Dr. Shubhra Prakash PaulMD (Ped) Part IIBangladesh Institute of Child Health
Particulars of the Patient Name JubayerMedical Case History Age 3years Sex Male Address Panchagar Date of Adm. 10/04/2012 Date of 12/04/2012 Exam.
Presenting Complaints with Duration Generalized swelling for 15 daysCase History Scanty Micturition for 10 days
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 micturitionCase History 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.
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 treatedCase History accordingly in Rangpur Medical College Hospital and subsequently at Dhaka Shishu Hospital with Tab. Cortan and syp. Neotack.
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,Case History chest pain, headache, passage of high color urine through out his illness. He suffered from occasional cough and cold.
Treatment History He was treated with optimum dose of Tablet Prednisolone and Syrup Ranitidine for optimal duration. Birth HistoryCase History He 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 HistoryCase History He 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.
Developmental Milestones His mile stone of development is age appropriate Family historyCase History He is the third issue of his non- consanguineous parents. Other sibs are healthy. All of his family members are healthy.
Socioeconomic History Jubayer belongs to a lower socioeconomic family; father being a farmer and mother housewife. Housing and Sanitation historyCase History He lives in a kacha house with his family members and drinks tube well water and uses sanitary toilet.
Physical Examination General Examination Appearance Playful but having puffy face and distended abdomen Built Average Nutrition AverageCase History Co-operation Co-operative Pallor Moderate Jaundice Absent Cyanosis Absent Clubbing Absent
Physical Examination contd. General Examination contd. Koilonychia Leuconychia Absent Dehydration Edema Present (bilateral pedal)Case History Temperature 990F Pulse 98 /min. Resp. rate 24/min Blood Pressure 95/50 mm of Hg
Physical Examination contd.….. General Examination contd.. Skin BCG mark present, no skin lesion is present Sign of Absent meningealCase History irritation Lymphnode Accessible nodes are not s enlarged
Physical Examination Contd.Case History Marked area (arrow) Bilateral pedal edema
Physical Examination Contd.Case History Marked area (arrow) indicates Puffy face and Ascites
Physical Examination contd. General Examination contd. HEENT Normal Bed side urine (++++) albumin Others IV cannula placed onCase History right hand
Physical Examination contd. Anthropometry Height Cm Weight 13 Kg Weight for Age + 2 SDCase History Height for Age + 0.8 SD Weight for SD height Body Surface 0.71 m2 area
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. PalpationCase History Abdomen is soft and non tender. There was no organomegaly. Both kidneys are not bimanually ballotable.
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 detectedCase History
Physical Examination Contd. Examination of Cardiovascular System No abnormality detected Examination of Respiratory SystemCase History No abnormality detected Examination of Alimentary System No abnormality detected
Timeline of illness Regular ANC -----No illness---- No drug, - radiation -----------Immunization-------- NVD at term at home Complementary Breast feeding Swelling, Puffiness of face untoward event Scanty micturitionCase History feeding No perinatal 6 mo. 3 years
Timeline of illness < 7 days > < 14 days > < 2 mo. > 07/12/11- 01/01/12 Swelling Swelling Swelling Swelling Tab. Frulac Tab. persist Decreased Deltasone Tab. Deltasone Tab. Cortan Syp. Gepin Syp. Gepin Syp. Neotack and frulacCase History Panchagar Rangpur Home DSH Medical College 3 years
Timeline of illness 22/03/12 26/03/12 < 15 days > 10/04/12 Dose of Swelling Swelling, Admission Steroid Reappear puffiness complete ed Scanty d micturitionCase History Home Home Home DSH 3 years
Salient Features Jubayer , 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 doseCase History 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.
Salient Features On 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 noCase History 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.
Differential Diagnosis Nephrotic syndrome other than minimalCase History change disease
Laboratory Investigations 1. Urine routine and microscopic examination (10/04/12) Appearance Color Straw Albumin +++ Microscopy Pus cell 1 - 2/HPFCase History RBCs Nil Epithelial cells 1 - 2 /HPF Spot protein creatinine ratio 3.5 II. Urine culture (10/04/12) No growth
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 Sodium 138.9 mmol/L Potassium 3.3 mmol/LCase History Chloride 101.8 mmol/L SGPT 38 IU/L Serum calcium 1.79 mmol/L C- Reactive Protein (CRP) 3.7 mg/L
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 %Case History Lymphocytes 35% Monocytes 02 % Eosinophil 03 %
Final Diagnosis Nephrotic Syndrome (1stCase History relapse)
Management A. General Supportive • Normal diet • Daily monitoring of Blood pressure, Weight, Bedside urine albumin, recording of intake and output, abdominal girth. B. SpecificCase History • Tab. Prednisolone 60 mg/m2/day for 4 - 6 weeks followed by 40 mg/m2 every alternate day for 4 – 6 weeks.