SKENARIO II - HEMATURIA – BLOK 10 1. Scenario : Seorang anak umur 7 th dibawa ibunya ke poliklinik karena keluhan mengalami hematuria dan bengkak-bengkak sejak 2 hari yang lalu. 24 jam terakhir hanya berkemih 2 kali. Ia juga mengeluh nyeri kepala dan tidak reda dengan pemberian parasetamol. Orangtuanya membawa anak tersebut ke bidan dan disarankan untuk periksa ke dokter. 2. Unfamiliar terms 1. Hematuria : i. Blood in urin urine become black, brown or red (contain RBC). 5-more blood cell/high power field in 3 speciment. (ono, aira, yovi) 3. Problem Identification, Brainstorming and Analyzing 1. Why this patient have swollen in the body? i. Retention of Na+ (NANA) 1. Glomerulonefritis decrease of plasma volume ren activating RAAS Aldosterone ADH water reabsorbtion compensation to make plasma volume stable imbalance of pressure in blood pressure OSMOTIC>ONCOTIC edema 2. Causing Hypertention ii. Protein loss (albumin) (YOVI) 1. Glomerulonefritis glomerulus disturb the filtration of the protein protein lost causing osmorality changes 2. Filtration of albumin decreasing osmotic pressure down decrease persist of the fluid in reabsorbtion will under normal. Make CIS full of fluid. iii. Have a relation with hypertension (NINDA) 1. Hypertension related with water balance. Hypertension eliminating pressure in vessel wall disturb the water balance. 2. (Temporary or permanent) will be disappeared when the causes removed 3. HT will permanent if the disease is chronic, usually after 2-3 weeks
2. What is the relation between hematuria and edema? i. Problem in renal (filtration) – wesa
1. Hematuria?? macroscopic (by eye) and microscopic (should using microscope) 2. streptococcal glomerulonefritis make tiny damage blood vessel in filtration unit. hematuria 3. They are “symtoms” of disease. Different things but have same etiology sometimes or can happen together. 4. Glomerulus like a window broken bigger hole bigger bigger too big 3. Headache and why it isn’t cure by paracetamol? i. Cure the symptoms but not the disease (nana). ii. Edema Hypertension headache (almas). Or it doesn’t strong enough to pass BBB or has unsufficient dosage iii. The etiology hypertension is still exist because paracetamol doesn’t 4. Why the patient only urinate 2 times in 24 hours? i. Decreasing of Filtration in glomerolus 1. If there is no blood pass glomerolus. There will be no urin produced. 2. Hypertensi belum tentu increasing blood flow to the ren 3. Very big reabsorption happen in proximal tubulus. The problem maybe in tubulus proximal or distal. For glomerolus - permeable for water or ion. But glomerolus only permeable for protein And RBC ii. Obstruction in UT 1. Blood clotting in urinary tract reducing the amount of urination 5. Additional test to diagnose? + radiology i. Urinanalisis – Aira 1. Shape and size of eritrosit a. Glomerular changed b. Non glomerular didn’t changed ii. Examination of urinary sediment 1. Protein evaluation protein + kidney disease a. Or infection detection iii. Plain abdomen and BNO-IVP – nana 1. Must did if the patient has abnormality in urinary tract. We can see the problem in UT, like hidronefrosis. iv. Biopsy of renal – yovi
1. To culturing bacterias 6. DD? i. Glomerulonefritis –yovi 1. Symptoms: hematuria, edema, hypertension ii. Acute post-streptococcal glomerulonefritis – aira 1. ASPGN sudden edema, and hematuria, 2. Most common form in children 3. Uncommon in adult f:1/10.000 people (BOSTON HOSPITAL) 4. Self-limiting disease cured without treatment 80% a. 20% chronic iii. Nephritic syndrome –ninda iv. Haemolytic uremic syndrome –dena 1. One of the common causes of nephritic syndrome a. Symp: Low urine output conclusion’s of ono’, nana, dewina : Infection nephritic syndrome glomerulonefritis kidney failure Complement system Antibody complex damaging glomerulus glomerulonefritis. 3-12 years old --> common to get streptococcal infection 7. Patophysiology? 8. Etiology & Risk Factors? 9. Complication 10. Treatment? i. Curative ii. Prevention 11. Prognosis
1. PICO, a. Try to discuss 2-4 journals that correlated with hematuria in children : (therapy for hematuria in children).
b. Choose one to do this work (untuk dibikin pico sama resepnya). c. Tugas ngisi PICO kelompok d. Tugas buat resep sendiri-sendiri :q 2. Another information about DD. Orang tua pasien tidak demam, kencing sedikit, merah agak keruh, tidak ada kemerahan kulit, bercak muntah. Bab biasa, mata sembab saat bangun tidur, siang hari muka normal, riwayat makan baik, 2 minggu lalu anak sakit tenggorokan dan sembuh sendiri. Tidak ada trauma. i. KU: Anak tampak lemah, gizi baik, ada edema muka ii. VS : TD 140/95, (Hipertensi Stadium I) RR/menit costoabdominal, Nadi : 100x menit regular, isi tekanan cukup kuat iii. kepala : mesocephal, edema periorbital, konjungtiva anemis sclera tidak ikterik. iv. Leher: Limfonodi tidak teraba JVP tidak terlihat/ normal v. Thorax : dalam batas normal vi. Jantung : normal vii. Abdomen : Dinding perut setinggi dada, supel, tidak teraba massa atau tekanan, peristaltic usus normal viii. Ekstremitas: Akral hangat Perfusi jaringan baik Nadi kuat Edem tungkai negative ix. Anogenital: Oue (-) Skrotum testis tidak edem, Tidak ada nyeri x. EM. Lab dasar Urine 1. Warna : kemerahan
2. 3. 4. 5. 6. 7.
Bj : normal Eritrosit +3 Leukosit 5-10/lap pandang Silinder eritro + Darah Al 7000 HB. 10
