Clinical case on

oedematous child

Roll no- 78, 79, 80

Contents
• History
• Physical examination
• Investigation
• Management
• Theory background
History
• Name - mg TPH
• Age - 4 yr & 2 month
• Address - ShweKyin village, Magway township
• Admission time – 11 January 2020 ( 2 pm )
• C/O - fever for 5 days
- cough for 2 days
- facial edema for 2 days &
- Become generalized within 2 days
History of present illness
• Fever for 5 days
• Intermitted
• Lowgrade
• No association with chill and rigor, vomiting & skin rash
• No evening rise in temperature and night sweating
• Cough for 2 days
• Dry cough
• No spasmatic cough
• No association with convulsion , vomiting & conjunctival
haemorrhage
• No history of atopy
• Edema
• Abrupt onset, start From face & become generalized within 2 days
• No oliguria
• Amount – she said to be normal
• Color –
• No frothy
• No skin infection
The mother denied the following symptoms
• Breathlessness
• Proximal nocturnal dyspnea
• Orthopnoea
• Palpitation & chest pain
• No history of yellowish coloration of skin & sclera
• No history of abdominal pain & distension
• No history of haematamesis & melaena
• No associated with diarrhoea
• No history of passing worm form mouth or bottom
(regular deworming 2 times per year)
• No loss of appetite before & after getting Edema
• No history of taking any medication before the onset of
edema
( no history of taking any particular food which can cause
allergy)
• No features of acute renal failure such as Oliguria, anuria
• No features of hypertensive heart failure (breathlessness,
PND, orthopnoea, palpitation , chest pain, haemoptysis)
• No features of Hypertensive encephalopathy ( headache,
projectile vomiting, confusion, seizure , convulsion)
• No history of hypovolaemic shock ( restlessness, drowsiness,
cold& clammy extremities )
• No history of TB , Pnemonia , chickenpox , measles , UTI
Past medical History
• No previous history of similar attack
• No history of hospitalization
• No history of sore throat , tonsillitis, skin rash, arthritis
• No history of blood transfusion
• No history of travelling to malaria endemic area
Drug History
• No history of regular taking drug
• No known drug allergy
Immunization history
• Complete ( mother said complete for his age)
Nutritional history
• Exclusive breast feeding
• Weaning diet start after 6 month
• no history of food fads
Family history
• 3 family members
• No similar illness between family members
• Balance income & outcome
• Mother is looking after child
• Mother is primary school level
Hospitalization
Investigation
Urine RE – macroscopic- color – yellow
- clarity – clear
- specific gravity - normal
- pH- 7 ( normal 4.8 – 7.5)
- protein ++ mg/dl
- Blood +++ Ery/microL
• Urine RE – microscopic - epithelial cells 0-1 /HPF
- pus cells 5-7 / HPF
- RBCs 3-5 /HPF
- cast(nil) , crystal( nil )
• Blood for CP – WBC (9.8
- RBC (4.75
- HGB (9.5 gm/dl)
- HCT (28.6
- Platelet count ( 449
- PCT (398
- sodium chloride (129.9 mmmol/L)
- potassium (3.01mmmol/L)
- chloride (109.8 mmol/L)
Renal Function test - creatinine 2.0
- Urea 26.3

Liver function test - total protein 5.3 (normal 6.6-8.7gm/dl)

- albumin 2.0 (normal 3.8-5.1 gm/dl)
- globulin 3.3 (normal 1.8-3.6gm/dl)
Cholestrol -234.8 (normal <200mg/dl)
Ultrasound
• Right minimal pleural effusion

ECG
• normal
Blood pressure BD chart
EXAMINATION
General condition – well & alert
- no dyspnoeic
- nutritional status is average for his age
- general edema presen
- no skin infection & scar
• Respiratory symptom – shape of the chest is normal
- RR is 32 breaths / min
- no respiratory distress
- movement equal on both sides
- air entry is equal on both sides
- no basal crepitation
• CVS - HR 120 beats/min
- normal 1st&2nd heart sound
- no other added sound or murmur
- apex beat is palpable at left 5th intercostal space within
the mid clavicular line
- no bilateral basal crepitation
- no liver tenderness
- no dependent edema or sacral edema
- BP 130/100 mmHg
Abdominal examination
On Inspection,
- abdomen is flat
- move with respiration
- no striae
- no abdminal tenderness
- flanks are not full
• Palpation - temperature is normal
- no tenderness
- no rigidity
- no guarding , no palpable mass
- liver is not palpable
- kidney are not blotable
• Percussion - no shifting dullness
• Urine albumin – can be assessed by using dip stick or by boiling
• Urine 10 parameter – urobilinogen 1mg%
- bilirubin 1mg%
- ketones 5
- blood +++
- protein trace
- nitrite negative
- leucocyte +
- Glucose negative
- specific gravity 0.103
Investigation
Urine RE – macroscopic- color – yellow
- clarity – clear
- specific gravity - normal
- pH- 7 ( normal 4.8 – 7.5)
- protein ++ mg/dl
- Blood +++ Ery/microL
• Urine RE – microscopic - epithelial cells 0-1 /HPF
- pus cells 5-7 / HPF
- RBCs 3-5 /HPF
- cast(nil) , crystal( nil )
• Blood for CP – WBC (9.8
- RBC (4.75
- HGB (9.5 gm/dl)
- HCT (28.6
- Platelet count ( 449
- PCT (398
- sodium chloride (129.9 mmmol/L)
- potassium (3.01mmmol/L)
- chloride (109.8 mmol/L)
Renal Function test - creatinine 2.0
- Urea 26.3

Liver function test - total protein 5.3 (normal 6.6-8.7gm/dl)

- albumin 2.0 (normal 3.8-5.1 gm/dl)
- globulin 3.3 (normal 1.8-3.6gm/dl)
Cholestrol -234.8 (normal <200mg/dl)
Ultrasound
• Right minimal pleural effusion

ECG
• normal
Blood pressure BD chart
• Treatment – oral nifedipine 2.5 mg bd
- oral penicillin 125 mg bd
ACUTE POST STEPTOCOCCAL
GLOMERULONEPHRITIS
APSGN is the commonest cause of an acute nephritic syndrome in
children resulting in abrupt onset of glomerular injury and inflammation
that leads to a glomerular filtration rate with sodium and water retention.

Patient may present with ,

- macroscopic or microscopic haematuria
- signs of fluid overload such as hypertension & oedema
- renal dysfunction
History & clinical features
• Any age- most common between at the age of 2 and 15 years
• Pharyngeal or less commonly , skin infection with groupA streptococcus
• Symptoms usually develop
 1-2 weeks after a throat infection or
 3-6 weeks after skin infection
• Gross haematuria 30-50%
• Volume overload severe congestive heart failure & pulmonary oedema
• Hypertension up to 80%
• Hypertensive encephalopathy 5%
INVESTIGATION
• Urinalysis
- proteinuria <2g/m2/day , not nephrotic range (<+++)
- haematuria – RBC & RBC cast (60-85%)
• For streptococcal infection
- skin/throat swab culture
- ASO titer
• Renal function test
- blood urea
- creatinine &electrolytes
MANAGEMENT
• Indication for hospitalization
- hypertension
- oliguria
- generalized edema
- signs of heart failure
- elevation of serum creatinine or potassium
- hypertensive encephalopathy
General measures
• Strict monitoring – daily fluid intake, urine output, weight, BP, urine albumin
• Closed monitor fluid intake& output
- “no added salt” diet
- if oliguria <0.5ml/m2/day , restrict fluid intake to replacement of
insensible losses ( 400ml/m2/day) plus previous day urine output
- if overload , give furosemide 1-2 mg/kg up to twice daily to induce a
negative fluid balance
Eradication of streptococci
Phenoxymethyl psnicillin – can’t alter natural history of disease
- prevents spread of nephritogenic stains of
GroupA streptococci

If hypersensitive to penicillin oral erythromycin 30-50mg/kg/day 4

divided dose
TREATMENT OF HYPERTENSION
Significant hypertension but asymptomatic
• Treat fluid overload (usual cause)
• Nifedipine – starting dose 200-300microg/kg three times daily
or Amlodipine – starting dose 100-200microg/kg once daily
• Avoid ACE inhibitors ( leading to reduce renal function)
• Beta blockers can exacerbate hyperkalaemia
Symptomatic, severe hypertension or hypertensive emergency/encephalopathy
• Features – headache, vomiting, loss of vision, convulsion, papiloedema
• Emergency management – to reduce BP sufficiently to avoid hypertensive
complication
• Target of BP control
Reduced BP to <90th percentile for age, gender and Height percentile
Total BP to be reduced = observed mean BP – desired mean BP
• Osmotic diuretics, such as mannitol 0.25mg/kg push may increase dose
gradually to 1mg/kg if necessary for satisfactory response
Treatment of circulatory congestion and pulmonary edema

• Prop patient up
• Give oxygen
• Sodium & fluid restriction
• Diuretics such as furosemide (2mg/kg), double dose if no response in
four hours
• Consider dialysis if no response to diuretics
• Digitalis is ineffective
• Preload & after load reductions ( nitrates, morphine, diuretics)
Complication
• Acute left ventricular failure
• Hypertensive encephalopathy
• Acute renal failure