MORNING REPORT

THURSDAY, OCTOBER 5 TH 2017

dr. Susi/ dr. Eddy/ dr. Mitha / dr. David/ dr. Patra
dr. Pridania/ dr. Kandar
dr. Fitri/ dr. Prabu

1
 PATIENT ADMISSION
MELATI 2 WARD :
T, 15 years old, 51 kgs, with steroid resistant nephrotic
syndrome, renal colic due to calculus of ureter dd calculus of
kidney, suspected SLE, wellnourished.

HCU NEONATUS: -
PICU :
HCU MELATI 2 :
NICU : -

2
 PATIENT IDENTITY
Name : T
Sex : male
Age : 15 years old
Body weight / length : 51 kgs / 157 cms
Address : Banyubiru, Ngawi
Medical record : 01389720
Date of Admission : October, 5th 2017

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CHIEF COMPLAINT

Right-sided Back pain

4
 At ER Moewardi
Hospital.
16 hours before Patient fully alert, still
admission he started to complain about right-
complain of back pain sided back pain, no
1 days before on the right side 1 hour dyspnea, no fever, no
admission patients after drank vomit, the last urination
discharged from cyclosporine and was at ER
RSDM, he hospitalized methylprednisolone,
due to steroid resistant the back pain
nephrotic syndrome worsened when cough
with suspected SLE, or move, no nausea, no
patient got MP and vomite, no fever,
cyclosporine, no urination yellow in
vomitting, no pain felt colour and no pain
in all part of his body, when urinate
no complain about
urination and 6 hours before
defecation admission the pain got
worsened and patient
taken to RSDM

CURRENT MEDICAL
HISTORY 5
PAST MEDICAL HISTORY

History of nephrotic syndrome therapy (+) at

Sragen General Hospital for 6 months
History of nephrotic syndrome therapy at
RSDM since August 2017 use initial nephrotic
syndrome protocol therapy for 5 weeks
On October 4th 2017 patient start to follow
resistant steroid protocol therapy for
nephrotic syndrome

FAMILY MEDICAL HISTORY

History of same illness in family(-)

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 HISTORY OF PREGNANCY AND DELIVERY
PREGNANCY
Her mother was 28 years old when pregnant, patient routine checked
up her pregnancy to the midwife, taken vitamin routinely from the
midwife during pregnancy, no history of hospitalization during
pregnancy.
DELIVERY
Patient was born by spontaneous delivery at 38 months of gestational
age, the mother forget about his body weight and body lenght, he
cried vigorously, actively move, spontaneously opened her eyes, no
cyanotic, meconeum was found shortly after birth

CONCLUSION : pregnancy and delivery were normal

7
HISTORY OF IMMUNIZATION
BCG : 1 month
Hepatitis B1 : 0, 1, 3 months
DPT : 2, 4, 6 months
Polio : 0, 2, 4, 6 months
Measles : 9, 18 months, 1st grade of
Elementary shool
Td : 2nd and 3rd grade of
elementary school
Conclusion : complete immunization based on
ministry of health schedule
8
 NUTRITION HISTORY
Patient eat 3 times a day with rice, various vegetables, egg, fish, and
meat. Patient usually ate up the food served to him
Conclusion: nutrition status is adequate in quantity and quality

Growth and Development History

He is 15 years old and he is studied in junior high school now, he had a lot of
friends, he can follow the lesson and he can communicate well with his peers
Conclusion: appropriate for his age

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NUTRITIONAL STATUS
W/A : 51/56 X100% = 91 %
p 25 <WA < p 50 (normoweight)
H/A : 157/170 X 100% = 92.2 % %
p 3 <HA < p10 (stunted)
W/H : 51/48 X 100% =106 %
p10 < WH < p 25 (well nourished)

Conclusion :
Well nourished, normoweight, stunted (CDC 2000)
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 FAMILY TREE

II

III

T, 15 years

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 PHYSICAL EXAMINATION
General appearance :
fully alert, GCS E4M6V5
Vital sign :
Heart Rate = 120 beat per minute
Respiratory rate = 22 breaths per minute
Temperature = 37.3 0 C peraxilar
O2 saturation = 97% S D
Blood pressure = 125/87 mmHg P95 134 85
Wong Baker Pain scale: 5 p99+5 147 98
HC 180 120
12
 Head : moon face (+), malar rash (+), discoid rash (+)
Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex
(+/+)
Nose : nasal flare (-/-), discharge (-/-), nose bleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic
Throat : hyperemic pharing (-), Tonsil T1T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-)
LUNG:
I: normal, symmetric, retraction (-)
P: fremitus right = left
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)

13
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)
ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: bowel sound (+) normal, costovertebral pain (+), good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis
pedis artery was palpable strong, sianotic (-/-), limited range of
movement of both knee due to pain
GENITALIA : phimosis (-)
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TOTAL SCORE = 5

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LABORATORY FINDINGS
(OCTOBER, 5 TH 2017)
Haemoglobine : 12.7 g/dl Albumine: 3.2 g/dl
Haematocryte : 38 % Urea : 52 mg/dl
Leucocyte : 10.6 thousand/ul Creatinine: 0.7 mg/dl
Platelet : 189 thousand/ ul Urinalysis:
Erithrocyte: 4.27 mil/ul Specific gravity: 1.010
MCV : 89.9/um protein : (+)
MCH : 29.7 pg Erithrocyte : (+)
MCHC : 33.1g/dl
Conclusion : limphocytopenia,
Neutrophyl : 73.10%
proteinuria and hematuria
Limphocyte : 19.60 %
Monocyte 6.70%
Eosinofil : 0.10 %
Basofil : 0.50 %
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 PROBLEM LISTS
T, 15 years old, 52 kgs with :
History taking:
1. Right-sided back pain
2. History of steroid resistant nephrotic syndrome on therapy
Physical examination:
1. Moon face, Malar rash, discoid rash
2. Costovertebral pain
3. Limitid ROM of both knee
Laboratory findings:
Limphocytopenia, proteinuria and hematuria

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 DIFFERENTIAL DIAGNOSIS
1. Steroid resistant nephrotic syndrome (on 1st week
therapy)
2. Renal colic due to calculus of ureter dd calculus of
kidney
3. Suspected SLE
4. Wellnourished, normoeight, stunted

18
 WORKING DIAGNOSIS
1. Steroid resistant nephrotic syndrome (on 1st week
therapy)
2. Renal colic due to calculus of ureter dd calculus of
kidney
3. Suspected SLE
4. Wellnourished, normoeight, stunted

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 THERAPY
1. Admitted to pediatric nephrology ward
2. Consult to allergic immunology division
3. IVFD D5 NS 80 ml/hour I.V
4. Nephrotic diet 2000 kkal/ day
5. Methilprednisolone 16 mg 3-0-0 p.o. Alternating dose
6. Cyclosporine 100 mg/12 hours p.o.
7. Irbesartan 150 mg/24 hours p.o.
8. Amlodipine 5 mg/ 24 hours p.o.
9. Ketorolac (0.25 mg/kgBw) 10 mg I.V (if pain)

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 1. Urinalisis
PLAN 2. Urologi ultrasound

General appearance / vital sign/8 hours

fluid balance / diuresis / 8 hours MONITORING
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FOLLOW UP, OCTOBER 6 TH 2017

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S: knee pain, swelling in both of knee, mouth ulcer,
no pain when urinate, waterry stool (+) 2 times
General appearance :
fully alert, GCS E4M6V5
Vital sign :
Heart Rate = 108 beat per minute
Respiratory rate = 24 breaths per minute
Temperature = 36.2 0 C (36 37) peraxilar
Blood pressure = 120/80 mmHg
S D
Wong Baker Pain scale: 5
P95 134 85
p99+5 147 98
HC 180 120
23
 Head : moon face (+), malar rash (+), discoid rash (+)
Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex
(+/+)
Nose : nasal flare (-/-), discharge (-/-), nose bleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic
Throat : hyperemic pharing (-), Tonsil T1T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-)
LUNG:
I: normal, symmetric, retraction (-)
P: fremitus right = left
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)

24
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)
ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: bowel sound (+) normal, costovertebral pain (+), good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis
pedis artery was palpable strong, sianotic (-/-), limited range of
movement of both knee due to pain, knee swelling (+/+)
GENITALIA : phimosis (-)
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TOTAL SCORE = 5

26
 WORKING DIAGNOSIS
1. Steroid resistant nephrotic syndrome (on 1st week
therapy)
2. Renal colic due to calculus of ureter dd calculus of
kidney
3. Suspected SLE
4. Arthritis of left knee
5. Wellnourished, normoeight, stunted

27
 THERAPY
1. IVFD D5 NS 80 ml/hour I.V
2. Nephrotic diet 2000 kkal/ day
3. Methilprednisolone 16 mg 3-0-0 p.o. Alternating dose
4. Cyclosporine 100 mg/12 hours p.o.
5. Irbesartan 150 mg/24 hours p.o.
6. Amlodipine 5 mg/ 24 hours p.o.
7. Ibu profen (10mg/kgBw/ 8 hours) 500 mg/8 hours p.o.
8. Oralit (10 ml/ KgBw/ diarrhea) 500 ml/ diarrhea p.o.
9. Zinc 20 mg/24 hours p.o.

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 1. Urinalisis
2. Stool analysis

PLAN 3. Knee X-ray examination

4. Urologi ultrasound examination
5. DS-DNA test

General appearance / vital sign/8 hours

fluid balance / diuresis / 8 hours MONITORING
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FOLLOW UP, OCTOBER 7 TH 2017

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S: knee pain decreased, swelling in both of knee,
mouth ulcer, no pain when urinate, waterry stool (+)
2 times
General appearance :
fully alert, GCS E4M6V5
Vital sign :
Heart Rate = 100 beat per minute
Respiratory rate = 22 breaths per minute
Temperature = 36.6 0 C (36 37) peraxilar
S D
Blood pressure = 110/70 mmHg
P95 134 85
Wong Baker Pain scale: 5
p99+5 147 98
HC 180 120
31
 Head : moon face (+), malar rash (+), discoid rash (+)
Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex
(+/+)
Nose : nasal flare (-/-), discharge (-/-), nose bleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic
Throat : hyperemic pharing (-), Tonsil T1T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-)
LUNG:
I: normal, symmetric, retraction (-)
P: fremitus right = left
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)

32
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)
ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: bowel sound (+) normal, costovertebral pain (+), good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis
pedis artery was palpable strong, sianotic (-/-), limited range of
movement of both knee due to pain, knee swelling (+/+) decreased
GENITALIA : phimosis (-)
33
 WORKING DIAGNOSIS
1. Steroid resistant nephrotic syndrome (on 1st week
therapy)
2. Renal colic due to calculus of ureter dd calculus of
kidney
3. Suspected SLE
4. Arthritis of left knee
5. Wellnourished, normoeight, stunted

34
 THERAPY
1. IVFD D5 NS 80 ml/hour I.V
2. Nephrotic diet 2000 kkal/ day
3. Methilprednisolone 16 mg 3-0-0 p.o. Alternating dose
4. Cyclosporine 100 mg/12 hours p.o.
5. Irbesartan 150 mg/24 hours p.o.
6. Amlodipine 5 mg/ 24 hours p.o.
7. Ibu profen (10mg/kgBw/ 8 hours) 500 mg/8 hours p.o.
8. Oralit (10 ml/ KgBw/ diarrhea) 500 ml/ diarrhea p.o.
9. Zinc 20 mg/24 hours p.o.

35
 1. Knee X-ray examination

PLAN 2. Urologi ultrasound examination

3. DS-DNA test

General appearance / vital sign/8 hours

fluid balance / diuresis / 8 hours MONITORING
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CLINICAL QUESTION: IS THERE ANY
CORRELATION BETWEEN RENAL COLIC WITH
NEPHROTIC SYNDROME PATIENT?
P: CHILD WITH RENAL COLIC COMPLAINT IN THERAPY WITH
NEPHROTIC SYNDROME PROTOCOL
I: CALCULUS OF URINARY TRACT
C: ISCHAEMIC OF BLOOD VESSELS
O: DIFFERENTIAL DIAGNOSIS

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