Welcome

Clinical Meeting

Dr. Shubhra Prakash Paul

MD (Ped) Part IIBangladesh Institute of Child Health

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Name JubayerAge 3yearsSex MaleAddress Panchagar

Date of Adm.

10/04/2012

Date of Exam.

12/04/2012

Particulars of the Patient

Presenting Complaints with Duration

Generalized swelling for 15 days

Scanty Micturition for 10 days

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History of Present Illness

According to his mother, Jubayer was quite well 15 days back. Then there developed generalized swelling starting from face. Mother complained also of scanty micturition for last 10 days. There is no history of sore throat or skin infection prior to this illness. There was no chest pain, breathlessness , headache during the courses of illness.

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History of Past Illness

Jubayer suffered from same type of illness i.e. generalized swelling starting from face,10 months back and diagnosed as a case of nephrotic syndrome first attack and treated accordingly in Rangpur Medical College Hospital and subsequently at Dhaka Shishu Hospital with Tab. Cortan and syp. Neotack.

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History of Past Illness

He was completely relieved from 1st attack of Nephrotic syndrome and completed the alternate day steroid for adequate duration. There was no history of breathlessness, chest pain, headache, passage of high color urine through out his illness. He suffered from occasional cough and cold.

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Treatment History

He was treated with optimum dose of Tablet Prednisolone and Syrup Ranitidine for optimal duration.

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Birth HistoryHe was delivered at term at home without any perinatal untoward event. His mother was on irregular antenatal check-up.

Immunization History

He is immunized as per EPI schedule

Feeding HistoryHe was on exclusive breast feeding up to 6 months of age, after that complementary food is introduced and tolerated. Now he is on family diet.

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Developmental Milestones

His mile stone of development is age appropriate

Family historyHe is the third issue of his non-consanguineous parents. Other sibs are healthy. All of his family members are healthy.

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Socioeconomic History

Jubayer belongs to a lower socioeconomic family; father being a farmer and mother housewife.

Housing and Sanitation history

He lives in a kacha house with his family members and drinks tube well water and uses sanitary toilet.

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Physical Examination

General Examination

Appearance Playful but having puffy face and distended abdomen

Built AverageNutrition AverageCo-operation Co-operativePallor ModerateJaundice AbsentCyanosis AbsentClubbing Absent

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Physical Examination contd.

General Examination contd.

Koilonychia AbsentLeuconychia

DehydrationEdema Present (bilateral

pedal) Temperature 990FPulse 98 /min.Resp. rate 24/minBlood Pressure 95/50 mm of HgC

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Physical Examination contd.…..

General Examination contd..

Skin BCG mark present, no skin lesion is present

Sign of meningeal irritation

Absent

Lymphnodes

Accessible nodes are not enlarged

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Physical Examination Contd.

Marked area (arrow) Bilateral pedal edema

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Physical Examination Contd.

Marked area (arrow) indicates Puffy face and Ascites

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Physical Examination contd.

General Examination contd.

HEENT NormalBed side urine albumin

(++++)

Others IV cannula placed on right hand

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Physical Examination contd.

Anthropometry

Height CmWeight 13 Kg

Weight for Age + 2 SDHeight for Age + 0.8 SDWeight for height

SD

Body Surface area

0.71 m2

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Physical Examination Contd.

Per abdominal Examination Inspection

Abdomen is distended, flanks are full, umbilicus is centrally placed and everted with transverse slit. Penis and both scrotum are normal.

Palpation

Abdomen is soft and non tender. There was no organomegaly. Both kidneys are not bimanually ballotable.

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Physical Examination Contd.

Per abdominal Examination Percussion

Percussion note is dull. Shifting dullness present

Auscultation

Bowel sound is present.No hepatic, renal or aortic bruit is detected

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Physical Examination Contd.

Examination of Cardiovascular System

No abnormality detectedExamination of Respiratory System

No abnormality detected

Examination of Alimentary System

No abnormality detected

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Timeline of illnessC

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Regular ANCNo drug, radiation

-----No illness-----

-----------Immunization--------

NVD at term at home No perinatal untoward event

Breast feeding

Complementary feeding

Swelling, Puffiness of faceScanty micturition

6 mo. 3 years

Timeline of illness

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< 7 days >

< 14 days >

< 2 mo. > 07/12/11- 01/01/12

Swelling Tab.

Frulac

SwellingTab.

Deltasone Syp. Gepin and frulac

Swelling persist

Tab. Deltasone Syp. Gepin

Swelling DecreasedTab. Cortan

Syp. Neotack

Panchagar

Rangpur Medical College

Home DSH

3 years

22/03/12

26/03/12

< 15 days > 10/04/12

Dose of Steroid completed

Swelling Reappear

ed

Swelling, puffinessScanty micturition

Admission

Home Home Home DSH

3 years

Timeline of illness

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Salient FeaturesJubayer , 3 years old boy, 3rd issue of his non-consanguineous parents from Panchagar was admitted with the complains of generalized oedema for 15 days and scanty micturition for 10 days. He suffered from nephrotic syndrome 1st attack 10 months back and was treated accordingly with prednisolone at optimal dose and duration. There was no history of skin infection or sore throat prior to this illness. There is no history of chest pain, breathlessness, headache, hypertension or passage of high colour urine. C

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Salient FeaturesOn examination Jubayer was found playful, oedematous, moderately pale. Vital signs are found within normal limit i.e. HR- Resp. Rate- Temp. 0F and blood pressure mm of Hg. Skin survey revealed presence of BCG mark and absence of any skin lesion. There is no lymphadenopathy. Bed side urine protein was 4+. Systemic examination revealed presence of ascites without hepatosplenomegaly. Examination of respiratory , cardiovascular and other system revealed no abnormality.C

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Provisional Diagnosis

Nephrotic Syndrome (1st relapse) most probably Minimal change disease

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Differential Diagnosis

Nephrotic syndrome other than minimal change disease

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Laboratory Investigations1. Urine routine and microscopic examination (10/04/12)

Appearance

Color Straw

Albumin +++

Microscopy

Pus cell 1 - 2/HPF

RBCs Nil

Epithelial cells 1 - 2 /HPF

Spot protein creatinine ratio

3.5

II. Urine culture (10/04/12)

No growthCas

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Laboratory Investigations

II. Biochemical Parameters (on 11/02/2012)

Serum Creatinine 33.2 µmol/L

Blood urea 2.2 mmol/L

Serum Albumin 7.5 gm/dL

Serum electrolytes

SodiumPotassiumChloride

138.9 mmol/L 3.3 mmol/L 101.8 mmol/L

SGPT 38 IU/L

Serum calcium 1.79 mmol/L

C- Reactive Protein (CRP)

3.7 mg/L

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Laboratory Investigations

III. Complete Haemogram (10/04/12)

Hemoglobin 10.1 gm/dL

ESR 125 mm in 1st hour

Total WBC Count 16,400 /cumm

Differential count of WBC

Neutrophil 60 %

Lymphocytes 35%

Monocytes 02 %

Eosinophil 03 %

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Final Diagnosis

Nephrotic Syndrome (1st relapse)

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Management

A. General Supportive• Normal diet• Daily monitoring of Blood pressure,

Weight, Bedside urine albumin, recording of intake and output, abdominal girth. B. Specific

• Tab. Prednisolone 60 mg/m2/day for 4 - 6 weeks followed by 40 mg/m2 every alternate day for 4 – 6 weeks.

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C. Counseling

Thank you