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CHAPTER 3

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

: all medicine from RSUP Haji Adam Malik


since hospitalized June, 10th 2016

History of family

: None

History of parents medication

: None

History of pregnancy

: Not clear.

History of birth

: Not clear.

History of feeding

: Not clear.

History of immunization

: Patient had a complete immunization.

History of growth and development : His mother said that her son is shorter
than his friends.
Physical Examination:
Present status:
Sensorium : Compos Mentis `

Upper arm circumference: 11 cm

Body temperature: 36,7C

BW/A: 90,3 %

Body Weight :20 kg

BL/A: 76,1 %

Body Length :110 cm

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

: both ear lobe in normal morphologic.

Nose : septum deviation (-), normal morphologic.


Mouth : cyanosis (-), normal morphologic.

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

: 1. Chronic Kidney Disease + Anemic et causa


Chronic Disease
2. Acute Kidney Disease + Anemic et causa
Chronic Disease
3. Acute Nephrotic Syndrome + Anemic et causa
Chronic Disease

Working diagnosis

: Chronic Kidney Disease stage V + Anemic et causa


Chronic Disease

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

Analisa Gas Darah


Test
pH
pCO2
pO2
Bicarbonate (HCO3)
Total CO2
BE
O2 Saturation

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

O2 Nasal Canule L/i


IVFD Dextrose 5% NaCl 0,225% 400 cc + Dextrose 40% 100 cc +

KCl 10 mEq + Ca Solution 10 cc 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

Planning Assesment:
FOLLOW UP

July, 8th 2016


Swelling (+); subfebris fever (+); seizure (-); good flow of
CAPD
Sens: GCS 11(E3V3M5); temperature: 37,9oC; Body weight : 20
kg
Head : Face swelling (+)

Eye

: loss of vision, isochoric pupil (+/+), pale

conjungtiva palpebral inferior (-/-), palpebral swelling

(+)
Ear
Nose
Mouth
Neck

: both ear lobe in normal morphologic.


: septum deviation (-), normal morphologic.
: normal morphologic
: lymph node enlargement (-)

Thorax : symmetric fusiform, retraction (-)


HR : 98bpm, reguler, murmur(-)
RR : 24bpm, reguler, rhonchi (-)
Abdomen: Distension, normal peristaltic, liver and spleen
unpalpabled, CAPD set.
Extremities : pulse : 98 bpm, regular, adequate p/v, warm

A
P

extremities,CRT < 3, generalized swelling


Chronic Kidney Disease stage V + Anemic et causa Chronic
Disease
-

O2 Nasal Canule L/i


IVFD Dextrose 5% NaCl 0,225% 400 cc + Dextrose
40% 100 cc + KCl 10 mEq + Ca Solution 10 cc

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

Swelling (+); fever (-); seizure (-); good flow of CAPD


Sens: GCS 11(E3V3M5); temperature: 36,8oC; Body weight : 20
kg
Head : Face swelling (+)

Eye

: loss of vision, isochoric pupil (+/+), pale

conjungtiva palpebral inferior (-/-), palpebral swelling

(+)
Ear
Nose
Mouth
Neck

: both ear lobe in normal morphologic.


: septum deviation (-), normal morphologic.
: normal morphologic
: lymph node enlargement (-)

Thorax : symmetric fusiform, retraction (-)


HR : 95bpm, reguler, murmur(-)
RR : 22bpm, reguler, rhonchi (-)
Abdomen: Distension, normal peristaltic, liver and spleen
unpalpabled, CAPD set.
Extremities : pulse : 95 bpm, regular, adequate p/v, warm
extremities,CRT < 3, generalized swelling

Chronic Kidney Disease stage V + Anemic et causa Chronic


Disease
-

O2 Nasal Canule L/i


IVFD Dextrose 5% NaCl 0,225% 400 cc + Dextrose
40% 100 cc + KCl 10 mEq + Ca Solution 10 cc

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

GFR :4,6 (N:96,5-136,9)


Na/K/Cl/Ca : 137/3/103/6,3
pH/PCO2/PO2/Total O2/BE/SpO2 : 7,42/17/185/11/11,8/11/100
R/ Hypocalcemia Correction 1cc/kgBB : 20cc Ca Glukonas
10% in 60cc Dextrose 5% (in 1 hour)
July 12-13st2016

S
O

Swelling (+); fever (-), generalized itch (+)


Sens: GCS 11(E3V3M5); temperature: 36,9oC; Body weight : 26
kg

Head : Face swelling (+)

Eye

: loss of vision, isochoric pupil (+/+), pale

conjungtiva palpebral inferior (-/-), palpebral swelling

(+)
Ear
Nose
Mouth
Neck

: both ear lobe in normal morphologic.


: septum deviation (-), normal morphologic.
: normal morphologic
: lymph node enlargement (-)

Thorax : symmetric fusiform, retraction (-)


HR : 98bpm, reguler, murmur(-)
RR : 24bpm, reguler, rhonchi (-)
Abdomen: Distension, normal peristaltic, liver and spleen
unpalpabled, CAPD set.
Extremities : pulse : 98 bpm, regular, adequate p/v, blood
pressure: 150/80 mmHg, warm extremities,CRT <

3, generalized swelling
Chronic Kidney Disease stage V + Anemic et causa Chronic
Disease
-

O2 Nasal Canule L/i


IVFD Dextrose 5% NaCl 0,225% 400 cc + Dextrose
40% 100 cc + KCl 10 mEq + Ca Solution 10 cc

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

Swelling (+); fever (-), generalized itch (+)


Sens: GCS 11(E3V3M5); temperature: 37oC; Body weight : 26 kg
Head : Face swelling (+)

Eye

conjungtiva palpebral inferior (-/-)


Ear
: both ear lobe in normal morphologic.
Nose : septum deviation (-), normal morphologic.
Mouth : normal morphologic
Neck : lymph node enlargement (-)

: loss of vision, isochoric pupil (+/+), pale

Thorax : symmetric fusiform, retraction (-)


HR : 102bpm, reguler, murmur(-)
RR : 24bpm, reguler, rhonchi (-)
Abdomen: Distension, normal peristaltic, liver and spleen
unpalpabled, CAPD set.
Extremities : pulse : 102 bpm, regular, adequate p/v, warm

extremities,CRT < 3, generalized swelling


Chronic Kidney Disease stage V + Anemic et causa Chronic
Disease
-

O2 Nasal Canule L/i


IVFD Dextrose 5% NaCl 0,225% 400 cc + Dextrose
40% 100 cc + KCl 10 mEq + Ca Solution 10 cc

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

Swelling (+); fever (-), generalized itch (+)


Sens: GCS 11(E3V3M5); temperature: 37oC; Body weight : 26 kg
Head : Face swelling (+)

Eye

conjungtiva palpebral inferior (-/-)


Ear
: both ear lobe in normal morphologic.
Nose : septum deviation (-), normal morphologic.
Mouth : normal morphologic
Neck : lymph node enlargement (-)

: loss of vision, isochoric pupil (+/+), pale

Thorax : symmetric fusiform, retraction (-)


HR : 92bpm, reguler, murmur(-)
RR : 24bpm, reguler, rhonchi (-)
Abdomen:

Soepel,

normal

peristaltic,

liver

and

spleen

unpalpabled, CAPD set.


Extremities : pulse : 92 bpm, regular, adequate p/v, warm

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

giving Vitamin C 1x50mg, Vitamin A 1x 200.000 IU (one time administration


only) and Folic Acid 1x1 mg (LD 1x5mg for the first day).
4.2. Summary
RS, 1 year 6 months old boy, that weighted 5,5kg and lengthed 71 cm, was
admitted to Pediatric Department Unit in H. Adam Malik General Hospital Medan
on May26th 2016complaining diarrhea since 3 days before hospital admission. He
is diagnosed with Marasmic - Kwashiorkor. Patient is treated with diet F75 and
resomal if the patient vomit or diarrhea. Antibiotic is used to prevent others
infections due to malnutrition. Micronutrients deficiencies are corrected by giving
Vitamin C 1x50mg, Vitamin A 1x 200.000 IU (one time administration only) and
Folic Acid 1x1 mg (LD 1x5mg for the first day). The patient was discharged from
the hospital in the 20thdays treatments with resolving edema and he has a good
appetite and is clinically well and alert.

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