This document summarizes a medical case report for a 3 year 8 month old female patient presenting with proteinuria, oliguria, facial puffiness, and cough for several days. She has a history of similar episodes treated previously with oral prednisolone. On examination, she is found to be edematous with a puffy face and highly positive urine albumin. Labs show normal kidney function and electrolytes. A diagnosis of infrequent relapse nephrotic syndrome with bronchopneumonia is made. Treatment includes a tapering course of oral prednisolone and antibiotics, with close monitoring during admission and follow up visits.

1. Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

2. Particulars of the patient
 Name: Sumaiya.
 Age: 3 year 8 months.
 Sex: Female.
 Address: Nogorpur, Tangail.
 Date of Admission: 06.03.2016.
 Date of Examination: 08.03.2016.

3. Chief Complaints
 White precipitation of urine on boiling
for 3 days.
 Scanty micturition for same duration.
 Facial puffiness for same duration.
 Cough for 10 days.

4. History of present illness
According to the statement of grandmother,
Sumaiya developed white precipitation of
urine on boiling for 3 days. She also developed
scanty micturition along with facial puffiness
for same duration. She had dry cough for
about 10 days. She had no history of reddish
urine, burning sensation during micturition,
headache or abdominal pain.

5. Cont..
She had H/O same type of attack for 2 times in
last 8 months. First attack was on her 3 years
of age and first relapse was 2 months prior to
this episode. She was admitted in hospital for
2 times and was treated with oral
prednisolone with adequate dose and duration
followed by complete remission. Each time
swelling appeared after 1-2 months of
completion of steroid treatment.

6. History of Past illness
She had no significant past illness.

7. Treatment History
She was admitted in hospital for 2 times and
each episode she was treated with oral
prednisolone with adequate dose and duration.
During last attack, after remission she was
advised for oral prednisolone at every alternate
day for 4 weeks.

8. Birth History
She was delivered normally at term without
any complication.
Feeding History
She is on family diet.
Immunization History
She is immunized as per EPI schedule.

9. Familly History
She is the only issue of her non-
consanguineous parents. Her other family
members are healthy.
Socio-economic History
She comes from a low socio-economic
background. She lives in a tin-shed house,
drinks tube-well water and uses sanitary
latrine.

10. Developmental History
She is developmentally age appropriate.

11. General Examination
Appearance: Puffy face.
Anaemia:
Jaundice:
Cyanosis:
Clubbing: Absent
Dehydration:
Oedema: ++

12. Cont..
Skin: BCG mark present.
Lymphnode: Not palpable.
Ear:
Nose: Normal
Throat:
Bedside Urine Albumin: +++

13. Cont..
Vital Signs:
Pulse: 100/min.
Respiratory Rate: 32/min.
Temperature: 98°F.
Blood Pressure: 90/60 mmHg.

14. Anthropometry:
Cont..
Weight: 12 kg.
Height: 89 cm.
HAZ: -2.4 SD (moderately stunted).
WHZ: -0.75 SD (normal).
BSA: 0.54 m2.

15. Systemic Examination
Abdomimal Examination:
Inspection:
Abdomen is mildly distended.
Flanks are full.
Umbilicus is centrally placed with
transversely slit.

16. Cont..
Palpation :
Abdomen is non tender.
Liver: Not palpable.
Spleen: Not palpable.
Kidneys: Not ballotable.
Renal angle: Not tender.
Fluid thrill: Absent.

17. Cont..
Percussion:
Shifting dullness: present.
Auscultation:
Bowel sound: present.
Genitalia:
Normal.

18. Cont..
Respiratory system :
Inspection :
Respiratory rate: 32/min.
Shape of the chest is normal.
Movement is bilaterally symmetrical.
No chest indrawing.

19. Cont..
Palpation :
Trachea is centrally placed.
Apex beat is in left 4th ICS medial to the
midclavicular line.
Chest expansion : Normal.
Vocal fremitus is normal in mid clavicular, mid
axillary & post. scapular line.

20. Cont..
Percussion:
Percussion note is resonant in MCL, MAL &
PSL in both lung field.
Auscultation:
Breath sound is vesicular and vocal resonance
is normal in MCL, MAL & PSL in both lungs.
There is no added sound.
Other Systemic examination: No abnormality.

21. Salient feature
Sumaiya, 3 years 8 months old immunized
girl presented with proteinuria, oliguria and
facial puffiness for 3 days and cough for 10
days. She had H/O same type of attack for 2
times in last 8 months and treated with oral
Prednisolone with adequate dose and
duration. She is oedematous, having puffy
face, bed side urine albumin was +++. There is
ascites without organomegaly. Her vitals are
within normal limit.

22. Provisional Diagnosis
Infrequent relapse Nephrotic syndrome.

23. Investigations
 Urine R/M/E:
Color: Straw.
Appearance: Clear.
Albumin: +.
RBC: Nil.
Pus cell: 0-2/HPF.
Urine C/S: No growth .

24. Cont..
 S. Creatinine: 35.2 µmol/l.
 S. Electrolytes:
Na+: 143.0 mmol/L.
K+: 4.4 mmol/L.
Cl-: 108.0 mmol/L.
 S. Albumin: 11.8 mmol/L
 CRP: 0.6 mg/L.

25. Cont..
Complete Blood Count :
• Hb: 12.9 gm/dl.
• WBC: Total count: 17,600/mm3.
Differential count:
o Neutrophil: 55%
o Lymphocyte: 40%
o Monocyte: 03%
o Eosinophil: 02%
o Basophil: 00%

26. Cont..
o RBC: Normocytic normochromic.
o WBC: Mature with above
distribution.
o Platelet: Adequate.
• Platelet: 304,000/mm3.
• PBF:
Blood C/S: No growth.

28. Final Diagnosis
Infrequent relapse Nephrotic syndrome
with Bronchopneumonia.

29. Management
Counseling to the parents.
 General treatment:
• Normal balance diet with adequate protein
(2-2.5 gm/kg/day).
• Calcium & Vit-D supplementation: 1 tab once
daily.
• H2 blocker: Syp. Ranitidine ½ tsf 12 hourly.

30. Cont..
Control of edema:
No added salt.
Fresh Frozen plasma transfusion.
 Treatment of Pneumonia:
Inj. Ampicillin 500 mg 12 hourly.
Inj. Gantamicin 30 mg 12 hourly.

31. Cont..
Specific treatment :
Tab. Prednisolone 25mg (2mg/kg/day ) in
single morning dose until urinary protein
become nil for 3 consecutive days.
Followed by
Tab.Prednisolone 20 mg (1.5 mg/kg/day) in
single morning dose on every alternative day
for 4 weeks.

32. Follow up
In hospital:
Record of vital signs: Pulse, BP, temperature.
Weight.
Edema.
Abdominal girth.
Intake-Output.
Bed Side Urine Albumin.

33. Cont..
After discharge:
2 weekly follow up -
 Response to drug.
Toxicity of drug.
Any infection.

34. THANK YOU