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CASE REPORT
3.1 Objective
The objective of this paper is to report a case of a 11 year 3 months old boy with a
diagnosis of Chronic Kidney Disease Stage V et causa Chronic Pyelonephritic
with Anemic et causa Chronic Disease.
3.2 Case
ARL, a 11 year 3 months old boy, with 20 kg of body weight and 110 cm
of body length, was hospitalized in RSUP Haji Adam Malik Medan on July, 6th
2016 with generalized swelling, penurunan kesadaran, and loss of vision.
History of disease:
ARL, a boy, 11 year 3 months old, with 20 kg of body weight and 110
cm of body length, was hospitalized in RSUP Haji Adam Malik Medan on July, 6th
2016 with generalized swelling, penurunan kesadaran, and loss of vision. He
using CAPD since June, 17th2016.
History of spontaneous bleeding (-), epistaksis (-), and history of
bleeding on gums (-).
History of demam hilang timbul dialami pasien since 1 year ago,
demam tidak terlalu tinggi.
History of incontinence urine (-). History of BAK berdarah (+) but his
mother not really know the exact time
Patient said that he often had a malaise and dizziness
Cough (-), flu (-), vomit (-), diarrhea (-), history of dyspnoe (-).
His mother said that her son is shorter than his friends.
History of medication
History of family
: None
: None
History of pregnancy
: Not clear.
History of birth
: Not clear.
History of feeding
: Not clear.
History of immunization
History of growth and development : His mother said that her son is shorter
than his friends.
Physical Examination:
Present status:
Sensorium : Compos Mentis `
BW/A: 90,3 %
BL/A: 76,1 %
BW/BL: 136,8 %
Cyanosis (-), Anemic (+), Icteric (-), Dyspnea (-), Edema (+)
Localized status:
Head
Face
Eye
:
: edema (+)
: loss of vision, isochoric pupil, pale inferior
palpebral conjunctiva (+/+)
Ears
Neck
:
Lymph node enlargement (-)
Thorax
:
Symmetrical fusiform, retraction (-)
HR:120 bpm, regular, murmur (-/-)
RR:24 bpm, regular, ronchi (-/-), wheezing (-/-)
Abdomen
:
Distension, normal peristaltic, liver and spleen unpalpabled,
CAPD set.
Extremities :
Pulse 120 bpm, regular,adequate p/v, felt warm, CRT < 3,
pale plantar and palmar (+)
Anogenital
:
Male, testis (+)
Differential diagnosis
Working diagnosis
Laboratory finding:
Complete blood analysis (July 11th 2016 / 12:46)
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte
Result
12,4
4,52
20.740
146
36
2,80
0,30
87,30
4,20
5,40
18,09
0,88
Unit
g/dL
106/L
/L
103/L
%
%
%
%
%
%
103/L
103/L
References
13 18
4,50 6,50
4.000 11.000
150 450
39 54
1,00 3,00
0,00 1,00
50,00 70,00
20,00 40,00
2,00 8,00
2,7 6,5
1,5 3,7
absolute
Monocyte absolute
Eosinophil absolute
Basophil absolute
MCV
MCH
MCHC
RDW
MPV
PDW
PCT
1,13
0,58
0,06
79
27,4
34,6
14,1
12,1
16,2
0,180
103/L
103/L
103/L
fL
Pg
g/dL
%
fL
%
%
0,2 0,4
0 0,10
0 0,1
81 99
27 31
31 37
11,5 14,5
6,5 9,5
10,0 18,0
0,100 0,500
CLINICAL CHEMISTRY
Result
7,420
17,0
185,0
11,0
11,8
-11
100,0
Unit
mmHg
mmHg
mmol/L
mmol/L
mmol/L
%
References
7,35-7,45
38-42
85-100
22-26
19-25
(-2) (+2)
95-100
g/dL
3,5 5,0
Liver Function
Albumin
2,6
Renal Function
Blood Urea Nitrogen
105
mg/dL
9 21
(BUN)
Ureum
225
mg/dL
19 44
Creatinine
13,22
mg/dL
0,7 1,3
Electrolyte
Calsium
6,30
mg/dL
8,4 10,2
Sodium
137
mEq/L
135 155
Potassium
3,0
mEq/L
3,6 5,5
Chloride
103
mEq/L
96 106
Therapy
Ferriz 1 x cth I
Cendo Vitrolenta 4 x gtt II ODS
Diet Nefrisol 20 cc/3 hours/ NGT + MII Nefritic
Planning Assesment:
FOLLOW UP
Eye
(+)
Ear
Nose
Mouth
Neck
A
P
4cc/hour.
IVFD Aminofusin 1,7 Kkal/kgBB 8 gram/hour =
6,6 cc/hour.
- Inj. Vancomycin 520 mg/8 hours/IV
- Inj. Manitol 20% 25cc/8 hours/IV
- Inj. Fenitoin 70 mg/12 hours/IV
- Inj. Furosemide 30 mg/6 hours/IV
- Inj. Omeprazole 40 mg/12 hours/IV
- Nifedipine 4x10 mg
- Valsartan 1x20 mg
- Amlodipin 1x5 mg
- Paracetamol 3x250 mg (K/P)
- Bicnat 0,3 x 12,1 x 20 = 73,6 mEq 73 mEq
- Calloz 3x1 tab
- Depakene 2x4,5 cc
- Ferriz 1 x cth I
- Cendo Vitrolenta 4 x gtt II ODS
- Diet Nefrisol 20 cc/3 hours/ NGT + MII Nefritic
R/ PRC Transfussion 30cc/12 hours
FFP Transfussion 200cc/3 days
Vipalbumin 3x1 sachet
June 9th2016 (5)
S
Eye
(+)
Ear
Nose
Mouth
Neck
4cc/hour.
IVFD Aminofusin 1,7 Kkal/kgBB 8 gram/hour =
6,6 cc/hour.
Inj. Vancomycin 520 mg/8 hours/IV
Inj. Manitol 20% 10cc/8 hours/IV
Inj. Fenitoin 70 mg/12 hours/IV
Inj. Furosemide 30 mg/6 hours/IV
Inj. Omeprazole 40 mg/12 hours/IV
Nifedipine 4x10 mg
Valsartan 1x20 mg
Amlodipin 1x5 mg
Paracetamol 3x250 mg (K/P)
Bicnat tab 3-3-3
Calloz 3x1 tab
Depakene 2x4,5 cc
Ferriz 1 x cth I
Cendo Vitrolenta 4 x gtt II ODS
Diet Nefrisol 20 cc/3 hours/ NGT + MII Nefritic
PRC Transfussion 30cc/12 hours
FFP Transfussion 200cc/3 days
July, 11th2016
Hb/Ht/L/Tr : 12,4/36/20.740/146.000
R/
Albumin : 2,6
Ur/Cr/BUN : 225/13,22/105
Laboratoriu
m Result
S
O
Eye
(+)
Ear
Nose
Mouth
Neck
3, generalized swelling
Chronic Kidney Disease stage V + Anemic et causa Chronic
Disease
-
Eye
4cc/hour.
- Inj. Vancomycin 520 mg/8 hours/IV
- Inj. Furosemide 30 mg/6 hours/IV
- Nifedipine 4x10 mg
- Valsartan 1x20 mg
- Amlodipin 1x5 mg
- Paracetamol 3x250 mg (K/P)
- Bicnat tab 3-3-3
- Calloz 3x1 tab
- Depakene 2x4,5 cc
- Cendo Vitrolenta 4 x gtt II ODS
- Diet Nefrisol 20 cc/3 hours/ NGT + MII Nefritic
R/ Albumin Transfussion
Sallicilic Talk
Cetirizine 1x5mg
Diet MB Nefritic 1700Kkal + 30 gram Protein
Consult to eye department
Physiotherapy (Monday-Wednesday-Friday)
No sign of retinopathy.
Department
July 19th-20th 2016
S
Eye
4cc/hour.
Inj. Furosemide 30 mg/6 hours/IV
Nifedipine 4x10 mg
Valsartan 1x20 mg
Bicnat tab 3-3-3
Calloz 3x1 tab
Depakene 2x4,5 cc
Cetirizine tab 1x5 mg
Cendo Vitrolenta 4 x gtt II ODS
Methylprednisolon 1x2,5 tab
Diet MII Low Salt 1500 Kkal with 25 gram
Protein + Nefrisol Milk and 60 cc water/3
hours/oral
Vit B Comp 1x1 tab
Vit C 1x100 mg
July 24th2016
S
Eye
Soepel,
normal
peristaltic,
liver
and
spleen
extremities,CRT < 3
Chronic Kidney Disease stage V + Anemic et causa Chronic
Disease
-
Threeway
Inj. Furosemide 40 mg/6 hours/IV
Nifedipine tab 1x20 mg
Valsartan 1x20 mg
Bicnat tab 3-3-3
Calloz 3x1 tab
Depakene 2x4,5 cc
Cetirizine tab 1x5 mg
Cendo Vitrolenta 4 x gtt II ODS
Methylprednisolon 1x2,5 tab
Diet MII Low Salt 1500 Kkal with 25 gram Protein +
Nefrisol Milk and 60 cc water/3 hours/oral
Vit B Comp 1x1 tab
Vit C 1x100 mg
July 24th2016
Patient Discharge
CHAPTER 4
DISCUSSION AND SUMMARY
4.1. Discussion
Severe acute malnutrition is defined as severe wasting and/or bilateral
edema. Severe wastingis diagnosed by a weight-for-length (or height) below 3
SD. In children ages 6-59 months, a mid-upper arm circumference <115 mm also
indicates severe malnutrition. Social, economic, biologic, and environmental
factors may be the underlying causes for the insufficient food intake that leads to
sever malnutrition. Inadequate sanitation also increasing the risk of infectious
diseases that increase nutritional losses and alters metabolic demands.Marasmic
kwashiorkor characterized with both wasting and edema. Wasting is preceded by
failure to gain weight followed by weight loss. The skin loses turgor and becomes
wrinkled and loose as subcutaneous fat disappears. The abdomen may be
distended or flat, with the intestinal pattern readily visible. There is muscle
atrophy and resultant hypotonia. In kwashiorkor, the edema is most likely to
appear first in the feet and then in the lower legs. Dermatitis is common, with
darkening of the skin in irritated areas. Depigmentation can occur after
desquamation in these areas, or it may be generalized. The hair is sparse and thin,
and in dark-haired children, it can become streaky red or gray. The treatment of
severe acute malnutrition includes 3 phases: initial phase (days 1-7), rehabilitation
phase (weeks 2-6), and follow up phase (weeks 7-26).
In this case, a 1 year and 6 months old boy with 5 kg of body weight and
71 cm of body length, come with diarrhea for 3 days with frequency 5-6 times in
one day. Weight-for-length is below -3 SD with mid upper arm circumference 110
mm. In physical examination, the clinical signs that found in this patient are both
wasting and edema. Flattened subcutaneous fat with edema in dorsum manus and
dorsum pedis and hair become streaky red. Patient is given diet F75 40 cc with 0,8
cc mineral mix every 2 hours and resomal 50 cc if the patient vomit or diarrhea.
Ampicillin injection 250 mg is given every 6 hours intravenously and gentamicin
injection 25 mg is given once a day intravenously. Antibiotic is used to prevent
others infections due to malnutrition. Micronutrients deficiencies is corrected by
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