Skenario D 2017

“ Because of you, i am changed”

Mr. Darmawan, a 40 years old, came to the emergency department of RSMP with a chief complain of
difficulty to urinate since 1 hours ago. 6 hours before coming to the hospital, patient also experiencing a colic
pain on his left and right waist. The pain was felt spreading to the stomach followed with nausea without
vomiting and peeing with a smells of jengkol. The patient wants to urinate, but the urine excreted were not
much, painful, and also followed with blood and some white stuff. 12 hours ago, the patient claimed that he was
comsuming 5 raw jengkol fruit.
Physical Examination:
General Appearance: Composmentis, looks mildly sick
Vital Sign: BP : 130/80 mmHg, HR : 118 x/m, regular, RR : 22x/m, T : 37,40C
Specific Examination :
Head: Anemic Conjungtive (-), Icteric Sklera (-), mouth and breat smells like jengkol.
Neck: JVP 5-2 cmH2O, there is no enlargement of the lymph nodes.
Thoraks: Normal Shape, simetry.
Heart:heart sound I-II (+) normal, mur mur (-), gallop (-)
Lung: Vesicular (+) normal, ronchi (-), wheezing (-)
Abdomen: normal bowel sound, suprapubic tenderness (+),CVA pain when being hit (+), ballotement (-), hepar
and lien were not palpable.
Ekstremity: CRT lest than 2 second, warm acral.
Urogenital: urine catether were inserted: 750 cc red colored urine were produced.
Laboratorium:
Blood test: Hb 12 g/dl; Ureum 78 mg/dl; Creatinin 3,0 mg/dl; Natrium 140 mmol/l; Kalium 3,7 mmol/l;
Urinalysis: pH urine 5,8; urine erythrocytes 90/LPB

A. What is the anatomy of system urinary (renal)?

Answer :
Anatomy kidney

Kidney is a bean-shaped organ that is located on both sides of the vertebral column. In adults, the
length of the kidney is around 12 cm-13cm (4.7 inches to 5.1 inches), wide is 6 cm (2.4 inches)
around 50 grams. Its size does not differ according to body shape and size. The right kidney is
slightly lower than the left kidney because it is pushed downward by the liver. The upper pole is
located as high as the twelfth rib. While the upper pole of the left kidney is located as high as a rib
 XI. The kidneys are located in the posterior part of the upper abdomen, behind the peritoneum, in
front of the last two ribs, and three large muscles: m. transversus abdominis, m. quadratus lumborum,
and m. psoas major. The kidney is held in this position by a thick fat pad. The adrenal glands are
located above the poles of each kidney. The kidneys are well protected from direct trauma. The
kidneys function to filter waste substances from the blood. The remaining substances are removed
together with excess water as urine.
The longitudinal incision of the kidney shows two different regions of the cortex and medulla.
The medulla is divided into triangular pieces called pyramids. These pyramids are surrounded by the
cortex and consist of tubular segments and nephron collecting ducts. The papillae or apex of each of
the Bellini papillary duct pyramid forms is formed from the union of many parts of the collecting duct
terminal. Each kidney tubules and form the glumerulus unity (nephron). Nephrons are the functional
unit of the kidney. Each kidney consist of one million nephrons. Nephron consists of Bowman
capsule, the proximal tubular contour, the Henle arch and the distal tubular contortus, which empties
themselves of the collectoral duct.
Kidney borders
Cranial : bordering diaphraghma
Caudal : bordering m.quadratus lumborum
Ventra ren dextra : liver, duodenum & ascendent colon
Ventra ren sinistra : gastric, splen, pancreas, jejunum and colon descendens
Kidney vascularization
The kidneys get blood from the abdominal aorta which has renal artery branching, these arteries are
left and right paired. Renal arteries branch off into interlobular arteries and then become aquaria
arteries. The interlobularis artery at the edge of the kidney is branched into a glomerular afferent
arteriole that enters the gromerulus. Blood capillaries that leave the gromerulus are called efferent
gromerular arterioles which then become renal veins into the inferior vena cava.
Kidney nerves
The kidney gets innervation from the renal nerve (vasomotor), the function of nerves to regulate the
amount of blood that enters the kidneys, nerves that travel together with blood vessels that enter the
kidneys.
(Snell, 2015)

B. How the physiology of urinate system (renal) ?

Answer :
 Non-protein Nitrogen Disposal Compound (NPN)
 This NPN excretion function is main function of the kidney. NPN is the remainder of the results the
body's metabolism of nucleic acids, amino acids, and protein. Three substances yield the excretions are
urea, creatinine and acids veins.
 Water Balance Settings
The role of the kidneys in maintaining balance body water is regulated by ADH (Anti-diuretic
Hormones). ADH will react to changes in osmolality and fluid volume intravascular. Increased
osmolality plasma or decrease in fluid volume intravascular stimulation of ADH secretion by posterior
hypothalamus, then ADH will increase tubule permeability distal contact and collective ducts, so that
reabsorption increases and urine become more concentrated. In thirst, ADH will be secreted to increase
reabsorption of water. Under dehydration, kidney tubules will maximize reabsorption of water to
produce a little urine and very concentrated with osmolality reach 1200 mOsmol / L. excessive fluid will
be produced a lot urine and dilute osmolality decreases up to 50 mOsmol / L.
 Electrolyte Balance Setting
Some electrolytes that are regulated by balance include sodium, potassium, chloride, phosphate,
calcium, and magnesium.
 Regulation of Acid-base Balance
Every day many leftovers are produced body metabolism is acidic like carbonic acid, lactic acid,
ketones, and others must be excreted. The kidneys regulate acid-base balance through regulation of
bicarbonate ions, and removal of metabolic waste acid.
 Endocrine Function
The kidneys also function as organs endocrine. The kidneys synthesize renin, erythropoietin, dihydroxy
vitamin D3, and prostaglandins

There are three normal urine formation processes to remove remains metabolism, namely plasma
gromerulus filtration, tubular reabsorption and secretion tubular. Gromerulus filtration consists of three
layers of cells. The first layer is capillary endothelium commonly called the lamina fenestra because
there are pores with a diameter of 50-100 nm. The second layer is a basement membrane consisting of
woven fine fibrils are embedded in a gel-like matrix and a third layer is a podocyte which is the visceral
layer of the bowman capsule. Blood cells and large molecules such as large proteins and negatively
charged proteins like albumin is held back by size selection and load selection is a characteristic of the
gromerulus filtration membrane barrier. While a molecule smaller size or with a neutral or positive load
such as water and crystalloids have been immediately filtered.
The next process is tubular resorption and secretion. There are three classes substances that are filtered
in the gromerulus, namely electrolytes, non-electrolytes and water. Some of the most important
electrolytes are sodium (Na +), potassium (K +), calcium (Ca ++), magnesium (Mg ++), bicarbonate
(HCO3-), chloride (Cl-) and phosphate (HPO4-). While the important non-electrolytes are glucose,
amino acids and metabolites which is the final product of the process of metabolizing proteins such as
urea, acids urate and creatinine.

This reabsorption and secretion process takes place through a transport mechanism active and passive.
Glucose and amino acids are completely reabsorbed throughout proximal tubules through active
transport. K+ and uric acid almost entirely actively reabsorbed and both are secreted into the distal
tubule. At least two thirds of Na + the filtered will be reabsorbed in the proximal tubule then continues
to the henle arch, distal tubules and collecting ducts.

Most of Ca2 + and HPO4-  reabsorbed in the proximal tubule actively while water, Cl- and urea is
passively reabsorbed. With the displacement of most Na + ions which is positively charged, then the
negatively charged Cl ion must be accompanied to achieve neutral conditions. The exit most of the ions
and non-electrolytes from the proximal tubular fluid cause the fluid undergoes osmotic dilution and
water diffuses out of the tubules and into to the peritubular blood. Urea then diffuses passively. Urea
concentration ratio rises along the tubules because 50% of the urea is re-absorbed. Ion H +, sour
organics such as para-amino-hipofurat (PAH), penicillin and creatinine all actively discretion into the
proximal tubule. Around 90% of HCO3- indirectly resorbed from the tubules proximal through the Na +
exchange- H +. H + which is secreted into the lumen tubules as Na + exchangers will bind to HCO3-
contained in Gromerulus filtrate to form carbonic acid (H2CO3). H2CO3 will dissociate into H2O and
carbon dioxide (CO2). H2O and CO2 will diffuse out of the tubular lumen, into the tubular cell. In these
tubular cells, carbonic anhydrase catalyzes the reaction of H2O and CO2 by forming H2CO3 once again.
H2CO3 dissociation produces HCO3 and H+. H+ secreted again and HCO3- will enter the peritubular
blood together with Na +. Besides reabsorption and rescue of most HCO3- the kidney also removes H +
that exaggerated. This process occurs in the nephron and is important in the concentration of urine.

There are several hormones that function to regulate tubular reabsorption and solute secretions and
water. Water reabsorption is influenced by antidiuretic hormones (ADH), aldosterone influences Na +
reabsorption and K + and parathyroid hormone (PTH) which regulates Ca ++ and HPO4 reabsorption -
along the tubule.

(Verdiansyah, 2016)
C. What is the meaning a chief complain of difficulty to urinate since 1 hours ago ?
Answer :
The meaning of difficulty to urinate since 1 hours ago is retention of urine which is probably caused b
y obstruction in the urinary tract.

D. What are the etiology of difficulty to urinate?

Answer :
the etiology of difficulty to urinate is caused of obstructive and non obstructive if there is an
obstruction ( kidney stones) and another cause is infection prostate enlargemen,nervous system
disorder and nerve damage (trauma).

E. How is the patofisiology of difficulty to urinate?

Answer :
consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin complex
and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free jengkolic
acid through to the membrane semipermeabel from glomerulus > occur procces of reabsorbtionof
water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid as a sharp crystal
needle shaped > obstruction of urinary tract > difficult to urinate.

F. What are the possible disease of difficulty to urinate?

Answer :
a. Prostate enlargement
According to the National Association for Continence, as men get older many men develop
benign prostates. When experiencing swelling, the prostate gland exerts pressure on the prostatic
urethra. This pressure makes men who suffer from prostate disease difficult to urinate and maintain
urine flow.
b. Nervous System Disorders and Nerve Damage
Nerves that are damaged or affected by certain diseases can interfere with urine flow. Nerve
damage can be caused by accidents, strokes, childbirth, diabetes, brain infections, or spinal cord.
Multiple sclerosis and other nervous system disorders can also cause nerve damage that results in
difficulty urinating.
c. Infection
Prostatitis is quite common in men. This is inflammation of the prostate gland that can be caused
by infection. This condition can cause the prostate to swell and press on the urethra, causing urine to
 stagnate. Urinary tract infections and sexually transmitted infections can also cause problems when
urinating in men and women.
d. Bladder stones
Bladder stones usually develop when the bladder is not completely empty, so urine forms
crystals. Enlargement of the prostate gland, damaged nerve conditions, inflammation, and the use of
medical devices such as catheters can also cause bladder stones.
e. Diabetes
People with type 2 diabetes will urinate frequently. This is because the volume of sugar that
builds up in the bloodstream makes the kidneys have to work harder to get rid of the excess sugar.
The more often you urinate, the greater the thirst you feel. As a result, you drink more fluids.
f. Kidney stones
Small kidney stones are hard objects made of minerals that form in the kidneys. Many triggers
for the emergence of kidney stones ranging from lack of drinking water, obesity, consumption of
certain drugs that are diuretic, consume too much protein and less fiber, and others. When a buildup
of kidney stones comes out through the urethra can cause urinary problems, such as increased
urination intensity, severe pain on one side or both back, pain when urinating, pink / red / brown
urine, and foul-smelling urine and halting.
g. Urine incontinence
If you can not control the flow of urine that means you have urinary incontinence (UI).
h. Jengkolat Acid Poisoning
Consuming raw or undercooked jengkol seeds is thought to play a role in providing a potential risk of
jengkol poisoning because jengkolat acid contained in raw jengkol seeds is still intact and active.
However, not all people who consume jengkol will experience poisoning because the main factor
causing poisoning due to jengkol depends on one's immune system, in this case the stomach
condition, not the age of the jengkol seeds, the amount of jengkol consumed, or how to cook it.
Someone who consumes jengkol in an acidic stomach condition will be more at risk of poisoning.

G. What is the impact that occurs when it is difficult to urinate?

Answer :
a) Urinary tract stone
b) Nerve damage
- Vaginal childbirth
- Brain or spinal cord infections
- Diabetes
- Stroke
 - Multiple Sclerosis
- Pelvic injury
- Heavy metal poisoning
c) Muscle damage
d) Blockage
A. What is the meaning 6 hours before coming to the hospital, patient also experiencing a colic
pain on his left and right waist ?
Answer :
The meaning is he experienced jengkol intoxication caused by jengkolat acid contained in jengkol.
Jengkol intoxication can occur due to crystallization of jengkolic acid in an acidic environment that
resembles a rosette needle that is difficult to dissolve in water, both acidic and basic. These crystals
can cause a blockage in the urethra (urinary tract) and also in the kidneys. Therefore, in the case of
symptoms of colic pain in the left and right waist caused by crystalline jengkolat acid.
(Bunawan et al, 2014)

B. What are the etiology of colic pain on his left and right waist ?
Answer :
- Ureteric stone
- Gall stone
- Jengkolism
- Apendiscitis
(Hardiansyah et al, 2013)

C. What is the possible disease colic pain on left & right waist ?
Answer :
 Urolithiasis
 Pielonefritis acute
 Cholelithiasis
 Apendisitis acute
(Hardiansyah et al, 2013)

D. How is the pathophysiology of colic pain on his left and right waist ?
Answer :
 Consumption 5 raw jengkol  Absorbtion of jengkolat acid by digestivus tract  Jengklat acid
through the glomerular membrane  Process of reabsorbtion of water in ansa henle 
Oversaturated jengkolat acid  Formation of deposits of the sharp like “needle-shaped crystals” 
obstruction of the urinary tract (in ureter)  Body compensation  Increased peristalctic  Colic
pain on his left and right waist.

E. What is the meaning about the pain was felt spreading to the stomach followed with nausea
without vomiting and peeing with a smells of jengkol ?
Answer :
 Pain was felt spreading to the stomach occurs due to the formation of crystals of jengkolic acid
sharp in the urinary tract injuring the ureteral wall.
 Nausea without vomiting occurs due to an increase in sympathetic nerves from the vagal nerve
due to obstruction.
 Peeing with a smells of jengkol means the presence of jengkolic acid in the urine, where a person
who consumes jengkol will generally produce a jengkol odor in his breath, mouth, and urine
The complaint above is a symptom of jengkolic acid poisoning. Where the symptoms that arise can
be in the form of abdominal pain that is sometimes accompanied by vomiting, colic attacks and pain
during urination, dysuria (urinary disorders), and hematuria (blood in the urine). The presence of
blood in the urine is caused by sores on the stomach, urinary tract, and even kidneys due to sharp
jengkolic acid crystals.

F. What is the patofisiology of pain spreading to the stomach followed with nausea and peeing
with a smells of jengkol?
Answer :
 Consumed 5 raw jengkol > jengkolic acid absorbed by digestive tract > filtrated in glomerulus >water
reabsorption in ansa henle> oversaturated jengkolic acid > accumulated of crystal jengkolic acid formed a
shape of needle or roset obstruction in urinary tract >peristaltic activity increased > nociceptor stimulated > >
stomach pain > stimulate vagus nerve > nausea
 Consumed 5 raw jengkol > jengkolic acid absorbed by digestive tract > filtrated in glomerulus > water
reabsorption in ansa henle> oversaturated jengkolic acid > contain sulfur> peeing with a smell of jengkol.

G. What is the relation between experiencing colic pain 6 hours ago and chief complain ?
Answer :
 The relationship between additional complain and the chief complain is the progressivity of the infla
mmation of the urinary tract that causes symptoms of colic pain and subsequent urinary tract obstruc
tion that causes urinary retention.
A. What is the meaning of patient wants to urinate, but the urine excreted were not much,
painful, and also followed with blood and some white stuff?
Answer :
patient wants urinate but excreted it means oliguria , painfull when urinate means dysuria, urine
followed with blood mean hematuria, and white stuff mean indication of stone/crystal.

B. How is the patophysiology of the urine excreted were not much, painful, and also followed
with blood and some white stuff?
Answer :
 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > obstruction of urinary tract > urine excreted not much
(oligouria).

 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > stimulated nocireceptors > pain.

 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > laceration kidney > urine excreted also
followed with blood (hematouria).
  consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > urine excreted also followed with some white stuff.

C. What is the meaning of 12 hours ago, the patient claimed that he was consuming 5 raw
jengkol fruit?
Answer :
the meaning is that he suffer djengkolism , with clinic manifestation are suprapubic
spasmodic ,urine obstruction, Acut kidney injury

D. What are the subtances contain in jengkol?

Answer :
Found chemicals found in the skin of jengkol (terpenoids, saponins, phenolic acids and alkaloids) ar
e effective for use as a pest attack plant. The tannin and flavonoid elements in jengkol skin are as eff
ective as tannin in woody plants and herbs that are made to protect themselves from pests. With this
tannin content, jengkol skin then has the potential to be used as a bioinsecticide.
The results showed that jengkol seeds contained nutrients needed by the body including carbohydrat
es, protein, vitamin A, vitamin B, phosphorus, calcium, and iron. Protein content in jengkol seeds (2
3.3 grams per 100 grams of material) exceeds protein levels in tempeh (18.3 grams per 100 grams of
material) so that jengkol can be a source of vegetable protein (Nurussakinah, 2010)

E. What is relation between consuming jengkol and chief complain ?

Answer :
The relation between of consuming jengkol with the main complaint is consuming jengkol is the
main cause of complaints experienced by Mr.Darmawan, because in jengkol there is jengkolat acid,
jengkolat acid will crystallize and can cause major complaints experienced by Mr. Darmawan.

F. What are the classification of food intoxication ?

Answer :
Food poisoning is a disease caused by consuming foods that contain hazardous / toxic or
contaminated ingredients. Contamination can be by bacteria, viruses, parasites, fungi, toxins.
Botulism
Botulinum is a nerve poison, produced by the bacterium Clostridium botulinum. Anaerobic bacteria
often grow on food or preserved food and the preservation process is not good, such as sausages,
meatballs, canned fish, canned meat, canned fruits and vegetables, honey.
Acute symptoms can appear 2 hours - 8 days after ingesting contaminated food. The shorter the time
between ingesting contaminated food and the onset of symptoms the more severe the degree of
poisoning. The initial symptoms can be hoarseness, dry mouth and discomfort in the epigastrium.
Can also arise vomiting, diplopia, ptosis, dysarthria, skeletal muscle paralysis and the most
dangerous is respiratory muscle paralysis. Consciousness is not disturbed, sensory functions are
within normal limits. Pupils can be wide, not reactive or can also be normal. Symptoms in infants
include hypotony, constipation, difficulty in drinking or eating, difficulty in standing the head and
vomiting reflexes.
Management includes decontamination by vomiting the contents of the stomach if the victim is still
conscious, gastric lavage can also be done. Activated charcoal can be given (if available). If
available botulinum antitoxin can be given in symptomatic poisoning (allergy testing needs to be
done before).
Bongkrek (tempe bongkrek, tamarind acid)
Bongkrek tempeh is made from coconut pulp. Toxic bongkrekic tempe contains poison of
bongkrekic acid produced by Pseudomonas cocovenenan which grows on the uncooked coconut
pulp. In the finished tempe, pseudomonas do not grow.
Symptoms of poisoning vary from very mild only: dizziness, nausea and abdominal pain to severe
forms of: failure of circulation and respiration, convulsions and death.
Specific antidote of bongkrekic poisoning does not yet exist. Nonspecific therapy is aimed at saving
lives, preventing further absorption of toxins and accelerating excretion. Overcome circulation and
respiration disorders, give activated charcoal.
Jengkol (jengkol acid)
Jengkol is a type of fruit that is usually eaten as fresh vegetables. Symptoms can occur 5-12 hours
after eating jengkol. Symptoms of poisoning: colic, oliguria or anuria, hematuria, acute kidney
failure. These symptoms occur as a result of urinary tract obstruction by jengkol acid crystals.
Management is intended to prevent the formation of crystals by giving sodium bicarbonate 0.5-2
grams 4 times per day orally. If acute kidney failure occurs, the management is in accordance with
acute kidney failure. There is no specific antidote.
Cyanide (HCN)
Cyanide is a chemical that is very toxic and is widely used in various industries. Also found in
several types of tubers or cassava. Symptoms can include headache, nausea, vomiting, cyanosis,
 dyspnea, delirium and confusion. It can also be immediately followed by fainting, convulsions,
coma and cardiovascular collapse which develop very quickly. Management of emergencies do
airway liberation, give 100% oxygen. Give sodium-thiosulfate 25% IV at a rate of 2.5-5 ml / min
until clinically improved. Thiosulfate is relatively safe and can be given even though the diagnosis
is still dubious. Management of coma, seizures, hypotension or shock with appropriate action. Don't
do an emesis because the victim can quickly turn unconscious.
(Anonym, 2016)

A. What is the interpretation of physical exam ?

Answer :
Examination In Case Normal Value Interpretation

General Appearance Composmentis Composmentis Normal

General Appearance Looks Mildly Sick Feel no pain Abnormal

Blood Pressure 130/80 mmHg 120/80 mmHg Hypertension

Heart Rate 118 x/m 80-100 x/m Tachycardia

Respiratory Rate 22x/m 16-24 x/m Normal

Temperature 37,4 oC 36,1 – 37,5 oC Normal

B. How is the pathophysiology of physical exam ?

Answer :
Comsuming 5 raw jengkol fruit  absorption of jengkolat acid by digestive tract  filtrated in
glomerulus  water reabsorption in ansa henle  oversaturated jengkolic acid  accumulated of crystal
jengkolic acid formed a shape of needle or roset obstruction in urinary tract  peristaltic activity increased
 nociceptor stimulated  stomach pain  looks mildly sick.

Comsuming 5 raw jengkol fruit  absorption of jengkolat acid by digestive tract  filtrated in
glomerulus  water reabsorption in ansa henle  oversaturated jengkolic acid  accumulated of crystal
jengkolic acid formed a shape of needle or roset obstruction in urinary tract  peristaltic activity increased
 stimulation of nociceptors  pain  adrenalin stimulation  increased TD & HR.

A. What is the interpretation of specific exam ?

Answer :
 Specific Examination Interpretation
Head: Anemic Conjungtive (-), Icteric Djengkolism
Sklera (-), mouth and breat smells like
jengkol.
Neck: JVP 5-2 cmH2O, there is no Normal
enlargement of the lymph nodes.
Thoraks: Normal Shape, simetry. Normal
Heart:heart sound I-II (+) normal,
mur mur (-), gallop (-)
Lung: Vesicular (+) normal, ronchi
(-), wheezing (-)
Abdomen: normal bowel sound, Colic Pain
suprapubic tenderness (+),CVA pain
when being hit (+), ballotement (-),
hepar and lien were not palpable.
Ekstremity: CRT lest than 2 second, Normal
warm acral.
Urogenital: urine catether were Hematuria
inserted: 750 cc red colored urine were
produced.

B. What is the pathophysiology of spesific exam ?

Answer :
- Consumption 5 raw jengkol   sulfur in jengkolat acid  mouth & breath smells like jongkol
- Consumption 5 raw jengkol  Absorbtion of jengkolat acid by digestivus tract  jengkolat acid
binds with complex serum albumin and dissociates to free jenkolat acid  free jengkolat acid
through the glomerular membrane  Process of reabsorbtion of water in ansa henle 
Oversaturated jengkolat acid  Formation of deposits of the sharp like “needle-shaped crystals”
 irritation kidney  laceration kidney  hematuria
- Consumption 5 raw jengkol  Absorbtion of jengkolat acid by digestivus tract  jengkolat acid
binds with complex serum albumin and dissociates to free jenkolat acid  free jengkolat acid
through the glomerular membrane  Process of reabsorbtion of water in ansa henle 
Oversaturated jengkolat acid  Formation of deposits of the sharp like “needle-shaped crystals”
  obstruction of the urinary tract (in ureter)  Body compensation  Increased peristalctic 
Colic pain.

A. What is the interpretation of laboratorium exam ?

Answer :
Type Case Normal Interpretation
Hb 12g/dl 14-18 g/dl Decreased
Ureum 78 mg/dl 40/60 mg/dl Increased
Creatinine 3,0 mg/dl 0,3-0,5 mg/dl Increased
Natrium 140 mmol/l 134-145 mmol/l Normal
Kalium 3,7 mmol/l 3,6-5,8 mmol/l Normal
PH 5,8 4,8-7,4 Normal
Urin erythrocytes 90 LPB 5-9 LPB increased

B. What is the patophysuology of laboratorium exam ?

Answer :
 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > laceration kidney and tractus urinarius >
urine excreted also followed with blood > Hb decreased.

 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > laceration kidney and tractus urinarius >
urine excreted also followed with blood > urine erythrocyte increased.

 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
 complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > jengkolic acid is nefrotoxic > decreased
function of kidney > icreased of ureum.

 consuming 5 raw jengkol > jengkolic acid absorbtion in the digestive tract > jengkolic is in the
blood vessels > jengkolic acid binds with complex serum albumin > the serum albumin
complex and the jengkolic acid dissociate into serum albumin and free jengkolic acid > the free
jengkolic acid through to the membrane semipermeabel from glomerulus > occur procces of
reabsorbtionof water in the henle arch > oversaturated jengkolic acid and settles jengkolic acid
as a sharp crystal needle shaped > irritation kidney > jengkolic acid is nefrotoxic > decreased
function of kidney > icreased of creatinin.

1. How to diagnose?
Answer :
From anamnesis
Chief complain : of inability to urinate since 1 hours ago.
Additional complaints : a colic pain on his left and right waist followed with nausea without vomiting
and peeing with a smells of jengkol. the urine excreted were not much, painful, and also followed with
blood and some white stuff. 12 hours ago, the patient claimed that he was consuming 5 raw jengkol
fruit.
Physical Examination:
General Appearance: looks mildy sick
Vital sign: HR: 118x/minute Specific Examination:
Head: mouth and breat smells like jengkol.
Abdomen: suprapubic tenderness (+), CVA pain when being hit (+),
Urogenital: urine chateter were inserted: 750 cc ed colored urine were produce.
Laboratorium:
Blood test:; Ureum 85 mg/dl; Creatinin 2,0 mg/dl
Urinalysis: pH urine 5,8; urine erythrocytes 100/LPB

2. What are the differential diagnosis?

Answer :
- Jengkol intoxication (Djenkolism)
 - Ureterolithiasis
- Vesicolithiasis

3. What are the additional examination?

Answer :
plain abdominal radiograph examination or BNO: to determine whether there is obstruction due to
spasm or abnormalities in the urinary system.
Abdominal Ultrasound (USG) : to find out whether there is renal hydronephrosis or not.
Histopathological examination (biopsy) of the kidneys and urinary tract: to find out whether there is
hyperemia on the kidney and hemorrhage in the urethra or not. Also to find out whether there has been
damage to the glomerulus or not. And whether there has been necrosis in the kidney tubules or not.
(Bunawan et al, 2014)

4. What is the working diagnosis in this case?

Answer :
Intoxication of jengkol (Djengkolism) and suspect of AKI

5. How is the treatment on this case?

Answer :
 Mild jengkolat acid poisoning (low back pain and abdominal pain) can generally be treated by
drinking plenty of water and giving 2 grams of sodium bicarbonate 4 times a day orally until the
symptoms disappear (asymptomatic).
 Symptoms of severe poisoning (oliguria, hematuria, anuria or unable to drink), the patient needs to be
referred to the hospital for further treatment.
Actions taken in the hospital include:
a. Basic Life Assistance (ABCs of Life Support).
b. Strict monitoring of the patient's fluid and electrolyte status because the patient's condition can deteri
orate suddenly and severely
c. Giving intravenous fluids and electrolytes if needed to restore and maintain fluid and electrolyte bala
nce.
d. Monitoring kidney function and alkaline urine to excrete jengkolat acid crystals
e. If acute kidney failure occurs, sodium bicarbonate is given by infusion at a dose adjusted for the resul
ts of blood gas analysis.
(Shukri et al, 2011).
 6. What are the complications?
Answer :
 Obstructive nephropathy
 Acute kidney failure
 Metabolic acidosis
 Hydronephrosis

7. What is the prognosis in this case?

Answer :
Quo ad vitam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam

8. What is the doctor competency on this case?

Answer :
4A
Doctor graduates are able to make clinical diagnoses and conduct management independently and
thoroughly but this competence is achieved when graduating doctor.

9. What are the Islamic view?

Answer :
Q.S. Al-Araf : 31
“ eat and drink, but not over do it “
Imam Muslim No.563
Whoever eats some of this foul-smelling tree, let him not approach our mosque! Because angels feel
hurt (disturbed) by something that humans also feel hurt (due to the smell). " (Narrated by Imam Muslim
no.563)

2.5 Conclusion
Mr. Darmawan 40 years old, came to the RSMP with chief complain difficulty to urinate because of
Intoxication of jengkol (Djengkolism) and suspect of AKI.
 Conceptual Framework

(Risk Factor)
Consuming 5 raw jengkol fruit

Jengkolic acid absorption in the

digestive tract

Jengkol intoxication
Jengkol (djengkolism)
intoxication (djengkolism)

Accumulation of jengkol acid in urinary bladder

Suspect AKI Renal disfunction

Ureum creatinin
Urinary tract obstruction

Difficult to Colic Urinary Urine Urine with some white

urinate pain pain with stuff
blood