mb: the power puff girl tmc: department of pediatrics
TRANSCRIPT
MB: THE POWER PUFF GIRL
TMC: Department of Pediatrics
Name: MBAge: 5Gender: FemaleNationality: FilipinoReligion: Roman CatholicStatus: ChildAdmitted: November 11, 2013Information: ME (Patient’s Mother) with 70% Reliability
Identifying Information
“Namamaga yung Mukha”Facial swelling of 2 Days Duration
Chief Complaint
History of Present Illness
Patient developed intermittent fever (Tmax 38°C) Treated with Ibuprofen (Advil)
100mg/5ml at 5.88mg/kg/dose Associated with the following
symptoms: Colds Productive cough with yellowish
phlegm Moderate, intermittent, non-radiating
RLQ pain No consultations sought
2 Weeks PTC
History of Present Illness
Patient afebrile Developed loose, watery stools (3
episodes) Non-foul smelling, non-mucoid, non-
bloody ½ cup per episode
No associated vomiting, headache, fatigue or weakness Sought consult at Ospital ng Maynila
Observation Sent home with Oral Rehydration
Solution
1 Week PTC
History of Present Illness
Onset of facial swelling, decreased urine output and easy fatigability
Patient brought to Evangelista Clinic CBC and Urinalysis were done
4 Days PTC
Parameters
Result Normal Value
Hemoglobin
10.0 12.0-16.0g/dL
Hematocrit 0.28 0.37-0.47
RBC 3.64 4.0-5.4x1012/L
WBC 12.6 5.0-10x109/L
Platelet 450 150-450x109/L
Neutrophils 0.34 0.45-0.65
Lymphocytes
0.51 0.25-0.40
Primary Impression:Post-infectious Glomerulonephritis
ADVISED TRANSFER
History of Present Illness
Onset of facial swelling, decreased urine output and easy fatigability
Patient brought to Evangelista Clinic CBC and Urinalysis were done
Parameters
Result
Color Amber
Transparency
Turbid
pH 5.0
Spec. Grav.
1.015
Protein (++)
Sugar (-)
Parameters
Result
Pus Cells 3-5/hpf
RBC TMTC
Epithelials Few
Urates Moderate
Bacteria Moderate
Primary Impression:Post-infectious Glomerulonephritis
ADVISED TRANSFER
4 Days PTC
History of Present Illness
Observed tea-colored urine Brought patient to JRRMMC
Noted to by hypertensive at 130/90
Had laboratory tests done: CBC, UA, C3, ASO titers and Electrolytes Not retrieved by patient’s relative
Transferred to OsMak for further management and evaluation, hence consult and subsequent admission
1 Day PTC
Review of Systems
General: (+) weight gain, (-) fever, (+) fatigue Integument: (-) rashes HEENT:
Head. (-) head injury, (-) tenderness, (-) changes in hair, (-) hair loss
Eyes. (-) blurring of vision, (-) diplopia, (-) spots or floaters, (-) loss of vision, (-) eye pain, (-) eye discharge, (-) conjunctival dryness, (-) excessive tearing
Ears. (-) tinnitus, (-) ear discharge, (-) ear pain Nose. (-) colds, (-) sinusitis, (-) loss of smell, (-) epistaxis Mouth. (-) mouth sores, (-) teeth problems, (-) tongue
lesion, (-) tonsillar inflammation Throat. (-) dysphagia, (-) sore throat
Review of Systems
Respiratory: (-) shortness of breath Cardiovascular: (-) chest pains, (-) palpitations GI: (-) vomiting, (-) diarrhea, (-) constipation, (-)
changes in eating habits, (-) pain or changes in defecation
GU: (-) dysuria Hematopoietic: (-) anemia, (-) easy bleeding Endocrine: (-) cold or heat intolerance, (-) excessive
sweating, (-) increased thirst Nervous: (-) memory impairment Psychiatric: (-) changes in mood, (-) suicidal
thoughts
Past Medical History
None None
Previous Conditions Previous Hospitalizations, Surgeries or Procedures
Asthma and Allergies
No known allergies or asthma
Family History
Filipino descent, Makati City
Hypertension (maternal grandfather)
Bronchial Asthma (maternal grandmother, maternal uncles and younger sibling)
Household Members: Paternal Grandmother Paternal Aunts and Uncles Parents Younger sister
Genogram
Birth/Maternal History
Birth: Born full-term via NSD to an 18-year old G1P1 (1001) with
a birth weight of 6lbs, unrecalled birth length APGAR 9,9
Maternal: 6 prenatal check-ups at Dona Mapa Lying-In Clinic starting
at 4 months AOG 1 Ultrasound done at 4 months AOG Took Ferrous Sulfate UTI at 6 months AOG
treated with Amoxicillin 500mg OD for 4 days (no repeat UA) Perinatal Complications:
Thickly meconium-stained
Nutritional History
Breastfeeding Period: 0-1 week Milk Formula: Bona until 6 months (1:1),
Bonamil until 8 months (1:2), Alaska until 2yo (1:4)
Complementary Feeding: cereals and vegetables (7mo), meat and fish (1yo)
Food Restrictions: low-salt foods 24-hour Diet Recall:
Breakfast: rice and fried chicken Snacks: Hansel biscuit and bananas Lunch and Dinner: rice and hotdog
Child History
1 dose of BCG 3 doses of DPT
and OPV 3 doses of
Hepatitis B 1 dose of Measles
Sitting alone at 6 months, walks alone at 11 months
“Mama” at 7 months Scribbling at 2 yo Social Smile at 2
months, Stranger anxiety at 6 months
Immunization History Developmental History
Personal, Social and Environmental History
Patient is a Grade I student Average
performance Likes dancing and
singing
Dwelling: 1-floor wooden shanty with 2 windows
12 inhabitants Electricity: Meralco Drinking Water Source:
Maynilad Water Services Waste Disposal: daily,
not segregated Exposure to tobacco
smoke from both parents
Personal and Social History
Environmental History
Stakeholder Analysis
Name Role Stand on
Issue
Intensity of
Stand
Action
MB’s Mother Primary Caregiver
High High Provides care for the patient
MB’s Father Breadwinner
High High Provides financial support for the patient’s health
plans
MB’s Paternal Grandmother
Secondary Caregiver
High Medium Provides care for the patient when the
primary caregiver is not available
MB’s Sibling Dependent Medium Medium Provides social support and camaraderie
Vital SignsHR. 89bpmRR. 23bpmT. 36°CBP. 120/80 (p>95%)
Physical Examination
AnthropometricsHeight. 102cm (p>-2)Weight. 17kg (p>-2)BMI. 16.3 (p>0)
For a 5-year old female, systolic range is 107-113 and the diastolic range is from 69-73.
Physical Examination
General: awake, alert, cooperative, not in cardiorespiratory distress
HEENT: Head. Normocephalic head, closed sutures and fontanelle Eyes. Symmetric eyes, no masses, lesions or discharge,
(+) facial edema, (+) periorbital edema, anicteric sclerae, pink palpebral conjunctivae, (+) ROR
Ears. Symmetric ears, patent canal, intact TM Nose. Midline nasal septum, patent nares, (+) dried
mucus at nasal opening Mouth. Moist lips and buccal mucosa, non-hyperemic
tonsils and pharynx Neck. (+) submandibular lymphadenopathy, left
Physical Examination
Respiratory: symmetric chest expansion, resonant in all lung fields, clear breath sounds
Cardiovascular: adynamic precordium, normal rate, regular rhythm, no murmurs, heaves or thrills
Abdominal : round abdomen, no scars or lesions, umbilicus midline, NABS, tympanitic in all 4 quadrants, nontender, liver span 6cm
GU: grossly female Extremities:
Upper: 5/5 motor, 100% sensory Lower: 5/5 motor, 100% sensory
Integumentary: normal skin color, no cyanosis or pallor
Salient Features
5-year old female History of intermittent fever with
productive cough and colds and RLQ pain
History of loose watery stools 4 day history of facial swelling,
decreased urine output and easy fatigability
1 day history of tea-colored urine Family history of HTN and BA Born full-term and thickly-
meconium stained via NSD to an 18yo G1P1 (1001)
Good nutrition and appetite, though on low salt and fluid diet
Exposed to tobacco smoke at home
Awake, alert, not in CR distress
Appropriate height and weight for age
Hypertensive (greater than 95th percentile)
(+) submandibular lymphadenopathy, left
Facial and periorbital edema Dried mucous at the nasal
opening
History Physical Examination
Recommended Diagnostics
Complete evaluation of patient’s history and PE Laboratory
Urinalysis Electrolyte Levels CBC Serum Chemistries (e.g. BUN, Creatinine) ASO Titers Complement Levels
Imaging Chest Radiograph (Plain)
Procedural Renal Biopsy
Indications for Renal BiopsyPersistently low C3 beyond 8 weeksPersistent heavy proteinuria after 6 monthsAtypical presentation (e.g. nephrotic syndrome, severe acute renal failure)Atypical course – failure of renal function to improve
Acute Glomerulonephritis
An inflammatory process affecting the glomerulus with infiltration and proliferation of acute immunologically-mediated inflammatory cells
Primary Impression
Diff
ere
ntia
l D
iag
nose
s
Differential Diagnoses
Primary Renal Diseases that manifest as Acute Glomerulonephritis
Anatomy of the KidneyEtiologyPathophysiologyClinical ManifestationsTherapeutic and Supportive PlanPrognosis
Discussion
Anatomy of the Kidney
Bean-shaped retroperitoneal organ
Measurements: 11-14cm in length, 6cm wide, 4cm thick
Supplied by the left and right renal arteries (receives 20% output); innervated by the renal plexus
Kidney
Functions: Filtration, reabsorption, and secretion; excretion of wastes; maintains body
homeostasis; regulates acid-base balance, electrolyte concentrations, extracellular fluid volume; regulated blood pressure; produces endocrine hormones
Kidney Anatomy
1. Renal Pyramid2. Interlobular
Artery3. Renal Artery4. Renal Vein5. Renal Hilum6. Renal Pelvis7. Ureter8. Minor Calyx9. Renal Capsule10. Inferior Renal
Capsule11. Superior Renal
Capsule12. Interlobular
Vein13. Nephron14. Minor Calyx15. Major Calyx16. Renal Papilla17. Renal Column
Etiology
Infectious (Bacteria, Parasite, Virus, Fungus) Most commonly Streptococcus species,
particularly serotypes 12 and 49Bacteria Virus Parasite Fungus
StreptococciDiplococci
MycobacteriaActinobacilliSalmonella
typhosaBrucella siuisTreponema
pallidumCorynebacteriu
m bovis
Cytomegalovirus
Epstein-Barr Vius
Hepattis BRubella
RicketsiaeMumps
Plasmodium malariae
Plasmodium falciparum
Schistosoma mansoni
Toxoplasma gondii
FilariasisTrichinosis
Trypanosomes
Coccidioides immitis
Etiology
Non-Infectious
Primary Renal Disease
Systemic Disease Miscellaneous
Membranoproliferative GN
Berger DiseasePure Mesangial Proliferative GN
Idiopathic Rapidly Progressive GN
VasculitisHypersensitivity
VasculitisCollagen-Vascular
DiseasesCryoglobulinemia
Polyarteritis nodosaHenoch-Schonlein
PurpuraGoodpasture
Syndrome
Guillain-Barre Syndrome
Irradiation of Wilm’s Tumor
DPT VaccineSerum Sickness
Pathophysiology
Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes
Kidneys may be enlarged up to 50% Histopathologic changes include mesangial
proliferation and PMN infiltration Immunofluourescence reveals a patter of
“lumpy-bumpy” deposits of immunoglobulin and complement on the glomerular BM and mesangium
Pathophysiology
Cellular proliferation increased number of glomerular tufts Proliferation may be
endocapillary or extracapillary Extracapillary
proliferation leads to cresent formation
GBM thickening Hyalinization/Sclerosis
Proteinuria Hematuria GFR reduction Active urine
sediment with RBCs and casts
Structural Changes Functional Changes
Pathophysiology
Glomerulus appears enlarged and relatively bloodless and shows mesangial proliferation and exudation of neutrophils.
Pathophysiology
Electron micrograph show electron-dense deposits (D) on the epithelial cell (Ep) side of the glomerular basement membrane. A polymorphonuclear leukocyte (P) is present within the lumen (L) of the capillary.
(BS) Bowman’s Space(M) Mesangium
Clinical Manifestations
Common in children aged 5-12yo Patient develops an acute nephritic syndrome 1-2
weeks after an antecedent pharyngitis, 0r 3-6 weeks after pyoderma.
Severity of kidney involvement varies from asymptomatic to acute renal failure Edema, hypertension and oliguria Risk for developing encephalopahty, heart failure,
pulmonary edema Nonspecific symptoms
Malaise, lethargy, abdominal or flank pain Nephrotic syndrome develops in <5% of cases
Symptom Timeline
Gross Hematuria
Hypertension
Hypocomplementemia (Low C3)
Persistent Proteinuria
Intermittent Proteinuria
Microhematuria
Onset of Symptom
s
2 weeks 4 weeks 2 months
6 months
1 year 2 years
Acute phase generally resolves within 6-8 weeks.
For this patient, the most important form of treatment is supportive since there is no specific treatment for Renal Disease
Therapeutic and Supportive Plan
PharmacologyDiuretics may be able to reduce congestive symptomsAntibiotics may be used to control local symptoms and prevent the spread of infection to close contactsThis does not prevent the development of AGN
Therapeutic and Supportive Plan
Diet and ActivitySodium and Fluid Restriction
Sodium: <2g/dayFluid (400ml/m2/day)
Bed Rest is recommended until signs of glomerular inflammation and circulatory congestion subsideContinuous Monitoring and Follow-Up
Therapeutic and Supportive Plan
Prognosis
95% of cases follow a course ending in complete patient recovery Mortality in the Pediatric Age Group: 0-7%
Other causes of AGN have outcomes varying from complete recovery to complete renal failure
Complications include renal failure, congestive conditions and hypersensitive encephalopathy
Prevention
Hygiene Early detection to prevent complications Continuous monitoring to prevent
chronic sequelae
Sources:Kliegman et al. 2011. Nelson Textbook of Pediatrics, 19th Ed. Elsevier Saunders. p. 1785-1789.Parmar MS. 2013. Acute Glomerulonephritis. http://emedicine.medscape.com/article/239278-overview. Accessed on March 08, 2013.
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