Mahmuda, a 2.5 year old girl, presented with swelling of the body for 15 days, decreased urine output, and red urine for 9 days. On examination, she had puffy face and swelling of the body. Tests found protein in the urine and low albumin levels. She was diagnosed with initial nephrotic syndrome and a urine infection. She received antibiotics, albumin infusion, diuretics to reduce swelling, and prednisolone for 6 weeks followed by a gradual taper, with calcium and vitamin supplements. Her parents were counseled and she will follow up every 2 weeks then monthly to monitor her response and for any side effects or infections.

1. WELCOME
TO
CLINICAL MEETING
on
Nephrotic Syndrome

2. Particulars of Patient
Name - Mahmuda
Age - 2 years 6 months
Sex - Female
Address - Mirzapur, Tangail
Date of Admission - 03. 03. 20
Date of Examination - 03. 03. 20
Informant - Mother

3. Presenting Complaints
1. Swelling of the whole body for 15 days.
2. Scanty Micturation for 15 days.
3. Passage of red colour urine for 9 days.

4. History of Present Illness
According to the statement of mother, her child was reasonably well
15 days back. Then she developed swelling of whole body which first
appeared on face and gradually became generalized and associated
with scanty micturation which gradually decrease in volume &
frequency for same duration. Pt’s mother also complained of passage
of red coloured urine which was uniformly red throughout the period
of urination. With these complaints he was admitted into Dhaka Shishu
Hospital for further evaluation and better management.

5. History of Past Illness
There was no significant past illness.
Treatment History
Pt’s wasn’t on any drugs till admission.

6. Birth history
Delivered by LUCS at term without any complication.
Feeding history
She is on Family diet.
Developmental history
Age appropriate.

7. Immunization History
Immunized as per EPI schedule.
Family History
2nd issue of non consanguineous parents. No family history of
such type of illness.
Socioeconomic History
Belongs to lower middle class family.

8. General Examination
Appearance - Puffy face
Anaemia : Mildly Anaemic (+)
Cyanosis
Jaundice Absent
Clubbing
Koilonychia
Leuconychia

9. General Examination Cont..
Oedema - Present
Dehydration- Absent
Lymph nodes- Not palpable
Bed side urine albumin : (+++)

10. General examination Cont..
Vital Signs:
Temperature: 980F
Heart rate: 96/min
Respiratory rate: 32/min
Blood pressure: 110/70 mm of Hg (50th centile)
BCG Mark: Present.
Other Skin Survey: Normal.

11. Anthropometry
Weight: 12 Kg
Height: ?? cm
Weight for Age: On 50th Centile
Height For Age: 0n 50th centile
BSA : 0.60m²

12. SYSTEMIC EXAMINATION

13. Alimentary & Genitourinary System Examination:
Inspection:
Abdomen is distended.
Flanks are full.
Umbilicus: Centrally placed, everted.
No visible pulsation or scar mark.

14. ALIMENTARY & GENITOURINARY SYSTEM contd.
Palpation :
Abdomen non tender.
Liver: Not palpable.
Spleen: Not palpable.
Kidneys: Not ballotable.
Renal angle: Non tender.
Fluid thrill: Absent.

15. ALIMENTARY & GENITOURINARY SYSTEM contd.
Percussion:
Shifting dullness : Present.
Auscultation:
Bowel sound: Present.
Genitalia : ??Normal.

16. Respiratory System Examination:
Inspection:
Respiratory rate: 32/min
No chest indrawing
Shape of the chest : Normal
Chest movement : Bilaterally Symmetrical

17. Respiratory system examination cont:
Palpation:
Trachea is centrally placed
Apex beat : felt over left 4th ICS medial to the midclavicular line
Symmetry of chest:
Chest expansion : Normal
Vocal fremitus :

18. Respiratory system examination cont:
Percussion:
Percussion note: Resonant along the mid-clavicular, mid-
axillary & scapular line.
Auscultation:
Breath sound is vesicular, no added sound
Vocal resonance is normal

19. Other System Examination:
Other systemic examinations including Cardiovascular system
revealed normal findings.

20. Salient features:
Mahmuda, 2 years 6 months old immunized young girl presented
with swelling of whole body started from face and scanty
micturation which was gradually diminished in volume &
frequency for 15 days with passage of red coloured urine for 9
days. She had no significant past illness. She was mildly pale,
normotensive having puffy face with anasarca. Bed side urine
albumin was 3+ & ascites was present. Her Respiratory and other
system revealed no abnormality.

21. Provisional diagnosis:
Initial attack of Nephrotic Syndrome with UTI.

22. Investigations:
• Urine R/M/E: (on admission)
Color: Redish.
Appearance: Hazy .
Albumin: +++.
RBC: Plennty.
Pus cell: 6-8/HPF.
• Urine C/S- No growth
• Blood C/S - No growth

23. Investigations: Cont..
• S. albumin: 11.2 gm/L
• S. Creatinine: 40.0 µmol/L
• S. Electrolytes:
Na+: 138.0 mmol/L.
K+: 4.15 mmol/L.
Cl-: 104.0 mmol/L

24. Investigations (cont…)
S. Calcium: ?? mmol/L
CBC:
Hb%: 10.8 gm/dl.
TC: 11,200/ cumm.
(N- 66%, L-33%, M-02%, E-02%)
Platelet : 3,28000/cumm.

25. Investigations:
• USG of W/A:
Bilateral renal parenchymal disease
Mild Ascites
Bilateral mild Pleural effusion

26. Final Diagnosis:
Initial attack of Nephrotic Syndrome with UTI.

27. • Counseling of the parents.
• General supportive measure :
Nutritional advice : Normal balanced diet with adequate protein
(2-2.5 gm/kg/day)
Vitamin & Mineral supplementation: Calcium supplementation
Treatment:

28. Treatment cont…
• Control of edema:
Salt restriction
Infusion of 20% albumin (0.5-1.0g/kg) with Inj. frusemide
• Prevention of infection :
Inj. Ceftriaxone 100mg/kg/day daily in two divided dose for 5 days
Inj. Amikacin 20mg/kg/day daily in two divided dose for 4 days
• Others:
Omeprazole Sachet 1 pack mixed with ½ glass of water once daily Before Meal
Tab. Folic Acid 5 mg once daily

29. Specific treatment :
Syp. Prednisolone 24 mg (2mg/kg/day ) in single morning dose for 6
weeks,
Followed by
1. Syp. Prednisolone 18 mg (1.5 mg/kg/day) in single morning dose
on every alternative day with gradual tapering over 3 months
2. Tab. Calcium 500 mg ???

30. Follow up:
In hospital:
Record of vital signs: Pulse , BP, temperature
Weight
Edema
Abdominal girth
Intake-Output
BSUA

31. After discharge :
2 weekly follow up, then monthly follow up to note
 Response to drug
Toxicity of drug
Any infection

32. Thank you all