clinical meeting

1. Dr. KANTA HALDER
Resident (MD;Phase A),
General Pediatrics;
Block: Pediatric Nephrology;
BICH.

2. 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.

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

4. 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.

5. 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.

6. 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.

7. Birth History
He was delivered normally at term without
any complication.
Feeding History
He is on family diet.

8. Developmental History
He is developmentally age appropriate.
Immunization History
He is immunized as per EPI schedule.

9. 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.

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

11. Cont..
Skin: BCG mark
present; there are
multiple healed
scar mark of
previous skin
infection present in
both legs and
hands.

12. Cont..
 Lymphnode: Not
palpable.
 Ear:
 Nose: Normal.
 Throat:
 Bedside Urine
Albumin: +

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

15. Anthropometry:
Cont..
Weight: 22 kg.
Height: 117 cm.
BMI: 16.07 kg/m2 (normal).
BSA: 0.85 m2.

16. Systemic Examination
 Abdominal Examination:
Inspection:
Abdomen is mildly distended.
Flanks are not full.
Umbilicus is centrally placed & inverted.

17. 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.

18. Cont..
Percussion:
Shifting dullness: Absent.
Auscultation:
Bowel sound: Present.
Genitalia:
Normal.

19. 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.

20. 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).

21. 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.

22. 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.

23. Nervous System Examination
Higher 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.

24. 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.

25. 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.

26. 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.

27. Provisional Diagnosis
Acute Post Infectious Glomerulonephritis
with Heart Failure.

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

29. 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.

30. 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.

31. 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%

32. 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.

33. 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.

35. Final Diagnosis
Acute Post Streptococcal Glomerulonephritis
with Heart Failure.

36. Management
 Counseling to the parents.
 General supportive & symptomatic
management:
• Bed rest.
• Propped up position.
• O2 inhalation.

37. 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.

38. 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

39. 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.

40. Thank You