MB: the power puff girl

MB: THE POWER PUFF GIRL

TMC: Department of Pediatrics

Name: MBAge: 5Gender: FemaleNationality: FilipinoReligion: Roman CatholicStatus: ChildAdmitted: November 11, 2013Information: ME (Patient’s Mother) with 70% Reliability

Identifying Information

“Namamaga yung Mukha”Facial swelling of 2 Days Duration

Chief Complaint

History of Present Illness

Patient developed intermittent fever (Tmax 38°C) Treated with Ibuprofen (Advil)

100mg/5ml at 5.88mg/kg/dose Associated with the following

symptoms: Colds Productive cough with yellowish

phlegm Moderate, intermittent, non-radiating

RLQ pain No consultations sought

2 Weeks PTC


Patient afebrile Developed loose, watery stools (3

episodes) Non-foul smelling, non-mucoid, non-

bloody ½ cup per episode

No associated vomiting, headache, fatigue or weakness Sought consult at Ospital ng Maynila

Observation Sent home with Oral Rehydration

Solution

1 Week PTC


Onset of facial swelling, decreased urine output and easy fatigability

Patient brought to Evangelista Clinic CBC and Urinalysis were done

4 Days PTC

Parameters

Result Normal Value

Hemoglobin

10.0 12.0-16.0g/dL

Hematocrit 0.28 0.37-0.47

RBC 3.64 4.0-5.4x1012/L

WBC 12.6 5.0-10x109/L

Platelet 450 150-450x109/L

Neutrophils 0.34 0.45-0.65

Lymphocytes

0.51 0.25-0.40

Primary Impression:Post-infectious Glomerulonephritis

ADVISED TRANSFER


Onset of facial swelling, decreased urine output and easy fatigability

Patient brought to Evangelista Clinic CBC and Urinalysis were done

Parameters

Result

Color Amber

Transparency

Turbid

pH 5.0

Spec. Grav.

1.015

Protein (++)

Sugar (-)

Parameters

Result

Pus Cells 3-5/hpf

RBC TMTC

Epithelials Few

Urates Moderate

Bacteria Moderate

Primary Impression:Post-infectious Glomerulonephritis

ADVISED TRANSFER

4 Days PTC


Observed tea-colored urine Brought patient to JRRMMC

Noted to by hypertensive at 130/90

Had laboratory tests done: CBC, UA, C3, ASO titers and Electrolytes Not retrieved by patient’s relative

Transferred to OsMak for further management and evaluation, hence consult and subsequent admission

1 Day PTC

Review of Systems

General: (+) weight gain, (-) fever, (+) fatigue Integument: (-) rashes HEENT:

Head. (-) head injury, (-) tenderness, (-) changes in hair, (-) hair loss

Eyes. (-) blurring of vision, (-) diplopia, (-) spots or floaters, (-) loss of vision, (-) eye pain, (-) eye discharge, (-) conjunctival dryness, (-) excessive tearing

Ears. (-) tinnitus, (-) ear discharge, (-) ear pain Nose. (-) colds, (-) sinusitis, (-) loss of smell, (-) epistaxis Mouth. (-) mouth sores, (-) teeth problems, (-) tongue

lesion, (-) tonsillar inflammation Throat. (-) dysphagia, (-) sore throat

Review of Systems

Respiratory: (-) shortness of breath Cardiovascular: (-) chest pains, (-) palpitations GI: (-) vomiting, (-) diarrhea, (-) constipation, (-)

changes in eating habits, (-) pain or changes in defecation

GU: (-) dysuria Hematopoietic: (-) anemia, (-) easy bleeding Endocrine: (-) cold or heat intolerance, (-) excessive

sweating, (-) increased thirst Nervous: (-) memory impairment Psychiatric: (-) changes in mood, (-) suicidal

thoughts

Past Medical History

None None

Previous Conditions Previous Hospitalizations, Surgeries or Procedures

Asthma and Allergies

No known allergies or asthma

Family History

Filipino descent, Makati City

Hypertension (maternal grandfather)

Bronchial Asthma (maternal grandmother, maternal uncles and younger sibling)

Household Members: Paternal Grandmother Paternal Aunts and Uncles Parents Younger sister

Genogram

Birth/Maternal History

Birth: Born full-term via NSD to an 18-year old G1P1 (1001) with

a birth weight of 6lbs, unrecalled birth length APGAR 9,9

Maternal: 6 prenatal check-ups at Dona Mapa Lying-In Clinic starting

at 4 months AOG 1 Ultrasound done at 4 months AOG Took Ferrous Sulfate UTI at 6 months AOG

treated with Amoxicillin 500mg OD for 4 days (no repeat UA) Perinatal Complications:

Thickly meconium-stained

Nutritional History

Breastfeeding Period: 0-1 week Milk Formula: Bona until 6 months (1:1),

Bonamil until 8 months (1:2), Alaska until 2yo (1:4)

Complementary Feeding: cereals and vegetables (7mo), meat and fish (1yo)

Food Restrictions: low-salt foods 24-hour Diet Recall:

Breakfast: rice and fried chicken Snacks: Hansel biscuit and bananas Lunch and Dinner: rice and hotdog

Child History

1 dose of BCG 3 doses of DPT

and OPV 3 doses of

Hepatitis B 1 dose of Measles

Sitting alone at 6 months, walks alone at 11 months

“Mama” at 7 months Scribbling at 2 yo Social Smile at 2

months, Stranger anxiety at 6 months

Immunization History Developmental History

Personal, Social and Environmental History

Patient is a Grade I student Average

performance Likes dancing and

singing

Dwelling: 1-floor wooden shanty with 2 windows

12 inhabitants Electricity: Meralco Drinking Water Source:

Maynilad Water Services Waste Disposal: daily,

not segregated Exposure to tobacco

smoke from both parents

Personal and Social History

Environmental History

Stakeholder Analysis

Name Role Stand on

Issue

Intensity of

Stand

Action

MB’s Mother Primary Caregiver

High High Provides care for the patient

MB’s Father Breadwinner

High High Provides financial support for the patient’s health

plans

MB’s Paternal Grandmother

Secondary Caregiver

High Medium Provides care for the patient when the

primary caregiver is not available

MB’s Sibling Dependent Medium Medium Provides social support and camaraderie

Vital SignsHR. 89bpmRR. 23bpmT. 36°CBP. 120/80 (p>95%)

Physical Examination

AnthropometricsHeight. 102cm (p>-2)Weight. 17kg (p>-2)BMI. 16.3 (p>0)

For a 5-year old female, systolic range is 107-113 and the diastolic range is from 69-73.


General: awake, alert, cooperative, not in cardiorespiratory distress

HEENT: Head. Normocephalic head, closed sutures and fontanelle Eyes. Symmetric eyes, no masses, lesions or discharge,

(+) facial edema, (+) periorbital edema, anicteric sclerae, pink palpebral conjunctivae, (+) ROR

Ears. Symmetric ears, patent canal, intact TM Nose. Midline nasal septum, patent nares, (+) dried

mucus at nasal opening Mouth. Moist lips and buccal mucosa, non-hyperemic

tonsils and pharynx Neck. (+) submandibular lymphadenopathy, left


Respiratory: symmetric chest expansion, resonant in all lung fields, clear breath sounds

Cardiovascular: adynamic precordium, normal rate, regular rhythm, no murmurs, heaves or thrills

Abdominal : round abdomen, no scars or lesions, umbilicus midline, NABS, tympanitic in all 4 quadrants, nontender, liver span 6cm

GU: grossly female Extremities:

Upper: 5/5 motor, 100% sensory Lower: 5/5 motor, 100% sensory

Integumentary: normal skin color, no cyanosis or pallor

Salient Features

5-year old female History of intermittent fever with

productive cough and colds and RLQ pain

History of loose watery stools 4 day history of facial swelling,

decreased urine output and easy fatigability

1 day history of tea-colored urine Family history of HTN and BA Born full-term and thickly-

meconium stained via NSD to an 18yo G1P1 (1001)

Good nutrition and appetite, though on low salt and fluid diet

Exposed to tobacco smoke at home

Awake, alert, not in CR distress

Appropriate height and weight for age

Hypertensive (greater than 95th percentile)

(+) submandibular lymphadenopathy, left

Facial and periorbital edema Dried mucous at the nasal

opening

History Physical Examination

Recommended Diagnostics

Complete evaluation of patient’s history and PE Laboratory

Urinalysis Electrolyte Levels CBC Serum Chemistries (e.g. BUN, Creatinine) ASO Titers Complement Levels

Imaging Chest Radiograph (Plain)

Procedural Renal Biopsy

Indications for Renal BiopsyPersistently low C3 beyond 8 weeksPersistent heavy proteinuria after 6 monthsAtypical presentation (e.g. nephrotic syndrome, severe acute renal failure)Atypical course – failure of renal function to improve

Acute Glomerulonephritis

An inflammatory process affecting the glomerulus with infiltration and proliferation of acute immunologically-mediated inflammatory cells

Primary Impression

Diff

ere

ntia

l D

iag

nose

s

Differential Diagnoses

Primary Renal Diseases that manifest as Acute Glomerulonephritis

Anatomy of the KidneyEtiologyPathophysiologyClinical ManifestationsTherapeutic and Supportive PlanPrognosis

Discussion

Anatomy of the Kidney

Bean-shaped retroperitoneal organ

Measurements: 11-14cm in length, 6cm wide, 4cm thick

Supplied by the left and right renal arteries (receives 20% output); innervated by the renal plexus

Kidney

Functions: Filtration, reabsorption, and secretion; excretion of wastes; maintains body

homeostasis; regulates acid-base balance, electrolyte concentrations, extracellular fluid volume; regulated blood pressure; produces endocrine hormones

Kidney Anatomy

1. Renal Pyramid2. Interlobular

Artery3. Renal Artery4. Renal Vein5. Renal Hilum6. Renal Pelvis7. Ureter8. Minor Calyx9. Renal Capsule10. Inferior Renal

Capsule11. Superior Renal

Capsule12. Interlobular

Vein13. Nephron14. Minor Calyx15. Major Calyx16. Renal Papilla17. Renal Column

Etiology

Infectious (Bacteria, Parasite, Virus, Fungus) Most commonly Streptococcus species,

particularly serotypes 12 and 49Bacteria Virus Parasite Fungus

StreptococciDiplococci

MycobacteriaActinobacilliSalmonella

typhosaBrucella siuisTreponema

pallidumCorynebacteriu

m bovis

Cytomegalovirus

Epstein-Barr Vius

Hepattis BRubella

RicketsiaeMumps

Plasmodium malariae

Plasmodium falciparum

Schistosoma mansoni

Toxoplasma gondii

FilariasisTrichinosis

Trypanosomes

Coccidioides immitis

Etiology

Non-Infectious

Primary Renal Disease

Systemic Disease Miscellaneous

Membranoproliferative GN

Berger DiseasePure Mesangial Proliferative GN

Idiopathic Rapidly Progressive GN

VasculitisHypersensitivity

VasculitisCollagen-Vascular

DiseasesCryoglobulinemia

Polyarteritis nodosaHenoch-Schonlein

PurpuraGoodpasture

Syndrome

Guillain-Barre Syndrome

Irradiation of Wilm’s Tumor

DPT VaccineSerum Sickness

Pathophysiology

Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes

Kidneys may be enlarged up to 50% Histopathologic changes include mesangial

proliferation and PMN infiltration Immunofluourescence reveals a patter of

“lumpy-bumpy” deposits of immunoglobulin and complement on the glomerular BM and mesangium

Pathophysiology

Cellular proliferation increased number of glomerular tufts Proliferation may be

endocapillary or extracapillary Extracapillary

proliferation leads to cresent formation

GBM thickening Hyalinization/Sclerosis

Proteinuria Hematuria GFR reduction Active urine

sediment with RBCs and casts

Structural Changes Functional Changes

Pathophysiology

Glomerulus appears enlarged and relatively bloodless and shows mesangial proliferation and exudation of neutrophils.

Pathophysiology

Electron micrograph show electron-dense deposits (D) on the epithelial cell (Ep) side of the glomerular basement membrane. A polymorphonuclear leukocyte (P) is present within the lumen (L) of the capillary.

(BS) Bowman’s Space(M) Mesangium

Clinical Manifestations

Common in children aged 5-12yo Patient develops an acute nephritic syndrome 1-2

weeks after an antecedent pharyngitis, 0r 3-6 weeks after pyoderma.

Severity of kidney involvement varies from asymptomatic to acute renal failure Edema, hypertension and oliguria Risk for developing encephalopahty, heart failure,

pulmonary edema Nonspecific symptoms

Malaise, lethargy, abdominal or flank pain Nephrotic syndrome develops in <5% of cases

Symptom Timeline

Gross Hematuria

Hypertension

Hypocomplementemia (Low C3)

Persistent Proteinuria

Intermittent Proteinuria

Microhematuria

Onset of Symptom

s

2 weeks 4 weeks 2 months

6 months

1 year 2 years

Acute phase generally resolves within 6-8 weeks.

For this patient, the most important form of treatment is supportive since there is no specific treatment for Renal Disease

Therapeutic and Supportive Plan

PharmacologyDiuretics may be able to reduce congestive symptomsAntibiotics may be used to control local symptoms and prevent the spread of infection to close contactsThis does not prevent the development of AGN


Diet and ActivitySodium and Fluid Restriction

Sodium: <2g/dayFluid (400ml/m2/day)

Bed Rest is recommended until signs of glomerular inflammation and circulatory congestion subsideContinuous Monitoring and Follow-Up


Prognosis

95% of cases follow a course ending in complete patient recovery Mortality in the Pediatric Age Group: 0-7%

Other causes of AGN have outcomes varying from complete recovery to complete renal failure

Complications include renal failure, congestive conditions and hypersensitive encephalopathy

Prevention

Hygiene Early detection to prevent complications Continuous monitoring to prevent

chronic sequelae

Sources:Kliegman et al. 2011. Nelson Textbook of Pediatrics, 19th Ed. Elsevier Saunders. p. 1785-1789.Parmar MS. 2013. Acute Glomerulonephritis. http://emedicine.medscape.com/article/239278-overview. Accessed on March 08, 2013.

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MB: the power puff girl