Summary of Database

Mr.JD / 17y.o/ w.27

Autoanamnesis
Chief Complaint:
Swelling on both leg
History of Present Illness:
- Swelling on both leg since 2 months ago, swelling does not disappear by lifting the leg and he
didn’t fell pain.
- He also complained about weakness exspecially when do activity, better with rest. There’s no
decrease of appetite.
- Urination was little bit cloudy yellow, foaming (+), blood (-), normal urine output, 4-6x /day, and
there’s no pain while urinating.
- Diagnosed with hypertension since 2 months ago, got some medicine from primary health care
in Purwodadi , and already consume furosemide routinely since one week, and he forgot about
another medicine that he took.
- history of fever, cough, shore throat was denied.
 Summary of Database
Past Medical History:
There is no remarkable history of any infectious disease, trauma or surgery.

Family History:
His father has passed away 5 years ago because of liver disease, there is no history
of DM, HT, malignancy, or autoimmune disease in his family.

Social History:
He lives with his mother, and doesn’t married yet.

Review of System:
• Defecation system was normal.
 Physical Examination
General appearance looked moderately ill Sat O2 98% RA
GCS 456 UOP : 1,5 cc/kgBB/jam

BP 160/ 79 mmHg PR 95 bpm regular strong RR 20 tpm Tax 36,6 oC

Head Edem palpebra (+/+) , Conjuctiva Anemic (-), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-),
Pupil Isocor,
Neck JVP R+ 2 cmH20

Chest Symmetrical, retraction (-)

Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-

Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor | Sonor Vesicular | Vesicular -
I- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Bowel Sound (+) normal, shifting dullness (-)

Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany

Extremities Edema pitting (+/+) , pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralisation (-)
5|5
 Laboratory Findings (4/5/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 9070 4.700 – 11.300 /µL Ureum 17,2 20-40 mg/dL

Hemoglobine 14,2 11,4 - 15,1 g/dl Creatinine 0,94 <1,2 mg/dL

PCV 43% 38 - 42% eGFR

Thrombocyte 337.000 142.000 – 424.000 /µL Natrium 136 136-145 mmol/L

MCV 83 80-93 fl Kalium 4,24 3,5-5,0 mmol/L

MCH 29,8 27-31 pg Chlorida 107 98-106 mmol/L

Eo/Bas/Neu/ 0,2/0,3/60/30 0-4/0-1/51-67/ Albumin 1,53 2,5

Limf/Mon /4 25-33/2-5
LDL 424
HDL 37 Kolestrol total 621
 Urinalysis (04/15/2) RSUD Lawang
LAB VALUE NORMAL LAB VALUE NORMAL
40 x
Color cloudy Erythrocyte 4-6 ≤3
pH 6.0 4.5 – 8.0 Leukocyte 2-3 ≤5
Spesific Gravity 1.025 1.005 – 1.030 Crystal urid acid (+)
Glucose negative negative Bacteria Negaitve ≤23 x 103/ml
Protein 3+ negative Funfal Negative

Keton Negative negative

Bilirubin Negative negative

Urobilinogen negative negative
Nitrite Negative negative
Leukocyte Negative negative
Blood 2+ negative
ECG (10/05/21)
 ECG (10/05/21)

• Sinus rythm, HR 88 bpm

• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0.08 “
• PR interval : 0.12 “
• QRS complex : 0.08 “
• ST segment : isoelectric
• QT interval : 0.36 sec
• T wave : normal

Conclusion : sinus rythm, HR 88 bpm

Chest Xray (10/05/21)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was normal and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovascular pattern was normal. No visible
infiltrate, cavity or nodules.
• Cor: site N, shape N, CTR 57 %

Conclusion:
• Normal CXR
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. JD/17 yo/ ward 27 1. 1.1 - Biopsi Non Pharmacology • Subjective
Subjective : Hypertension Nephrotic Ginjal - Bed Rest • Vital sign
- Edema on lower leg since 2 + bilateral leg Syndrome - UL Plus - Diet 1800 HCHP • Edema
months ago edema + 1.2 - USG kcal/day, low salt < • Albumin post
- Diagnosed with hypertension dislipidemia + Nephritic Abdomen 2gr/day tranfusion
since 2 months ago Severe Syndrome -ASTO
hypoalbumine 1.3 Mixed Pharmacology Education:
Objective: mia + type - PO furosemide - diagnosis,
BP 160/79 mmHg proteinuria 3x40 mg treatment,
Edema Palpebra (+/+) minimal - PO Captopril restriction of
Edema Extremitas Inferior 3x12,5 mg fluid intake
Bilateral - PO Simvastatin
1x20 mg
Laboratorium :
Albumin : 1,53 g/dL
Cholesterol Total : 621 mg/dL
Cholesterol LDL : 424 mg/dL

Urinalisis :
Protein +3
Blood +2
40 X : Disfmorfik 4-6
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. JD/17 yo/ ward 27 2. 2.1 Funduscopy Non Pharmacology • Subjective
Subjective : Hypertension Seconday - Bed Rest • Vital sign
- Diagnosed with hypertension stage 2 2.2 - Diet 1800 kcal/day,
since 2 months ago Primary low salt < 2gr/day Education:
- diagnosis,
Objective: Pharmacology treatment,
BP 160/79 mmHg - PO furosemide restriction of
3x40 mg sodium intake
- PO Captopril
3x12,5 mg
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. JD/17 yo/ ward 27 3. Severe 3.1 Renal - Non Pharmacology • Subjective
Subjective : Hypoalbumine Loss - Bed Rest • Vital sign
- Edema on lower leg since 2 mia - Diet 1800 HCHP • Edema
months ago kcal/day, low salt < • Albumin post
2gr/day tranfusion
Objective:
Edema Palpebra (+/+) minimal Pharmacology Education:
Edema Extremitas Inferior - Tranfusion albumin - diagnosis,
Bilateral 20% 100 until treatment,
Albumin > 2,5 restriction of
Laboratorium : gr/dL fluid intake, diet
Albumin : 1,53 g/dL high protein

Urinalisis :
Protein +3
 Problem Analysis

Proteinuria
Minimal Change

Nephrotic MGN
Hypoalbuminemi syndrome
a FSGS

Diffuse proliferate GN
Nephritic
Edema
syndrome Crescentic GN

Hyperlipidemia Membranoproliferativ
e GN
Mixed
IgA Nephropathy

Microscopic
Hematuria
Key Messages Diagnostic
Key Messages Diagnostic
Key Message Pathophysiology
 Management Analysis

PROBLEM THEORY FACTUAL

• Blood pressure medications.

• Water pills (diuretics).
• Cholesterol-reducing medications.
• Immune system-suppressing medications. On This Patient :

- PO simvastatin
Nephrotic 1x20 mg
Syndrome - PO Furosemide
2x40 mg
- PO Captopril
3x12,5 mg
 Key Messages Managements

1. General treatment measures

2. Treating edema
3. Anticoagulation for venous thrombosis
4. Treating and preventing infection
5. Treating dyslipidemia
6. Antiproteinuric treatment
7. Immunosuppressive therapy
 GENERAL TREATMENT MEASURES

1. Routine treatment of patients with NS include restricting dietary sodium

to less than 3 g per day and restricting fluid to less than 1,500 mL per
day.

2. Protein intake of 1.0–1.1 g/kg body weight (BW)/day in minimal change

nephrotic syndrome and 0.8 g/kg BW/day in other nephrotic syndromes.

3. Calorie intake of 35 kcal/kgBW/day is recommended.

(Kodner 2016) (Nishi et al 2016)

 TREATING EDEMA

1. In edematous patients with nephrotic syndrome, we recommend oral diuretics,

particularly loop diuretics, for reducing edema

2. The use of intravenous diuretics should be considered if the effect of oral diuretics
is insufficient

3. Albumin administration does not improve hypoalbuminemia or edema in patients

with nephrotic syndrome and may exacerbate hypertension. However, in cases of
severe shock or pulmonary edema, albumin administration may have a temporary
but useful effect

4. In nephrotic syndrome, we recommend the extracorporeal ultrafiltration method

(ECUM) for removing body fluids in refractory edema and ascites that are difficult
to control using drug-based treatment.

(Nishi et al 2016)
 TREATING EDEMA
Furosemide (Lasix) at 40 mg orally twice daily or
bumetanide at 1 mg twice daily

Inadequate improvement in
edema or other evidence of fluid overload

Doubling of the dose every one to three

days

Inadequate clinical response,

changing to intravenous loop diuretics or adding Giving an intravenous bolus of 20% human albumin
oral thiazide diuretics prior to an intravenous diuretic bolus

Extracorporeal ultrafiltration method (ECUM)

(Kodner 2016) (Nishi et al 2016)
 TREATING DYSLIPIDEMIA

1. Lipid-lowering agents are helpful in managing dyslipidemia in adults

with NS.

2. In nephrotic syndrome, we recommend that statins be prescribed for

lipid metabolism abnormalities

3. In nephrotic syndrome, we do not recommend ezetimibe monotherapy

4. In patients with refractory nephrotic syndrome and high LDL cholesterol

levels, we recommend LDL apheresis for reducing the urinary protein
level

(Kodner 2016) (Nishi et al 2016)

 ANTIPROTEINURIC TREATMENT

Angiotensin-converting enzyme inhibitors or angiotensin receptor

blockers

(Kodner 2016)
Prognosis Analysis
 Key Message Social

• Patient with Nephrotic syndrome should be

educated for the compliance of the drugs and
planning treatment
• Good emotional support from the family, health
care provider, and spiritual support must be given to
the patient
• Family support is an important key for the patient to
continue the treatment
• Need to explain the complication that will happen in
the future.
 Condition this morning

GCS : 456
BP 146/70 mmHg
HR: 78bpm
RR: 18bpm
Tax: 36,7 C
SpO2: 98% RA
THANKYOU