Submitted by:

Section 3A

, MD
Date of interview: January 27, 2019

Time of interview: 10:00AM

Informant: LB (Grandmother)

Reliability: 90%

General Data: Patient JM is a 5 years old Filipino male currently living in Manila. He was born on June 9,
2013 in Paco, Manila. He was admitted in Ospital last January 1. It was his first time to be admitted in
Ospital.

Chief complaint: Edema of the eyes and cheeks

History of Present Illness:

2 weeks PTA, the patient complained of throat pain (5/10). No measures are done to alleviate
the pain and no consult was done. He did not experience cough, colds, and fever.

The patient was apparently well. No other symptoms were reported until 1 week PTA.

1 weeks PTA, the sore throat of the patient spontaneously resolved. The patient’s face was noted
to be edematous, particularly in the periorbital area. There were no noted swelling of the extremities
and other body parts. No measures were done to alleviate the swelling and no consult was done. The
patient did not experience coryza, conjunctivitis, no headache, no vision changes, jaundice, palmar
erythema, itching, vomiting, or diarrhea, difficulty of breathing, and orthopnea.

In the interim period, the facial edema persisted. There were still no measures were done to
alleviate the symptoms. No functional limitations with daily activities and the patient was able to go to
school.

2 days PTA, there was an onset of tea-colored urine. He also experienced a decrease in urinary
output, approximately less than 100mL from the usual approx. 250mL per episode. Other than the
symptoms presented, the patient did not experience pain during urination, back pain, flank pain, genital
swelling and genital discharge.

1 day PTA, the informant reported worsening of the facial edema. No noted swelling of upper
and lower extremities, and other body parts.

Review of Systems:

General:

The patient did not experience weight loss/gain.

Skin:

The patient did not experience rashes and skin pigmentation.

Hair:

The patient did not experience hair loss.

Head:

The patient did not experience headache and dizziness.

Eyes:

The patient did not experience excessive lacrimation and visual difficulty.

Ears:

The patient did not experience difficulty in hearing and discharge.

Nose:

The patient had episodes of epistaxis.

Mouth:

The patient did not experience toothache, bleeding gums.

Cardiovascular:

The patient did not experience cyanosis, easy fatigability, and fainting spells.

Respiratory:

The patient did not experience chest pain.

Gastrointestinal:

The patient did not experience constipation, jaundice, passage of worms, and food intolerance.

Genitourinary:

The patient did not experience dysuria and enuresis.

Endocrine:

The patient did not experience polyuria, polydipsia, and heat/cold intolerance.

Nervous/Behavioral:

The patient did not experience tremors and sleep problems.

Musculoskeletal:

The patient did not experience pain and in the bone, joint, or muscle and limping.
Hematologic:

The patient did not experience pallor, bleeding, and easy bruising.

Personal History:

Feeding History

The patient has a good appetite. He likes eating junk foods and is not fond of eating vegetables.
His usual breakfast is 2 cups of rice, egg, hotdog. For lunch, he eats 2 cups of rice, soup, and meat
(chicken or pork). For dinner, he eats 2 cups of rice, meat. He usually drinks 12 glasses of water every
day. In addition, he does not have any food intolerances and does not take any multivitamin and iron
supplements.

Developmental History

At 5 years old, the patient can do the following:

 Able to run and skip

 Can draw a person
 Dresses and undresses unaided
 Can name 4 or more colors
 Counts more than 10
 Completed toilet training (No urinary incontinence)
 No temper tantrums, head banging, and phobias
 No night terrors and sleep disturbances

Past Illnesses

The patient did not have any allergies to food, medication, pollen or animals. He did not have a
history of contagious diseases such as polio, chicken pox, measles, mumps, and pertussis and rheumatic
fever. He also did not have previous hospitalizations and surgical procedures done.

Immunization History

The immunization history of the patient was not recalled by informant.

Family History

The patient's mother is 29 years old, currently unemployed and is generally healthy. His father's
details are unknown by the informant. The patient has no siblings. He had a cousin (10 years old) that
had a sore throat 2 months ago and another cousin (9 years old) had a history of PSGN 2 months ago. His
grandfather in his mother's side has diabetes and cancer while his grandmother in his mother's side has
asthma and hypertension.
Socioeconomic History:

They have been living in Paco, Manila for 6 years. They had no previous geographic moves. His
playmates are mostly his cousins that are living next door and their neighbors. Their house has 1 room
with 3 occupants. No member of the family is currently working and their source of funds is the
boyfriend of his mother.

Environmental History:

The source of drinking water of the patient is tap water and mineral water from local retailer.
They use tap water as their washing water. Their garbage collected every morning by the Manila LGU.
They have a pour-flush toilet. He had a pet rabbit and dogs from his neighbors and is taken care of by the
mother of the patient. Their neighborhood is described as noisy but generally safe.

Physical Examination:

General Survey

The patient was alert and well kept. There were no signs of cardiopulmonary distress. The
patient was also ambulatory, well-nourished, and not ill-looking. He was awake, the skin color was not
pale, his lips were moist and his eyes were not sunken.

Vital Signs

 Temperature: 36.4 oC (R aural)

 Cardiac rate: 89 bpm
 Respiratory rate: 18 bpm
 BP: 130/90 mmHg (Sitting, L &R)
 SaO2: 99

Anthropometric Data

 Weight: 20 kg
 Height: 1.14 m
 BMI: 15.4
 PATIENT’S SCORE INTERPRETATION
Height-for-age 0 Normal
Weight-for-age Above 0 Normal
BMI-for-age Above 0 Normal

HEENT

The head of the patient is normocephalic. There were no deformities, hair loss, lice and dandruf
but has facial edema. The face is symmetric upon inspection.

The eyes of the patient have periorbital edema. Bulbar conjunctiva are pink and moist. The
sclera are white. There is an intact visual fields via confrontation. Visual acuity is 20/20 on both eyes
through Rosenbaum chart. Pupil equally constricts from 5-3cm. Extraocular muscles are intact on both
eyes. Direct and consensual pupillary reflex are intact and there is a positive near reaction to light.
Fundoscopy was not done to the patient.

The ears of the patient is normoset. Auricles are mobile, firm and non-tender. No pain upon tug
test. Both pinna recoil when folded. There are no aural discharge. There are intact hearing on both ears
via rubbing finger test and was able to hear for 40cm on both ears. Otoscopy is not done to the patient.

The nose of the patient has symmetric nasolabial folds. There are patent nares. Nasal mucosa
are pink and moist. The right nares is obstructed by dried blood due to epistaxis. There were no alar
flaring, nasal discharge, and frontal and maxillary sinus tenderness. Nasal speculum exam is not done.
 The lips are pink and moist. Gums are pink in color and have no bleeding. No dental carries on all
teeth. Tongue is in midline. There are no atrophy and fasciculation and it moves from side-to-side. Uvula
is in the midline. There is a Brodsky grade 3 tonsils, tonsils are non-hyperemic and have no exudates. Gag
reflex is intact.

The neck is supple. No masses and swelling observed. There are no venous engorgement.
Trachea is in midline. Lymph nodes are non-palpable. Thyroid is non-palpable.

Chest and lungs

Upon inspection, there are no scars, striations and lesions, asymmetry, bone abnormality nor
other deformities. Anterior diameter is one half of the transverse diameter. There are no chest
retractions and use of accessory muscles of respiration. Breathing is quiet and regular in rhythm and
depth.

There are no masses and areas of tenderness upon palpation. Chest expansion is symmetrical.
Tactile fremitus is equal on both lung fields. All lung fields are resonant during percussion. Vesicular
sounds are heard over most lung fields. There are no adventitious breath sounds and altered breath
sounds upon auscultation.

Heart and Vascular system

The patient has a dynamic precordium. There are no visible pulsations, scars, lesions, and
striations upon inspection. There are heaves felt along 3 rd and 4th ICS, left parasternal area. Point of
Maximal Impulse is at 3rd ICS, medial to left midclavicular line. In auscultation, there is a distinct heart
sounds. S1 is heard louder than S2 at the base, S2 is heard louder than S1 at the apex of the heart. There
were no murmurs heard.

Carotid arteries are easily palpable. The jugular veins not distended. JVP is 8cm from Right
Atrium in a 30o bed elevation. There are regular, bounding peripheral pulses (radial, femoral, anterior
tibial, and posterior tibial artery) and is graded 2+.

Abdomen

The abdomen is flat with inverted umbilicus. There are no irregular contours, striations, lesions,
scars, distension, dilated blood vessels, pulsations and peristalsis. Bowel sounds are normoactive at
7/min. There are no abdominal bruit, no venous hum and no friction rubs upon auscultation. In
palpation, the abdomen is soft and non-tender. There are no muscle guarding, palpable masses and
spleen and liver are non-palpable. The abdomen is tympanic in most areas. Liver span is 6cm right
midclavicular line. Kidneys are non-palpable and there are no costovertebral tenderness elicited.

Inguinal region

There were no masses and swelling.

Male genitalia

The penis has no hypospadias and epispadias. There were no discharge, lesions, ulcers and scars.
The left scrotum was lower than the right scrotum. There were swelling with loss of scrotal folds and is
positive to transillumination.
Extremities

There were no clubbing, cyanosis, signs of inflammation, and joint deformity.

Spine

There were no deformity, sacrococcygeal dimple, and local tenderness between vertebrae.

Lymph nodes

There were no palpable lymph nodes.

Neurological examination

The patient was alert, aware, coherent, and cooperative at all times. He has a good eye contact
and is able to maintain attention during history and physical exam. He also have a good recall on
symptoms.

All CN was tested and intact. It was tested as follows:

 Olfaction: able to identify cofee

 Optic Nerve: visual acuity of 20/20
 Oculomotor, Trochlear, Abducens Nerves: unremarkable
 Trigeminal Nerve: unremarkable, corneal reflex present
 Facial Nerve: unremarkable, symmetrical smile, frown, eye closure
 Vestibulocochelar Nerve: able to respond to the sound of the tuning fork
o Webber Test: symmetrical
o Rinne Test: AC>BC both L & R ear
o Caloric testing: not performed
 Glossopharyngeal and Vagus Nerves: uvula at midline, gag reflex intact, symmetric
sternocleidomastoid
 Hypoglossal nerve: tongue protrudes at the midline

Gross assessment of the muscle bulk and tone are symmetrical. Manual muscle testing is
unremarkable. Grip strength of both hands are equally strong, all muscle groups were normotonic. There
are no observed fasciculation, involuntary movements, and weakness.

Gait and posture assessments were not performed due to patient refusal.

Both upper extremities and lower extremities was able to trace touch and pain, position sense,
and vibration. Stereognosis, two-point discrimination, and graphestesia are all intact and has a negative
Romberg sign.
 All deep tendon reflex were graded as +. Reflexes were hypoactive and Babinski reflex is absent.
Coordination assessments were not performed due to patient refusal.

Salient features:

PERTINENT POSITIVES PERTINENT NEGATIVES

 5 years old  (-) Fever
 Male  (-) Cough
 Symptom free until 2 weeks prior to  (-) Colds
admission wherein he had throat pain  (-) Dysuria
with spontaneous resolution  (-) Back pain
 Periorbital edema since a week PTA
followed by episodes of tea-colored urine
 Oliguria 2 days PTA
 Hypertensive in PE

Approach to Diagnosis

The patient presented with hematuria and periorbital edema would delineate the condition to
renal problem. This can be caused by non-glomerular or glomerular pathology. In non-glomerular
pathology, the symptoms presented can be caused by UTI or Nephrolithiasis. In glomerular pathology, it
can be caused by Rapidly Progressive Glomerulonephritis (RPGN) or Post-Streptococcal
Glomerulonephritis (PSGN).

Differential Diagnosis:

UTI Nephrolithiasis Rapidly Progressive Post-Streptococcal

Glomerulonephriti Glomerulonephriti
s s
More common in ✔ ✔ ✔
males
5 years old ✔ ✔
History of sore ✔
throat
Periorbital ✔ ✔
edema
Tea-colored ✔ ✔ ✔ ✔
urine
Oliguria ✔ ✔
No dysuria ✔ ✔
Hypertensive ✔ ✔
No fever

Urinary tract infection (UTI) is one of the most common pediatric infections. It has a bimodal
presentation, usually at infancy and 2-4 years old at the start of toilet training. Escherichia coli is the
organism that is most commonly isolated from pediatric patients with UTIs. It develop when
uropathogens that have colonized the periurethral area ascend to the bladder via the urethra. From the
bladder, pathogens can spread up the urinary tract to the kidneys (pyelonephritis) and possibly to the
bloodstream (bacteremia). Common manifestations of UTI are the following: fever, flank/back pain,
dysuria, incontinence, hematuria, strong smelling urine. In the case of the patient, most of the common
symptoms were not presented by the patient which is why this diagnosis was ruled out (Kasper, et.al.,
2018).

Renal stones occur as a result of the following 3 factors: supersaturation of stone-forming

compounds in urine, presence of chemical or physical stimuli in urine that promote stone formation,
inadequate amount of compounds in urine that inhibit stone formation (magnesium, citrate). History
should include questions to identify frequent urinary tract infections, frequent bouts of abdominal pain,
hematuria (gross or microscopic), passage of previous calculus, dietary intake (oxalate, purine, calcium,
phosphate, fructose, animal protein), drug intake (anticancer drugs, glucocorticoids, allopurinol, loop
diuretics), vitamin intake (A, D), fluid intake, habitual fluid type (water, milk, tea, sports drinks). In the
case of the patient, this diagnosis cannot explain most of the symptoms presented which is why this is
ruled out (Kasper, et.al., 2018).
 Rapidly progressive glomerulonephritis (RPGN) is a disease of the kidney characterized clinically
by a rapid decrease in the glomerular filtration rate (GFR) of at least 50% over a short period, from a few
days to 3 months. The age range is 2-92 years. However, the disease is rare in the pediatric population. It
is postulated that ANCAs induce a premature degranulation and activation of neutrophils at the time of
their margination, leading to the release of lytic enzymes and toxic oxygen metabolites at the site of
injury. Most common prodrome is flulike symptoms characterized by malaise, fever, arthralgias, myalgias,
anorexia, and weight loss. Although this diagnosis may present most of the symptoms presented by the
patient, its rarity on children and the history of sore throat would cause this diagnosis to be ruled out
(Kasper, et.al., 2018; Kumar, et.al., 2015).

Clinical Diagnosis:

Acute Glomerulonephritis T/C: Post Streptococcal Glomerulonephritis

Poststreptococcal glomerulonephritis is prototypical for acute endocapillary proliferative

glomerulonephritis. In underdeveloped countries, it usually afects children between the ages of 2 and
14 years, but in developed countries is more typical in the elderly, especially in association with
debilitating conditions. It is more common in males, and the familial or cohabitant incidence is as high as
40%. Poststreptococcal glomerulonephritis due to impetigo develops 2–6 weeks after skin infection and
1–3 weeks after streptococcal pharyngitis. Clinical manifestation is a classic acute nephritic syndrome
which includes hematuria, edema, hypertension, and renal Insufficiency. Patient can also present with
lethargy, generalized weakness, and anorexia depending on the disease severity (CDC, 2018; Kasper,
et.al., 2018).

Pathophysiology:

Glomerular lesions are result of glomerular deposition or in situ formation of immune

complexes. On gross appearance, the kidneys may be enlarged up to 50%. Histopathologic changes
include swelling of the glomerular tufts and infiltration with polymorphonucleocytes. A streptococcal
neuraminidase may alter host immunoglobulin G (IgG). IgG combines with host antibodies. IgG/anti-IgG
immune complexes are formed and then collect in the glomeruli. In addition, elevations of antibody
titers to other antigens, such as antistreptolysin O or antihyaluronidase, DNAase-B, and streptokinase,
provide evidence of a recent streptococcal infection.

Cellular and humoral immunity is important in the pathogenesis of this disease. The exact
mechanism remains to be determined. The 2 most widely proposed theories include (1) glomerular
trapping of circulating immune complexes and (2) in situ immune antigen-antibody complex formation
resulting from antibodies reacting with either streptococcal components deposited in the glomerulus or
with components of the glomerulus itself (molecular mimicry) (Kasper, et.al., 2015).

Confirmatory tests:

Throat culture Assess the presence of bacterial infection


Antistreptolysin O titers
Renal function studies
Serum complement levels
Positive throat culture → might support the
diagnosis of PSGN
Confirms a recent streptococcal infection
Rising antibody titer to streptococcal antigen(s)
→ streptococcal pharyngeal infection
Blood Urea Nitrogen (BUN)
Serum Creatinine
- Elevated values → decrease in GFR
- Usually transient and normalize within several
weeks or months
Serum C3 and serum CH50
Low values → indicative of antigen-antibody
interaction

Treatment:

Therapy for PSGN is supportive and involves dietary sodium restriction, diuretics, and
antihypertensive agents as needed. Diuresis may be induced by giving furosemide IV 1-3mg/kg. Although
treating the streptococcal infection does not prevent PSGN, antibiotic treatment is still warranted with
active streptococcal infection. Also, if there is a documented streptococcal infection among family
members, a 10 day course of penicillin may be given to limit the spread of nephritogenic organisms
(Kliegman, et.al., 2016).

References:

CDC (2018). Post-Streptococcal Glomerulonephritis. Retrieved in

https://www.cdc.gov/groupastrep/diseases-public/post-streptococcal.html

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, J., & Loscalzo, J. (2018). Harrison's principles of
internal medicine (20th edition.). New York: McGraw Hill Education.

Kliegman, R., Stanton, B., St. Geme, J. W., Schor, N. F., & Behrman, R. E. (2016). Nelson textbook of
pediatrics (Edition 20.). Phialdelphia, PA: Elsevier

Kumar, V., Abbas, A., & Aster, J. (2015). Robbins and Cotran pathologic basis of disease (Ninth edition).
Philadelphia, PA: Elsevier/Saunders.