Welcome to Clinical Meeting

Dr. KANTA HALDER Resident (MD;Phase A),

General Pediatrics;Block: Pediatric Nephrology;

BICH.

Particulars of the patient Name: Arif. Age: 7 years. Sex: Male. Address: Modhukhali, Faridpur. Date of Admission: 03.04.2016. Date of Examination: 03.04.2016.

Chief Complaints

Swelling of face for 10 days. Passage of scanty reddish colour urine for 7 days. Respiratory distress for 1 day.

History of present illness According to the statement of mother, her

child developed swelling of face specially around the eyes for 10 days. Mother also stated that her child was passing small volume of reddish colour urine 3-4 times per day for 7 days which was not associated with burning sensation. He also had respiratory distress for 1 day. He had no H/O same type of illness previously, no H/O fever, headache, convulsion, loss of conciousness or blurring of vision.

Cont.. On query, mother stated that her child has H/O

skin infection about 1 month prior to this illness. With these complaints they consulted a local doctor who advised some oral medication and then referred to Dhaka Shishu Hospital for further evaluation & better management.

History of Past illness Nothing significant.

Treatment History He was treated with some oral medication

advised by the local doctor, but mother could not mention the name.

Birth History He was delivered normally at term without any complication.

Feeding History He is on family diet.

Developmental History He is developmentally age appropriate.

Immunization History He is immunized as per EPI schedule.

Family History He is the 2nd issue of his non-

consanguineous parents. His other family members are healthy.

Socio-economic History He belongs to a middle income family.

General Examination Appearance: Dyspnoeic, puffy face. Anaemia: Mild. Jaundice: Cyanosis: Clubbing: Absent Dehydration: Ankle oedema: Present. Neck vein: Not engorged.

Cont..Skin: BCG mark

present; there are multiple healed scar mark of previous skin infection present in both legs and hands.

Cont.. Lymphnode: Not

palpable. Ear: Nose: Normal. Throat: Bedside Urine

Albumin: +

Cont..Vital Signs:

Pulse: 110/min.Respiratory Rate: 32/min.Temperature: 98°F.Blood Pressure: 130/90 mmHg. (above 99th centile).

Anthropometry:

Cont..

Weight: 22 kg.Height: 117 cm.BMI: 16.07 kg/m2 (normal).BSA: 0.85 m2.

Systemic Examination

Abdominal Examination: Inspection:

Abdomen is mildly distended.Flanks are not full.

Umbilicus is centrally placed & inverted.

Cont.. Palpation : Abdomen is soft, non tender.

Liver is palpable 3 cm from right costal margin along the mid clavicular line which is non tender, surface is smooth, regular border. Upper border of liver dullnes present at right 5th intercoastal space. Spleen: Not palpable.

Kidneys: Not ballotable. Renal angle: Not tender. Fluid thrill: Absent.

Cont.. Percussion: Shifting dullness: Absent. Auscultation:

Bowel sound: Present. Genitalia: Normal.

Cont.. Cardiovascular System: Pulse: 110/min, regular, high volume,

No radio-femoral delay. Blood pressure: 130/90 mmHg. Precordium:

Inspection:Shape of chest: Normal.Visible pulsation: Absent.Engorged vein: Absent.

Cont..Palpation: Apex beat: Left 5th ICS, lateral to mid-clavicular

line.Thrill: Absent.P2: Not palpable.Lt. parasternal heave: Absent.Auscultation:1st & 2nd heart sounds are audible in all 4 areas.Added sound: Absent.Basal crepitation: Present (bilateral).

Cont.. Respiratory system :Inspection : Respiratory rate: 32/min.

Shape of the chest is normal & movement is bilaterally symmetrical. Mild subcostal indrawing is present.

Palpation : Trachea is centrally placed.

Chest expansion : Normal. Vocal fremitus is normal in mid clavicular, mid axillary & post. scapular line.

Cont..Percussion: Percussion note is resonant in MCL, MAL &

PSL in both lung field.Auscultation: Breath sound is vesicular and vocal resonance

is normal in MCL, MAL & PSL in both lungs. Basal crepitation is present in both lung fields.

Nervous System ExaminationHigher psychic Function : Conscious & oriented to surroundings.Cranial nerves examination : No facial asymmetry.

Pupillary size and shape is normal, light reflex is present. Eye balls moves in all direction.

Cont..Motor function : Muscle bulk: Normal

Muscle tone: Normal in all 4 limbs. Muscle power: 5/5 Reflexes: Normal Planter response: Bilaterally flexor.

Sensory function : Intact. Fundoscopy : Normal.

Other Systemic examination: No abnormality.

Salient feature Arif, 7 years old immunized boy has

presented with facial puffiness for 10 days, oliguria and hematuria for 7 days and respiratory distress for 1 day. He has H/O skin infection about 1 month prior to this illness. He is dyspnoeic, mildly pale, having puffy face and ankle oedema. There are multiple blackish healed scar present in both legs and hands.

Salient feature (cont..) He is hypertensive & tachypnoeic; there is

tachycardia, apex beat lies in left 5th ICS lateral to the mid-clavicular line, bilateral basal crepitation is present in both lungs. There is hepatomegaly without ascites. Other systems reveal normal findings.

Provisional Diagnosis

Acute Post Infectious Glomerulonephritis with Heart Failure.

Differential Diagnosis

Nephrotic syndrome (other than minimal change) with heart failure.

.

Investigations Urine R/M/E:

Color: Reddish.Appearance: Hazy.Albumin: +.RBC: Plenty.Pus cell: 2-3/HPF.

Epithelial cell: 5-6/HPF. Urine C/S: No growth. Spot urinary Protein Creatinine ratio: 0.8.

Cont.. B. Urea: 8.0 mmol/L. S. Creatinine: 88.4 µmol/L. S. Electrolytes:

Na+: 137.0 mmol/L.K+: 4.8 mmol/L.

Cl-: 100.0 mmol/L. S. Albumin: 29.10 mmol/L. S. Cholesterol: 4.1 mmol/L.

Cont.. Complete Blood Count :

• Hb: 9.3 gm/dl.• WBC: Total count: 9,600/mm3. Differential count:

o Neutrophil: 58%o Lymphocyte: 36%o Monocyte: 02%o Eosinophil: 04%o Basophil: 00%

Cont..

o RBC: Normocytic normochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 209,000/mm3.• PBF:

Complement 3 (C3): 0.27 g/L.ASO titre: <200 IU/ml.

Cont.. USG of W/A: Liver: Enlarged in size (14.3 cm). Shows uniforn

parenchymal echotexture. Kidneys: Bipolar length of Right kidney is 8.1 cm &

of left kidney is 7.9 cm.Both are normal in size according to age. Raised renal parenchymal echo of both kidneys. Pelvicalyceal systems of both kidneys are not dilated. Cortex & medulla of both kidneys are well differentiated.

Comment: Hepatomegaly. Bilateral raised renal parenchymal echo.

Final Diagnosis

Acute Post Streptococcal Glomerulonephritis with Heart Failure.

Management Counseling to the parents. General supportive & symptomatic

management: • Bed rest.• Propped up position.• O2 inhalation.

Management (cont..)• Control of blood pressure & management of

heart failure: Salt & fluid restriction. Inj. Frusemide 20 mg 12 hourly. Tad. Nifidipine (20 mg): ½ tab 12 hourly.

• Inj. Ceftriaxone 1 gm 12 hourly.

Follow up (In hospital)Date Subjective Objective

Respi. distress

Hemat-uria

Oedema RR /min

Pulse /min

BP mmHg

Intake ml

Output ml

Weight kg

Day 2 Present Present Present 30 110 140/90 950 650 22.5

Day 3 ↓ " " 28 104 120/90 1000 2100 21.0

Day 4 Absent " ↓ 28 100 110/90 250 1300 19.5

Day 5 " " Absent 26 80 95/60 620 750 19.0

Day 6 " " " 28 100 110/80 1050 1300 20.0

Day 7 " ↓ " 26 100 110/70 550 700 20.0

Day 8 " ↓ " 26 80 110/70 800 1070 19.0

Day 9 " Absent " 24 80 105/60 1100 1650 18.5

On 7th day

Patient is dischared on 11.04.2016 with –

• Tab Frusemide (20 mg) 1 tab daily for 7 days.• Urine R/M/E after• Follow up 2 weeks.• S. C3 level after 6-8

weeks.

Thank You