CCP:

INVESTIGATION

By: Phong Qiu Shi

061303542

Group B2 ( Z )

URINE CULTURE AND SENSITIVE (3/12/2011) Result : show contaminated mixed growth

WBC 3 cell/ uL

RBC 0

Epithelial Cell 0

Crystal 0

Cast 0

Dsymorphic RBC 0

Other 0

Positive > 3/uL

Borderline 2-3/uL

No 0-1/uL

URINE PROTEIN CREATININE RATIO

(6/12/2011)

Protein Creatinine Ratio 830 ( <200 )

Creatinine ( urine ) 4882 umol/ L ( 2470 -19200)

Urine protein 4.05 g/L ( < 0.150 )

URINE BIOCHEMISTRY ( 5/12/2011)

Criteria 4/12/2011

(0032H)

4/12/2011 (0829H) 5/12/2011

pH 7.0 (4.8-7.4) 7.0 8.0

Specific Gravity(SG) 1.023 1.017 1.015

Leucocyte (pus cell) Negative 1+ Negative

Nitrate Negative Negative Negative

Urine Protein 4+ 4 + 4+

Urine Glucose Normal Normal Normal

Ketone Negative Negative Negative

Urobilinogen Normal Normal Normal

Bilirubin Negative Negative Negative

RBC Negative Negative Negative

HEAMATOLOGY ( PT/APTT )

PROTHROMBIN TIME

PT test 10.9 sec ( 9.1-12.1)

PT control 10.6 sec

PR 1.03

INR 1.03

APTT

APTT Test 35.6 sec ( 21.4-36.8)

APTT control 29.3 sec

APTT ratio 1.22

NEPHROTIC CHART

Date Daily Urine Total

BP Weight Albumin ESBACH Input Output

3/12/2011 - - - Set at 6 420 600

4/12/2011 140/86 64 kg ++ 3 gm 1300 1450

5/12/2011 120/86 64 kg ++ 3 gm 1060 1600

6/12/2011 133/74 63 kg ++ - - -

URINE OUTPUT

Date Urine output

Full Blood Count ( 3/12/2011 )

Results Normal values

Hb 136 g/L 120-150

T.R.B.C 4.86 x 1012/L 3.8- 4.8

HCT 40.4 % 36- 46

MCV 83 fL 83- 101

MCH 28 pg 27- 32

MCHC 33.6 g/dL 31.5- 34.5

RDW-CV 14.2 % 11.6- 14

Platelets 254 x109/L 150- 410

TWBC 7.4 x109/L 4-10

Results Normal values

Lymphocytes 0.7x103/uL 1- 3

Neutrophils 6.6 x103/uL 2- 7

Monocytes 0.1 x103/uL 0.2- 1

Eosinophils 0.0x103/uL 0- 0.5

Basophils 0.0 x 103/uL 0- 0.1

Lymphocytes 9.8 % 20- 40

Neutrophils 88.3 % 40- 80

Monocytes 1.4 % 2- 10

Eosinophils 0.3 % 1- 6

Basophils 0.2 % < 1- 2

LIVER PROFILE (3/12/2011)

Total bilirubin 2.2 micromol/L <17.1

Total protein 50 g/L 64-83

Albumin (Blood) 25 g/L 38-54

Globulin 25 g/ L 23-45

Alkaline phosphatase 99 u/L <300

Alanine transaminase (SGPT) 9 u/L <41

BUSE/CREA( 3/12/2011)

Results Normal values

Urea 3.4 mmol/L 1.7- 8.3

Sodium 139 mmol/L 136- 145

Potassium 3.8 mmol/L 3.5- 5.1

Chloride 106 mmol/L 98- 107

Creatinine 38 umol/L 5- 52

Results Normal values

CRP 1.7 mg/L <2.8

C- REACTIVE PROTEIN (3/12/2011)

TREATMENT DONE &

PROGRESS/ OUTCOME

DAY 1 : (3/12/2011)

Impression :

Relapse Nephrotic syndrome

TRO Urinary tract infection

TRO Deep vein thrombosis of Left Leg

TREAMENT PLAN

Monitor BP and Pulse rate 4 hourly

Strict input / output chart

Start nephrotic chart

Trace old note and paediatric card

KIV for induction with Tab. Prednisolone

60mg/m2/day.

KIV for USG doppler of left leg

Trace and review all blood investigation

KIV start Tab. Penicillin 500mg BD

Encourage orally

CHILD’S PROGRESSION

Child is comfortable , present of facial

puffiness, pink and moist tougue.

Bilateral pedal oedema up to mid-shin level

Left lower limb – able to move left limb without much

pain, mild tenderness of the right side , slight

swollen of the left calf.

Cardiovascular system

Respiratory system Normal

Gastrointestinal system

( Continue Tab.predisolone 10mg )

Urine dipstick stat.

Inform if calf swelling / pain worsening.

( 2245 H )

BP raised – 160/100 mmHg.

Child did not have headache, vomiting, blurring of

vision.

Monitor BP manually

Investigate for steroid Toxicity.

Unlikely to be urinary tract infection.

DAY 2 – 4/12/2011

Child is comfortable, ambulate well, leg pain

resolve, facial swelling had reduced, no

headache, no nause and vomiting, no abdominal

pain, no chest pain.

On examination: child is active, alert and conscious.

Not tachypnoiec, hydration-good.

CRT <2 sec. Temperature-37 ̊c

BP-127/77mmHg. RR-28 breath/min

Minimal bilateral leg swelling.

Lungs – clear

Abdomen soft and non tender

1100 H

Urinary tract infection symptoms resolved

BP ( 162/93 mmHg )

Left calf – not tender, not erythematous, no localize

raised in temperature, dorsalis pedis palpable.

TREAMENT PLAN Tab prednisolone 80 mg OD ( 40 mg –morning +

40 mg-night ) until remission.

Follow by Tab. Prednisolone 55mg daily for 4 weeks.

Repeat BP hourly till stable.

KIV antihypertensive if BP persistently high.

Find out expected BP range.

Eye assessment – steroid toxicity

Strict I/O chart

Trace Urine protein creatinine ratio

Penicillin 500 mg OD

Continue nephrotic charting.

Expected range : systolic : 119 – 123 mmHg

diastolic: 77-81 mmHg

At 1730 H – BP range is

Systolic 154-108 mmHg

Diastolic 90-102 mmHg

Plan : Tab . Nifedipine 5 mg stat.

BP monitoring.

At 2145 H , BP – 146/87 mmHg. Child is active, alert ,

conscious and comfortable. Not tachypnoiec ,

tachycardic. Improve facial puffiness. No other acute

complains

Plan- Tab. Nefidipine 10mg BD 0.2 mg/kg/dose

DAY 3 ( 5/12/2011)

BP range : systolic 115-125 mmHg

diastolic 88-104 mmHg

According mother, child complaint of headache. No

nausea, vomiting, blurring of vision.

On examination respitaroty rate, pulse rate and

temperature are within the normal range.

Cardiovascular system

Respiratory system Normal

Abdomen

Repeated BP – 147/95 mmHg.

Glucometer stat – 7.8 mmol/L ( at 1545 H )

Treatment plan –-Tab. Nefidipine 10mg BD 0.2 mg/kg/dose

-Tab prednisolone 80 mg OD ( 40 mg –morning +

40 mg-night )

-Penicillin 500 mg OD

-Trace urine protein creatinine ratio.

DAY 4 (6/12/2011)

On examination:

Child is well, comfortable,

no headache,abdominal pain / discomfort.

no nausea and vomiting

Reduced pedal oedema

Tolerating oral well

Loss 1 kg ( 63 kg )

Vitals are stable ( temperature – 37 ̊̊ C; pulse rate 80

bpm; respiratory rate 20 breath per minute. )

BP range : systolic 127-134 mmHg

diastolic 74-81 mmHg

Planning for discharge after review by pediatric specialist

Educate child’s mother regarding the importance and

compliance of the medication.

Daily BP monitoring at nearby “ Klinik kesihatan” as well as

urine dipstick test.

Treatment on discharge : Tab. Nefidipine 10 mg

TDS for 1 week; Tab. Penicillin 500 mg BD for 5 days; Tab

prednisolone 40 mg ( 20 mg- morning ; 20 mg-night)

ESBACH ALBUMINOMETER