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CASE PRESENTATION
General Objective
To present a case of Acute Glomerulonephritis
Specific Objectives
To discuss Acute Glomerulonephritis as to
definition, etiology, epidemiology, and pathophysiology To generate appropriate differential diagnosis To recognize the typical clinical manifestations To provide the proper management and prognosis of the disease
GENERAL DATA
J.R.N., 5 years old, EDS Roman Catholic Born on June 18, 2002 1st time admission on March 1, 2008
CHIEF COMPLAINT:
abdominal distention
10 days PTA
9 days PTA
8 days PTA
7 days PTA
5 days PTA
(+) facial and periorbital edema (-) changes in urine color and frequency self-medicated with Dicycloverine 5ml q6 hours x 2 days (+)Facial and periorbital edema receding edema persisted now associated with abdominal distention No consult nor medications
1 day PTA
(+) abdominal distention, puffy eyelids and facial edema (+) bipedal edema (-) change in color of the urine Consult: Fort Magsaysay Station Hospital (-) laboratory examinations Dx: Allergic Reaction Meds:Chlorphenamine maleate 2mg/5ml, 5ml TID (+) abdominal pain persistence of symptoms consult: private physician Dx: Acute Glomerulonephritis Urinalysis
Color Amber Transparency turbid Reaction 5.0 Sp. Gravity 1.015 Sugar Protein +4 RBC plenty Pus cells 80-90
admitted
PRENATAL Hx:
Cognizant at 1 month AOG
sulfate denies any exposure to radiation, infections, communicable diseases, intake of teratogenic drugs
NATAL Hx:
born to a 29 y/o G5P5 (5005), FT
FEEDING Hx:
Birth 1 mos old pure
breastfeeding
1mos 6 mos - BONNA 6mos 16 mos pure breastfeeding 16mos - present Bear brand weaning - 7 months solid foods at 10 months At present - 1 cup of rice per meal and prefers to eat hotdog, salted fish. Drinks 12 glasses of milk formula (Bearbrand) per day
IMMUNIZATION
BCG
OPV3 DPT3
Measles
Gross motor Can ride a tricycle, jump Fine motor Imitate a circle and draw lines, can write name Language Can count 1-10, can identify colors Personal/social Plays interactive games, washes and dries hand
PAST MEDICAL Hx
8 mos old admitted for 5 days at PJN
(Cabanatuan City) due to Bronchopnuemonia 2-3 episodes of cough and colds a year lasting for 5-7 days no allergy to foods and drugs no childhood diseases noted
FAMILY Hx:
Father- 40 y/o, soldier Mother- 35 y/o, housewife Siblings 1- 16 y/o, female 2- 14y/o, female 3- 11y/o, female 4- 8y/o, male
5- index patient 6- 4y/o, male (+) DM and (+) HPN maternal grandfather (+) bladder stone maternal grandfather (+) BA maternal uncle (+) kidney diseases maternal cousins (-) malignancy, PTB
5th of 6 siblings lives with 8 other household members bungalow type of house with 3 BR and 2 CR Mother primary caregiver Water source - deep well Garbage - disposed properly
REVIEW OF SYSTEMS:
Constitutional: (-) fever, (-) weakness HEENT: (-) blurring of vision, (-) sore
throat, (-) nasal obstruction Respiratory: (-) hemoptysis, (-) shortness of breath GIT: (-) vomiting, (-) constipation, (-) diarrhea GUT: (-) dysuria, (-) urethral discharge NS: (-) headache, (-) LOC, (-) numbness Extremities: (-) stiffness of joints
PHYSICAL EXAMINATION:
General Survey: conscious, coherent, ambulatory, afebrile, not in distress Vital Signs: BP- 150/100 CR- 98 RR- 32 T- 36.80C Anthropometrics: Wt 20 kg (p75) IBW 18 kg Ht 106 cm (p25) IBH 112 cm G - 111% S - 94.6% W - 114.3%
Skin: warm, moist, good skin turgor and elasticity, CRT < 2sec HEENT: pink palpebral conjunctivae, anicteric sclera, intact tympanic membrane AU, no nasoaural discharge, no tonsillopharyngeal congestion, (+) facial edema, (+) puffy eyelids
Chest/Lungs: symmetrical chest expansion, clear breath sounds, no retractions, good air entry Heart: adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: distended, slit-like umbilicus, AC = 52cm, soft, non-tender, no organomegaly, (-) fluid wave Extremities: no gross deformities, full and equal pulses, bipedal edema, (+) healed pyodermal lesions, no cyanosis
ASSESSMENT:
Salient Features:
5 years old, male History of pyodermal lesions
PE: Abdominal pain and distention Edema periorbital, bipedal Slit like umbilicus Hypertension
Urinalysis C3, ASO CBC Serum electrolytes BUN, Crea TPAG KUB UTZ
Therapeutics
Furosemide 1mkdose Pen G 100,000 u/kg/day Nifedipine 5mg prn for BP >120/80
ASO negative
1st
S>
hospital day
with hypertensive episodes abdominal pain O > conscious, ambulatory BP 150-120/80-90 CR 80-88 bpm cpm Temp 36.5-37.10C slit like umbilicus, AC = 52cm bipedal edema facial edema A > AGN prob PSGN P > HL Meds: Pen G 100,000u/kg/day Furosemide q12H
RR 20
2nd
hospital day
S/O > (+) facial and bipedal edema (-) abdominal pain BP 110-130/70-100 AC = 51 cm (52cm) Adequate urine output (1.6 cc/kg/hr) A> AGN prob PSGN P> Oral fluid intake limited to 190ml qshift Furosemide 1mkdose q12 hours Pen G continued - receding
C3 430mg/L
Color Amber Transparency turbid Reaction 6.0 Sp. Gravity 1.015 Sugar Protein RBC TNTC Pus cells 0-2
6th
hospital day
S/O > (-) hypertensive episodes (-) edema (-) abdominal pain A> PSGN P> Pen G IV shifted to Sumapen 250mg/5ml, 6.5 ml q6H referral to Pedia Nephrologist (Furosemide q8H then taper)
Final Diagnosis:
Post Streptococcal Glomerulonephritis
DISCUSSION
ACUTE GLOMERULONEPHRITIS
- Usually signifies an inflammatory process causing renal dysfunction over days to weeks that may or may not resolve
Currents, 2003
Sudden onset of gross hematuria, edema, hypertension, and renal insufficiency One of the most common glomerular causes of gross hematuria in children
Nelsons, 17th ed
Etiology
Streptococcal pharyngitis (serotype 12) cold
weather months Streptococcal skin infections or pyoderma (serotype 49) warm weather months
Epidemiology
Post -infectious type most common
most common in males (1.7 -2:1) ages 6 to 10 but can occur at any age
Pathophysiology
pyodermal lesions
OLIGURIC PHASE Inc ASO, antistreptokinase
Ag-Ab complex
decrease C3 Ag-Ab complement complex
Clinical Manifestations
Hematuria Proteinuria Edema Hypertension Oliguria Nonspecific symptoms Abdominal pain Malaise Fever
Stages
- typical course lasts 7-10 days for each of
the 3 phases
Oliguric phase acute salt and water
overload
Diuretic phase BP normalizes Convalescent phase
Diagnosis
Urinalysis
CBC Blood chemistries C3, ASO Renal biopsy
Complications
Acute Renal Failure
Hypertensive encephalopathy
Congestive Heart failure
Treatment
Supportive
vasodilators, ACEI
Prognosis
More than 95% of affected children eventually recover totally with conservative therapy aimed at maintaining sodium and water balance.
Follow-up Care
Proper education about patients condition
SUMMARY
Thank You!