Dr.

Gajendra Deshpande

A CASE OF NEPHROTIC SYNDROME

A 6 year old boy Ajit who is first born child of non-consanguineous

parents, residing at Kochi, brought to hospital by his mother who gives
fairly reliable history , c/o diminished urine output since past 10 days,
H/O Facial puffiness and abdominal distension of 10 days duration.
Child has been hospitalized at Institute of Child Health for past 1 week
and is on treatment.
Mother gives H/O diminished urine output for past 10 days. Child was
initially voiding urine for 6-7 times a day; frequency of micturition has
decreased to 2-3 times a day and according to mother quantity of urine
also decreased.
No H/O associated dysuria.
No H/O fever with chills.
No H/O passing red or cola colored urine.
Mother has not given H/O any dribbling or poor urinary stream.
There is H/O facial puffiness and abdominal distension for 10 days
duration. Mother initially noticed facial puffiness more in periorbital
region and more when child gets up from bed in morning and decreases
as day progresses.
There is H/O abdominal distension for past 10 days, according to mother
it is of insidious onset, progressing gradually and not associated with
abdominal pain.
There is also H/O swelling of both legs.
There is no H/I swelling of scrotum.
There is H/O cough for past 1 week but child does not produce any
sputum.
There is no diurnal or postural variation and it is not associated with
wheeze.
There is H/O occasional breathlessness on exertion but there is no H/O
paroxysmal nocturnal dyspnea or orthopnea.
There is no H/O sore throat or any skin infection preceding the illness.
No H/O headache, blurring of vision, altered sensorium, seizures or limb
weakness.
No H/O chest pain, palpitations or right hypochondrial pain.
No H/O yellowish discoloration of urine, hematemesis or malena.
No H/O progressive pallor.
Mother doesn’t give H/O any vitamin deficiency or worm infestation.
No H/O fever with skin rashes or joint pain.
No H/O insect bite or drug allergy.
No H/O abdominal pain associated with fever or vomiting.
No H/O failure to thrive or any bony deformity.
No H/O Recent vaccination.
PAST HISTORY
There is H/O previous similar episodes. Mother gives H/O child had 3
similar previous episodes over the past 3 years. The first episode was
when child was 3 year old. Child was hospitalized in Govt. Hospital for
1 week. Child was discharged with oral medications. Child was advised
to follow up on OPD and was advised to continue medications for 2
months, following which child was improved symptomatically and child
was asked to stop those medications.
2nd episode occurs after 1 year. Child was again hospitalized and similar
treatment was given.
3rd episode occur after 1 year of 2nd episode. Relatives brought child to
Govt. Hospital, as the symptoms are recurring they referred child here.
Mother doesn’t give H/O any invasive procedure done during previous
hospitalizations.
There is H/S/O varicella infection when child was 3 years old.
H/O jaundice at about 4 years of age which lasted for 1 week, child was
not taken to any hospital and was given indigenous medicines following
which jaundice disappear.
No H/O prior blood transfusion.
No H/O any recurrent respiratory tract infections.
No H/O pulmonary tuberculosis in child.
ANTENATAL HISTORY
Mother was a registered and immunized case. Her antenatal period was
uneventful. There is no H/S/O congenital intrauterine infection like fever
with skin rash associated with swelling in the neck.
Mother doesn’t give H/S/O oligohydramnios or polyhydramnios. No
antenatal ultrasound scan was actually done.
There is no H/O gestational diabetes mellitus, pregnancy induced
hypertension or ant antepartum hemorrhage.
NATAL HISTORY
Mother was delivered by full term normal delivery. Child was normal
sized baby. Mother doesn’t know about any H/O large placenta. Birth
weight was 3 kg, child cried immediately after birth.
No H/O admission to neonatal intensive care unit.
Child voided urine within 24 hours of birth.
There is no H/O neonatal jaundice, seizure, cyanosis or respiratory
distress.
DEVELOPMENTAL HISTORY
Developmental milestones are appropriate for age. Child studying at
present in 1st std. Despite this illness child has got very good scholastic
performance.
DIETARY HISTORY
Prior to hospitalization child was taking 1000 cal as against 1600 cal
with gap of 600 cal and 29 grams of proteins as against 40 grams of
protein with protein gap of 11 grams. On hospitalization child is on low
salt diet provided by hospital.
FAMILY HISTORY
He is first born child of non consanguineous parents, he is got sibling
who is 5 years old, sibling is alive and healthy. There is no family H/O
similar illness.
SOCIOECONOMIC HISTORY
They come under class IV of kuppuswami scale of socioeconomic
status.
IMMUNIZATION HISTORY
The child is immunized appropriate to age according to universal
programme of immunization but child is not immunized for
H.influenzae and Pneumococcal vaccine.
CONTACT HISTORY
There is no H/O contact with open case of adult TB.

Summarizing the history

This is a 6 year old boy come with H/O oliguria with generalized edema
without hematuria without symptoms suggestive of hypertension without
cardiac or respiratory symptoms, I would like to think of renal pathology
and like to examine abdomen first.
(Since there is H/O oliguria with generalized edema without hematuria
without symptoms of hypertension without any previous episode of sore
throat or skin lesions with H/O Previous similar episodes with relapses
and remissions, I would like to think of Nephrotic syndrome as
possibility).
GENERAL EXAMINATION
Child is conscious, oriented, co-operative, afebrile.
He has got facial puffiness, periorbital puffiness, B/L pitting edema. He
has got mild pallor.
He is not icteric, not cyanosed.
No clubbing or significant lymphadenopathy.
BCG scar is present.
Few post-inflammatory hypopigmented scars are present over face,
abdomen and legs.
There is no purpura, no joint swelling, no skin rashes, no signs of any
vitamin deficiency, no signs of liver cell failure.
PR- 86/min, normal volume, rhythm, no specific characters, no radio-
radial or radiofemoral delay.
RR-28/min, thoraco-abdominal in type.
BP- 90/60 mm of Hg, in right upper limb in sitting position.
JVP is not raised.
ANTHROPOMETRY
Child weighs 20 kg as expected.
His height is 113 cm, expected is 115 cm.
Head circumference is 49 cm and chest circumference 58 cm.
SYSTEMIC EXAMINATION
P/A-
Inspection- Abdomen is distended, flanks are full, umbilicus is pushed
down, it is transverse and is flushed with surface.
All quadrants of abdomen moves well with respiration.
No dilated veins.
Few hyperpigmented atrophic scars present (s/o varicella infection).
No sinuses, no ascetic fluid tap mark present.
Hernial orifices are free.
Palpation- abdomen is soft, mild abdominal wall edema is present.
Abdomen is non-tender, no renal angle tenderness.
The umbilicus is pushed down.
Distance between umbilicus and xiphiternum is 15 cm while between
umbilicus and pubic symphysis is 11 cm. The abdominal girth is 58.5
cm.
Liver span is 7 cm, which is normal for his age. Spleen is not palpable.
No other mass palpable.
Hernial orifices are free. External genitalia are normal. Both testis are
palpable, testicular sensations present, no phimosis, and no hydrocele.
Percussion- Fluid thrill is present.
Auscultation- No bruit, no venous hum.
CVS-
S1 S2 normal, apical impulse is in left 5th intercostals space in
midclavicular line, no cardiomegaly.
RS-
Air entry B/L present, B/L scattered wheeze heard.
CNS-
Child is conscious, oriented, higher functions are normal, spinomotor
and sensory systems are normal, no focal neurological deficit.
DIAGNOSIS-
A case of nephrotic syndrome with infrequent relapse probably steroid
responsive with anaemia without any complications.

------------------------------Thank You-----------------------------------