte

2. Infection prevention and leucocytosis

20th October 2021 (2 days of hospitalization)

21st – 22nd October 2021 (3th – 4 thday of hospitalization)

23rd - 24th October 2021 (5th-6th day of hospitalization)

25th October 2021 (7th day of hospitalization)

Prior to observation by candidate

“W” Hospital “W” Hospital “W” Hospital

• Initial onset of NS • Generalize edema.

• Diet solid 1890 kcal,

“W” Hospital “W” Hospital

Diagnosis : Infrequent relapse nephrotic syndrome + Leucocytosis

Examination date : October, 19 th 2021

Examination date : October, 20th 2021

Parent report score Teen report score

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