upper respiratory tract infection by manilachamara

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     History was obtained from mother and father

The presenting complaint.

     Periorbital swelling   -   for 2 days duration.

     Common cold            - for 7 days
     Cough


History of presenting complaint.


      Previously apparently well schoolboy developed common
cold & cough one week ago. It was associated with mild
intermittent fever. Cough was productive & sputum was
whitish in colour. There was no sore throat. On day 2 of
illness child was taken to general practionar. After treatment
he was improving.
      On day 6 mother has noticed periorbital swelling in the
morning. In 2nd day it was increased. It was not associated with
ankle, scrotal,or abdominal swelling.
      Mother denied that child passes frothyurine, reduction of
urine output, dysuria, increased frequency of urination, poor
stream or loin pain. There was no discolouration of urine to
suggest haematuria.
      He has no shortness of breath. No pink frothy sputum. He
is not orthopnic, or no having paroxysmal nocturnal dyspnoea.
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     give a He has no severe abdominal pain or fever
suggestive of peritonitis. He had no nousea, loss of appetite,
haematamesis or malena.
      No history of projectile vomiting, drowsiness,
convulsion, or focal neurological signs.
      No history of diarrhoea with bulky offensive stool.
      No jaundice.
      He did not have skin or throat sepsis.
      No history suggestive of purpuric, urticarial dermatosis
like rash.
      No history of arthralgea.
      There was no history of beastings. He did not history of
oral ulcers, or alopecia.




     Past medical history.

     No history of previous hospital admission.
     No past history of chronic diarrhoea.
     He did not have feeding difficulties or recurrent chest
infection in the past.No bronchial asthma.
     No history of hepatitis B infection or malaria.
     He has not undergone any surgical procedure.



     Allergy history.
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    He has no history of urticaria, or other allergic
manifestation. No known allergy to food drug or plasters.


Development history


Development milestones were achieved at appropriate age.
Normal in gross motor, fine motor, vision, speech and hearing
and in social development.

    Drug history

     No known history suggestive of chronic drug or metal
ingestion.


    Birth history

     He has born to non consanguenous parents as the 1st and
only child in the family. The child was delivered at THM at
the maternal age 28. It was term normal vaginal delivery. Birth
weight was 2.9kg. No antenatal, perinatal, postnatal
complications. No admitted to special care baby unit.




    Family history
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    Immunization history

    Immunization was completed up to date according to EPI
schedule.


    Dietery history

     Exclusively breast fed up to the age of 6 months.
Weaning food started at the age of 6 month with soup, fruit
juice, in a feeding bottle and cup. Formula milk was started at
age 8 months. Also egg , thriposha, potatoes and vegetables
introduced at 8 month of age. He was started rice on 11th
month of age and gradually changed over to normal adult diet.
     Now he takes 3 sources of rice with vegetables, fish, meat
or egg. 3 sources of bread, cheese, butter, and fruits in
adequate amount.


    Social history

      His mother is 32 year old housewife, educated up to O/L.
Father is 41 year old gem businessman, educated up to grade
8.
      They have satisfactory income.
      They live in their own house which contains 2 bed rooms,
a living room, and kitchen with attached bath room and toilet.
Floor is made up of cement and floor tiles and roof is made up
                                                                 5


of tiles. Bedrooms are well ventilated with windows. Toilet is
watersealed.
      They use tap water after boiled and cooled.
      Land area which land is situated is 15 perches.
Sorrounding area is not much overcrowded.
      They dispose garbage to polythene bags which carried by
municipal council.
      While child is in hospital mother and father stay at
hospital. Nearest hospital is THK. Bus fare is 30 Rs per one.
They have their own motor bicycle.
      Child is studying in preschool in international college.
His school performance are good.




    Examination

     General examination

     Child looks well.
     Weight – 15kg – 10th centile
     Height - 103cm – 25th centile
     Body surface area – 0.68m2
     Afebrile
     Periorbital swelling on both eyes
     CRFT less than 2 seconds
     Not pale, icteric
     No bitot spots
     Not cyanosed
     No alopecia or oral ulcers
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     No skin sepsis, petichae, or purpuric rash
     No arthritis
     Ear, throat normal
     Mild bilateral ankle oedema.

     Abdominal examination

     Abdomen is not distended
     Moves with respiration
     No surgical scars
     Non tender
     No palpable or ballotable masses to deep or superficial
palpation.
     No enlarged liver or spleen
     No shifting flank dullness
     Bowel sounds were presence
     No scrotal swelling
     No sacral oedema



     Cardiovascular system examination

     Pulse – 90bpm , good volume
     BP – 100/60mmHg
     Apex is in the normal position
     Heart sounds normal and no murmurs.

     Respiratory system

     Not dyspnoic
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    RR – 20breaths/min
    Trachea lies midline
    Chest expansion normal and same in both sides
    No evidence of pleural effusion
    No basal crepitions.




Centrel nervouss system

    Child is conscious and rational
    Cranial nervous are normal
    Muscle power, tone, reflexes are normal
    No cerrebellar signs
    Optic fundi are normal




Summery

 Previously apparently well 4 ½ year old boy presented with
periorbital puffiness which increases in the morning for 2days
duration. Before 1 week he had been trearted for common cold
and cough.
     He had no haematuria, oliguria or no skin sepsis or rash.
No abdorminal pain or breathing difficulty.
     No history of similar episode in the past.
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     On examination he has periorbital swelling, mild bilateral
ankle oedema. No skin sepsis. No abdominal tenderness or
abdominal distension or free fluid. Blood pressure was normal
and was not on heart failure. No evidence associated infection.


     Problem list

     Medical problem

     1. Child has facial puffiness with ankle swelling
proceeded by URTI.

     Social problem

     2.During the hospital stay child couldn’t attend school.
     3. Parents have anxiety about the disease.
     4. father couldn’t attend his job.

     Discussion

According to the history and examination I would consider
following differential     diagnosis.
      1. Nephrotic syndrome
      2. Acute glomerular nephritis

     Features favouring a diagnosis of nephrotic syndrome
     are

  1. the age of onset
  2. gradual progression of oedema
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It is likely to be primary nephrotic syndrome as there is
nothing to suggest heavy metal poisoning, chronic drug
ingestion. In a 4 ½ year old child it is more likely to be
an idiopathic.
    The absence of haematuria and hypertension makes it
more likely to be minimal change nephrotic syndrome.
But this has to be confirmed with relevant investigation
later.
    Features favouring a diagnosis of acute glomarullar
nephritis are
       1.presence of facial puffiness and less oedema
       2.common age
 But the early age of onset, absence of skin sepsis or sore
throat, haematuria hypertension and any evidence of
heart failure makes it unlikely. So considering above
differential diagnosis , I would like proceed with the
following investigation.


Urine ward test

It shows the 3+ values at the admission.
Doing this test can get idea about the amount of
poriteinuria.If it is heavy proteinuria shows 3+ or more
and favour of nephrotic syndrome.


Urine full report
to do urine culture and ABST to recognize of causative
organism.
Pale yellowish
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Appearance- slightly turbid
Albumin - ++
Pus cells - 2-4
Red cells - nil
Epithelial cells - +
Casts        - granular casts +

If pus cells are in significant number [75/hpf] and
granular casts indicate pyuria. I would like
If red cells with red cell casts and deformed RBC
indicate glomarullar pathology. Hyaline casts indicate
high proteinuria.

Serum protein level

Serum protein – 5.8/l [6.6-8.7g/l]
Albumin       - 2.6g/l [3.5- 6.3g/l]
 Albumin is reduced and albumin/globulin ratio is
reversed in nephritic syndrome.



Serum cholesterol level

-302g/l[ <200mg/dl]
Serum cholesterol is high in nephrotic syndrome.


24 hour urine sample

If this more than 3g/24 hours indicate nephrotic
syndrome.
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 If the patient having macroscopic haematuria and
 hypertention with evidence of renal impairment
 following investigation have to be done.

 1. ASOT
 2. ESR
 3. C3 and C4
 4. Antinuclear antibody and double standard DNA
 5. Hepatitis B surface
 6. HIV screening
 If patient is steroid resistant have to do renal biopsy.

 Management

1. First I would like to reassure the parents, to advice
   to bed rest.
2. Input/output
3. Blood pressure daily
4. Weight daily
5. Urine ward test daily
6. Diet
  A normal diet with adequate proteins and calories. Have
  to reduce salt and fat from the diet. Fluid restriction if
  oedema is very severe otherwise no need.

 7.Prednesolone therapy

 Prednesolone 30mg/m2 per day given for 4 weeks and
 the rest decided acoording to progress.
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8Antibiotics

Children with nephrotic syndrome are more prone to get
bacterial peritonitis and pneumoniae. Oral penicillin is
recommonded during relapses.

9. Lipid lowering agent

In minimal change disease hypercholeserolaemia is transient.
There for no need of lipid lowering agent.

10. Discharge plan

 On discharge I would like to educate parents about the
illness and its prognosis. I like to reassure about that,
progression to end stage renal failure is extremely rare.
Have to give a history diagnosis card including clinical
history, examination, investigation and management
plan.
    Due to this is an initial episode have to educate about
urine heat test and its grading.
     Examination should be done every morning during
hospital stay. If child get even mild periorbital oedema,
fever, common cold, urine should be examined.
      To perform the heat test 2/3 of a test tube is filled
with urine and the lower half of the tube is heated if
turbidity appears add two drops of acetic acid then
degree of turbidity is read.

      Nil    - turbidity
     Trace -      slight turbidity with no difficulty in
reading the print
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           +     - clouding of print, but possible to read the
   print
           ++   - cannot read the print but can notice black.
           +++ - cannot notice black.
           ++++ - cannot notice black with precipitate.

   Parents should be advised to seek early treatment for
   infections.
   Important to advice about balance diet with adequate
   protein and calories to reduce saturated fat and salt from
   the diet.

   Corticosteroid treatment increases the appetite. There for
   advice about the physical activity and prevent excessive
   weight gain.

   During minor and major surgeries patient need high
   doses of IV steroid while on prednesolone treatment or
   until 1 year after the discontinuation of treatment. There
   for I would like to advice to show diagnosis cards, if
   child undergone a surgical procedure.

   I would like to review in clinic after two week time.




Dr. Nayana Liyanarachchi.
    Consultant paediatrician.
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CASE DISCUSSION - 01




          STUDENT -
                J. L. RUBASINGHE.
                NO. 91
               GROUP-03
               26TH BATCH


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