1 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. 2 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. 3 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 4 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 6 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 7 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. 8 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 9 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 10 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. 11 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. 12 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 13 + - 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. 14 CASE DISCUSSION - 01 STUDENT - J. L. RUBASINGHE. NO. 91 GROUP-03 26TH BATCH .
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