Agn@rph case management
-
Upload
bngcrz -
Category
Health & Medicine
-
view
1.373 -
download
0
Transcript of Agn@rph case management
![Page 1: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/1.jpg)
Case Management:Acute Glomerulonephritis
Presentor: Ma. Nieves Elizabeth N. Cruz, MD
Rizal Provincial HospitalRizal Provincial HospitalMay 25, 2010May 25, 2010
1
![Page 2: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/2.jpg)
• J.C., 8/f• Cardona, Rizal
• Admitted: April 22, 2010• Discharged: April 26, 2010
GENERAL DATA
2
![Page 3: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/3.jpg)
CHIEF COMPLAINT
tea-colored-urine
3
![Page 4: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/4.jpg)
HISTORY OF PRESENT ILLNESS
4 days PTA fever, intermittent; resolved with intake of Paracetamol
3 days PTA tea-colored urine dec.urine output
1 day PTA consult with a PMD
RPH
4
![Page 5: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/5.jpg)
PERTINENT P.E. FINDINGS
• Wt = 28kg• Temp = 36°C• BP = 100/70 mmHg• CR = 100 bpm• RR = 23 cpm
5
![Page 6: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/6.jpg)
PERTINENT P.E. FINDINGS
•No pallor•No facial edema•+ clear breath sounds•No respiratory distress•No abdominal distension•No visible lesions/wounds on extremeties
•No scrotal/bipedal edema
6
![Page 7: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/7.jpg)
ADMITTING DIAGNOSIS
T/C Acute Glomerulonephritis
7
![Page 8: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/8.jpg)
COURSE IN THE WARD
1st HD low salt dietIVF: D5W x kvoDx’cs: CBC, PC, UA, 24hr-urine-chon, BUN, Crea, ASO, C3, KUB-UTZ
8
![Page 9: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/9.jpg)
120/90mmHg
Tx’cs: Pen G, Paracetamol,Furosemide
Nifedipine, 5mg/cap, half cap/SL
COURSE IN THE WARD
9
![Page 10: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/10.jpg)
COURSE IN THE WARD
2nd HD
Yellowish urine
IVF: D5 0.3%NaClOral fluids limited
(accdg.to BSA)
BSA (wt)4(9)/100 x 100
Furosemide IV shifted to p.o.
10
![Page 11: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/11.jpg)
COURSE IN THE WARD
3rd HDu.o. = 0.8cc/24°/kg
4th HDu.o. = 0.9 cc/24°/kg
Furosemide ↑ q6°
11
![Page 12: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/12.jpg)
COURSE IN THE WARD
6th HD DischargedHome meds: TMP-SMZ Furosemide x 3daysAscorbic acid
Advised repeat KUB-UTZ after 2 weeks
12
![Page 13: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/13.jpg)
Urinalysis:
(4/19/10) (4/21/10) (4/25/10)
Color: dark yellow, turbid yellow, turbid yellow,sl.turbidpH: acidic acidic acidicsp.gr.: 1.010 1.010 1.010Albumin: +4 +4 traceRBC: loaded plenty 5-7WBC: 5-7 plenty 1-2
LABORATORY RESULTS
13
![Page 14: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/14.jpg)
CBC (4/19/10) WBC 8.0 seg 0.89 lympho 0.30 eos 0.01
Hgb 110 hct 0.33 Platelet 232
LABORATORY RESULTS
14
![Page 15: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/15.jpg)
(4/22/10) ASO 400IU/ml
C3 28.774 mg/L BUN 6.30
Crea 0.70 24°-urine-chon 793.8mg/ 24°
LABORATORY RESULTS
15
![Page 16: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/16.jpg)
KUB-UTZ:
pelvicocaliectasia, rt kidney; left kidney & UB, normal
LABORATORY RESULTS
16
![Page 17: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/17.jpg)
Acute glomerulonephritis (AGN)
is a disease characterized by the sudden appearance of edema, hematuria, proteinuria, and hypertension.
It is a representative disease of acute nephritic syndrome in which inflammation of the glomerulus is manifested by proliferation of cellular elements secondary to an immunological mechanism.
17
![Page 18: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/18.jpg)
PATHOPHYSIOLOGY
Immune-complex disease
18
![Page 19: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/19.jpg)
A schematic representation of the proposed mechanism for acute poststreptococcal glomerulonephritis (APSGN). C = Activated complement;
Pl = Plasmin; NAPlr = Nephritis-associated plasmin receptor; SK = Streptokinase; CIC = Circulating immune complex.
19
![Page 20: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/20.jpg)
Normalization of urine sediment
Parameter
• Gross hematuria• Complement level• Proteinuria• Micro-hematuria
Resolved by
• 2-3 weeks• 6-8 weeks• 2-6 months• 6-12 months
20
![Page 21: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/21.jpg)
TYPICAL COURSE
• Latent - few days to 3 weeks• oliguric – 7 to 10 days• diuretic – 7 to 10 days• convalescent – 7 to 10 days
21
![Page 22: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/22.jpg)
CLINICAL & LABORATORY PROFILE
• hematuria (gross) 100%• proteinuria 86%• edema 85%• hypertension 82%• hypocomplementenemia 80%• cryoglobulinemia 63%• gen. malaise, weakness 55%• oliguria 52%• nausea & vomiting 15%• dull, lumbar pain 5%
22
![Page 23: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/23.jpg)
ETIOLOGY
1. InfectionsBacterial: GABS, Strep. Viridans, strep.
Pneumoniae, S. aureus, S. epidermidis, T. pallidum, Leptospira, S. typhi
Viral: hep B, measles, mumps, CMV, enterovirus, GBS, onconavirus
Parasitic: toxoplasma, P. malariae, P, falciparum, schistosoma
Rickettsial: scrub typhusFungal: coccidioides immitis
23
![Page 24: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/24.jpg)
2. Drugs: toxins, antisera, vaccines, DPT
3. Misc: tumor antigen, thyroglobulin, autologous Ig
ETIOLOGY
24
![Page 25: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/25.jpg)
Group A Beta-hemolytic streptococcus (GABS) Nephritogenic strains
Sites: 1. Upper resp. tract: pharyngitis, M1, 2, 4, 12, 18, 252. Skin: pyoderma, M49, 55, 57, 603. Middle ear : rare
ETIOLOGY
25
![Page 26: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/26.jpg)
LABORATORY DIAGNOSIS:
Urinalysis
• dec. volume & sp. gravity• casts (fine & granular)• hematuria (dysmorphic rbc)• proteinuria
26
![Page 27: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/27.jpg)
Bacteriology/serology• culture of GABS• strp antibody titers – ASO
(pharyngitis) antiDNAse B (pyoderma), streptozyme
• serum complement – C3, generally dec. in acute phase, rises during convalescence, normal in 10% of cases
LABORATORY DIAGNOSIS:
27
![Page 28: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/28.jpg)
Renal function
• BUN, Crea – usually normal• In marked azotemia – metab.acidosis,
hyperK, hypoNa, inc. crea
LABORATORY DIAGNOSIS:
28
![Page 29: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/29.jpg)
• Hematology: +dilutional anemia, transient hypoalbuminemia
• Radiography: CXR – sunburst in congestion, renal utz
LABORATORY DIAGNOSIS:
29
![Page 30: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/30.jpg)
DIFFERENTIAL DIAGNOSES
• Low serum complement level• Systemic diseases• SLE (focal, 75%; diffuse, 90%)• Subacute bacterial endocarditis (90%)• Visceral abscess• "Shunt" nephritis (90%)• Cryoglobulinemia (58%)
30
![Page 31: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/31.jpg)
• Renal diseases
• Acute postinfectious glomerulonephritis (>90%)
• MPGN - Type I (50-80%), type 2 (80-90%)
31
DIFFERENTIAL DIAGNOSES
![Page 32: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/32.jpg)
• Normal serum complement level• Systemic diseases• Polyarteritis nodosa group• Hypersensitivity vasculitis• Wegener granulomatosis• HSP• Goodpasture syndrome
32
DIFFERENTIAL DIAGNOSES
![Page 33: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/33.jpg)
• Renal diseases• IgA (or IgG-IgA) nephropathy• Idiopathic rapidly progressive
glomerulonephritis (RPGN)• Anti-glomerular basement membrane
(GBM) disease• Negative immunofluorescence findings• Immune complex disease
33
DIFFERENTIAL DIAGNOSES
![Page 34: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/34.jpg)
MANAGEMENT
Supportive & Symptomatic• bed rest, prn• fluid & salt restriction• Fluids: 400-600 ml/m2/day + UO 24h• NaCl ≤ 2g/day• K ≤ 40mEq/day
34
![Page 35: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/35.jpg)
Antibiotics: • Penicillin 50000-100000 u/kg/d tid-qid x
10days
Specific interventions:• hypertension• CHF• Furosemide 2mg/kg/dose/IV• Dialysis: if refractory indications: uremia,
intractable hyperK, CHF
MANAGEMENT
35
![Page 36: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/36.jpg)
NORMAL BP VALUES
Age
NB8-30days1 mo – 2 yrs2-5y6-11y>12y
Upper limit
95 mmHg, systolic
105115/75130/80135/85140/90
36
![Page 37: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/37.jpg)
PROGNOSIS
• complete resolution • 5-10% progress to chronic state
37
![Page 38: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/38.jpg)
Mortality Rate:
• 0-7% due to sepsis, CHF, hypertensive enceph
38
![Page 39: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/39.jpg)
Consultation with a pediatric nephrologist isnecessary when one or more of the following arepresent:
• Severe hypertension• Severe oliguria• Severe edema• Nephrotic-range proteinuria• Azotemia (moderate to marked)• Recurrent episodes of gross hematuria• Persistently depressed C3 (past 8-10 wk)
39
![Page 40: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/40.jpg)
Consultation with a pediatric nephrologist is necessary when one or more of the following are present:
Atypical onset
• Absence of latent period• No evidence of streptococcal illness
40
![Page 41: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/41.jpg)
Failure of expected resolution of clinical signs• Gross hematuria within the preceding 10-14
days• Microscopic hematuria within 1 year• Edema within 2 weeks• Proteinuria (>50 mg/dL) within 6 months• Azotemia within 1 week• Hypertension within 6 weeks
41
Consultation with a pediatric nephrologist is necessary when one or more of the following are present:
![Page 42: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/42.jpg)
FOLLOW-UP
Further Inpatient Care
Only a small percentage of patients with acute glomerulonephritis (AGN) require initial hospitalization, and most of those are ready for discharge in 2-4 days.
42
![Page 43: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/43.jpg)
Further Inpatient Care
As soon as the blood pressure (BP) is under relatively good control and diuresis has begun, most children can be discharged and monitored as outpatients.
43
![Page 44: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/44.jpg)
Further Outpatient CareFollow up at 0-6 weeks as frequently as
necessary to determine the following:Hypertension has been controlled.Edema has started to resolve.Gross hematuria has resolved.Azotemia has resolved.
.
44
![Page 45: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/45.jpg)
Follow up 8-10 weeks after onset to determine the following:Azotemia has subsided.Anemia has been corrected.Hypertension has resolved.C3 and C4 concentrations have returned
to normal.
45
![Page 46: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/46.jpg)
Follow up at 3, 6, and 9 months after onset to check the following:Hematuria and proteinuria are subsiding
gradually.BP is normal.
46
![Page 47: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/47.jpg)
Follow up at 2, 5, and 10 years after onset to check the following:Urine is normal.BP is normal.Serum creatinine level is normal
47
![Page 48: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/48.jpg)
Follow up at 12 months after onset to determine the following:Proteinuria has disappeared.Microscopic hematuria has disappeared.
48
![Page 49: Agn@rph case management](https://reader034.fdocuments.in/reader034/viewer/2022052323/55852316d8b42ae4748b4dd4/html5/thumbnails/49.jpg)
49