19

CHAPTER III
CASE REPORT
Name

: RZ

Age

: 8 years 8 months

Sex

: Boy

RM

: 00.64.29.96

Date of Admission

: 21 May 2015

Chief Complain

: Eyes swollen

History
: Swollen on the eyes has been happened for 2 weeks. Swollen first was in
the eyes and then separated to the legs and hands. Pale has been
happened by the patient 4 days ago, history of

previous pale 4

months ago and got transfussion 525cc. Fever (+), for 2 weeks, fever
was increasing up and down and fever decrease with the fever-lowering
medicine. Dyspnoe (-), history of dyspnoe (-).Stomach pain (+), 1
month,pain in the whole abdominal region. Cough (-), history of cough
(-). Bleeding cough (-).Urinate in the normal range. Patient had been
taken to Subulussalam Hospital for a day and sent to RSHAM. Patient
has diagnosed as Nephrotic Syndrome with Gastritis.
History of Previous position
The patient was reference from RSUP Subulussalam with diagnosis of
Helminthiasis + recurrent abdominal pain + protein energy malnutrition.
Birth history : RZ was the third boy. Birth spontaneously, helped by tocologist,
cried hard. Cyanosis (-), birth weight: 3,2 kg.
Pregnancy history : mother age 34 years old, medical history (-), drug exposure
(-), herb exposure (-).

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Immunization History
Complete, BCG I, DPT III, Polio III.Campak I, Hepatitis III
Feeding History:
From birth to 6 months: Breast feeding only,
From 6 months to 9 months : Breast milk with rice porridge
From 9 months to 1,5 years

: Breast milk with soft rice

From 1,5 years until now

: Family food

History of Growth and Development

Sitting

: 5 months

Crawling

: 8 months

Standing

: 10 months

Walking

: 18 months

Medical History: The patient was reference from RSUP Subulussalam with
diagnosis of Helminthiasis.
Drug use history: Inj.ceftriaxone 200 mg / 12 hours, inj.ranitidin 20mg / 24 hours,
inj. Furosemide 25mg/ 12 hours, paracetamol 250mg, albendazole 1mg.
Physical Examination:
Generalized Status:
Body weight: 25 kg
Body length: 136 cm
Body weight in 50th percentile according to age: 40 kg
Body length in 50th percentile according to age: 150 cm
Body weight in 50th percentile according to body length: 22 kg
BW/BL: 25/23 x 100% = 92,5 %
BW/age: 25/40 x 100% = 92,6 %
BL/age : 136/150 x 100% = 103 % (Normal)

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Presence status:
Consciousness: Compos Mentis
Heart Rate: 108 x/i regular
Respiratory Rate: 26x/i regular
Body Temperature: 37,1C
Anemic (+), icteric (-), cyanosis (-), edema (-), dyspnea (-),
Localized Status

Head: light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+),
fontanella open flat, icteric sclera (-/-), face edema (-), inferior and
superior palpebrae edema (-), Ear/ Nose/ Mouth: within normal limit/ O2

nasal kanal/ mucosa is pale.

Thorax: symmetricaol fusiformis, chest retraction (-) epigastric and
intercostal, breath sound: vesikular, additional sound: ronchi -/-, wheezing

(+), murmur (-)

Abdomen: soepel, peristaltic (+) Normal, liver is palpable 2 cm,spleenis

not palpable
Extremities: pulse 108 x/i , adequate pressure and volume, warm, CRT < 3

second, pitting edema (-). Hematoma (-)

Urogenital: male scrotum (+), penis (+), anus (+)

Laboratory finding
Complete blood analysis
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte

Result
7,80
3,26
34,95
1505
25,30
0,00
0,100
68,60
21,70
9,60
23,96
7,60

Unit
G%
106/mm3
103/mm3
103/mm3
%
%
%
%
%
%
103/L
103/L

Referral
11,3-14,1
4,40-4,48
6,0-17,5
217-497
37-41
1-6
0-1
37-80
20-40
2-8
1,9-5,4
3,7-10,7

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absolute
Monocyte absolute
Eosinophyl absolute
Basophyl absolute
MCV
MCH
MCHC

103/L
103/L
103/L
fL
Pg
g%

3,37
0,00
0,02
77,60
23,90
30,80

0,3-0,8
0,20-0,50
0-0,1
81-95
25-29
29-31

Clinical Chemistry
Test
Carbohydrate Metabolism
Blood Glucose
Electrolite
Natrium
Kalium
Cloride

Result

Unit

Referral

102.60

mg/dL

< 200

129
2,5
95

mEq/L
mEq/L
mEq/L

135-155
3,6-5,5
96-106

Differential Diagnosis

: Nephrotic syndrome, Gastritis and Malnutrition

Working Diagnosis

: Nephrotic syndrome

Management
-

O2 1-2 L/i
IVFD D5% NaCl 0,225% 20 gtt/i micro
Aspar-k 3x625mg
Furosemide 2x20mg
Aldacton 2x25mg

Follow Up
May, 24th 2015
S Swollen Eyes (+) , fever (-)
O Cons: alert, Temp: 37,1oC.
Body weight: 25 kg, Body length: 136 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra

(+/+).Ear/ Nose/ Mouth: within normal limit/ within normal limit /

Neck
Thorax

:
:

Abdomen :

mucosa is pale .
Lymph node enlargement (-).
Symmetrical fusiformis. Chest retraction (-). HR: 112x/i, regular,
murmur (-). RR: 24x/i, reguler, ronchi (-).
Soepel (+),peristaltic (+) normal, liver : palpable for 2 cm, Spleen :not
palpable

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Extremities: Pulse 112x/i, regular, adequate pressure and volume, warm, CRT < 3.
Genital
Male. Scrotum (+). Edema (-).
A
P

:
Nephrotic syndrome
Management:
-

IVFD D5% NaCl 0,225% 20 gtt/i micro

Inj. Furosemide 25mg/12 hours/iv

Inj. Ampicillin 50mg/kgBW/6 hours

Inj. Ceftriaxone 1gr/12hour/iv

Aldacton 2x25mg

Aspar-k 3x625mg

May, 25th 2015

S Swollen Eyes (+) , fever (-)
O Cons: alert, Temp: 37.1oC.
Body weight: 25 kg, Body length: 136 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra
(-/-).Ear/ Nose/ Mouth: within normal limit/ within normal limit /within

A
P

Neck
Thorax

normal limit.
Lymph node enlargement (-).
Symmetrical fusiformis. Chest retraction (-). HR: 116x/i, regular, murmur

Abdomen

(-). RR: 20x/i, reguler, ronchi (-).

Soepel (+),peristaltic (+) normal, liver : palpable for 2 cm, Spleen :

Extremitie

palpable S II- SIII, episgatrium pain (-)

Pulse 116x/i, regular, adequate pressure and volume, warm, CRT < 3.

s
Genital
Male. Scrotum (+). Edema(-).
- Nephrotic syndrome
Management:
-

prednisone 4-3-3
Inj. Ceftriaxone 1gr/12hour/iv
- Blood transfusion PRC III 75 cc ( enter 100 cc , needed 260 cc )

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Inj. Ranitide 25mg/8 hours/iv

Aldacton 2x 25mg .

May, 26th 2015

S
O

Swollen Eyes (+) , fever (-)

Cons: alert, Temp: 37.0oC.
Body weight: 25 kg, Body length: 136 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (+/+).Ear/ Nose/ Mouth: within normal limit/ within normal

Neck
Thorax

limit /within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis. Chest retraction (-). HR: 116x/i, regular,

Abdomen

murmur (-). RR: 22x/i, reguler, ronchi

Soepel (+),peristaltic (+) normal, liver : palpable for 2 cm, Spleen :

Extremitie

palpable S II- SIII

Pulse 116x/i, regular, adequate pressure and volume, warm, CRT < 3.

s
Genital
Male. Scrotum (+). Edema (-).
A- Nephrotic syndrome
P Management:
-

prednisone 4-3-3
Inj. Ceftriaxone 1gr/12hour/iv
Inj. Ranitide 25mg/8 hours/iv
Inj. Ampisilin 50mg/kg/6 hours
Aldacton 2x25mg