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URINE CULTURE AND SENSITIVE (3/12/2011) Result : show contaminated mixed growth
WBC 3 cell/ uL
RBC 0
Epithelial Cell 0
Crystal 0
Cast 0
Dsymorphic RBC 0
Other 0
Positive > 3/uL
Borderline 2-3/uL
No 0-1/uL
URINE PROTEIN CREATININE RATIO
(6/12/2011)
Protein Creatinine Ratio 830 ( <200 )
Creatinine ( urine ) 4882 umol/ L ( 2470 -19200)
Urine protein 4.05 g/L ( < 0.150 )
URINE BIOCHEMISTRY ( 5/12/2011)
Criteria 4/12/2011
(0032H)
4/12/2011 (0829H) 5/12/2011
pH 7.0 (4.8-7.4) 7.0 8.0
Specific Gravity(SG) 1.023 1.017 1.015
Leucocyte (pus cell) Negative 1+ Negative
Nitrate Negative Negative Negative
Urine Protein 4+ 4 + 4+
Urine Glucose Normal Normal Normal
Ketone Negative Negative Negative
Urobilinogen Normal Normal Normal
Bilirubin Negative Negative Negative
RBC Negative Negative Negative
HEAMATOLOGY ( PT/APTT )
PROTHROMBIN TIME
PT test 10.9 sec ( 9.1-12.1)
PT control 10.6 sec
PR 1.03
INR 1.03
APTT
APTT Test 35.6 sec ( 21.4-36.8)
APTT control 29.3 sec
APTT ratio 1.22
NEPHROTIC CHART
Date Daily Urine Total
BP Weight Albumin ESBACH Input Output
3/12/2011 - - - Set at 6 420 600
4/12/2011 140/86 64 kg ++ 3 gm 1300 1450
5/12/2011 120/86 64 kg ++ 3 gm 1060 1600
6/12/2011 133/74 63 kg ++ - - -
Full Blood Count ( 3/12/2011 )
Results Normal values
Hb 136 g/L 120-150
T.R.B.C 4.86 x 1012/L 3.8- 4.8
HCT 40.4 % 36- 46
MCV 83 fL 83- 101
MCH 28 pg 27- 32
MCHC 33.6 g/dL 31.5- 34.5
RDW-CV 14.2 % 11.6- 14
Platelets 254 x109/L 150- 410
TWBC 7.4 x109/L 4-10
Results Normal values
Lymphocytes 0.7x103/uL 1- 3
Neutrophils 6.6 x103/uL 2- 7
Monocytes 0.1 x103/uL 0.2- 1
Eosinophils 0.0x103/uL 0- 0.5
Basophils 0.0 x 103/uL 0- 0.1
Lymphocytes 9.8 % 20- 40
Neutrophils 88.3 % 40- 80
Monocytes 1.4 % 2- 10
Eosinophils 0.3 % 1- 6
Basophils 0.2 % < 1- 2
LIVER PROFILE (3/12/2011)
Total bilirubin 2.2 micromol/L <17.1
Total protein 50 g/L 64-83
Albumin (Blood) 25 g/L 38-54
Globulin 25 g/ L 23-45
Alkaline phosphatase 99 u/L <300
Alanine transaminase (SGPT) 9 u/L <41
BUSE/CREA( 3/12/2011)
Results Normal values
Urea 3.4 mmol/L 1.7- 8.3
Sodium 139 mmol/L 136- 145
Potassium 3.8 mmol/L 3.5- 5.1
Chloride 106 mmol/L 98- 107
Creatinine 38 umol/L 5- 52
Results Normal values
CRP 1.7 mg/L <2.8
C- REACTIVE PROTEIN (3/12/2011)
DAY 1 : (3/12/2011)
Impression :
Relapse Nephrotic syndrome
TRO Urinary tract infection
TRO Deep vein thrombosis of Left Leg
TREAMENT PLAN
Monitor BP and Pulse rate 4 hourly
Strict input / output chart
Start nephrotic chart
Trace old note and paediatric card
KIV for induction with Tab. Prednisolone
60mg/m2/day.
KIV for USG doppler of left leg
Trace and review all blood investigation
KIV start Tab. Penicillin 500mg BD
Encourage orally
CHILD’S PROGRESSION
Child is comfortable , present of facial
puffiness, pink and moist tougue.
Bilateral pedal oedema up to mid-shin level
Left lower limb – able to move left limb without much
pain, mild tenderness of the right side , slight
swollen of the left calf.
Cardiovascular system
Respiratory system Normal
Gastrointestinal system
( 2245 H )
BP raised – 160/100 mmHg.
Child did not have headache, vomiting, blurring of
vision.
Monitor BP manually
Investigate for steroid Toxicity.
Unlikely to be urinary tract infection.
DAY 2 – 4/12/2011
Child is comfortable, ambulate well, leg pain
resolve, facial swelling had reduced, no
headache, no nause and vomiting, no abdominal
pain, no chest pain.
On examination: child is active, alert and conscious.
Not tachypnoiec, hydration-good.
CRT <2 sec. Temperature-37 ̊c
BP-127/77mmHg. RR-28 breath/min
Minimal bilateral leg swelling.
Lungs – clear
Abdomen soft and non tender
1100 H
Urinary tract infection symptoms resolved
BP ( 162/93 mmHg )
Left calf – not tender, not erythematous, no localize
raised in temperature, dorsalis pedis palpable.
TREAMENT PLAN Tab prednisolone 80 mg OD ( 40 mg –morning +
40 mg-night ) until remission.
Follow by Tab. Prednisolone 55mg daily for 4 weeks.
Repeat BP hourly till stable.
KIV antihypertensive if BP persistently high.
Find out expected BP range.
Eye assessment – steroid toxicity
Strict I/O chart
Trace Urine protein creatinine ratio
Penicillin 500 mg OD
Continue nephrotic charting.
Expected range : systolic : 119 – 123 mmHg
diastolic: 77-81 mmHg
At 1730 H – BP range is
Systolic 154-108 mmHg
Diastolic 90-102 mmHg
Plan : Tab . Nifedipine 5 mg stat.
BP monitoring.
At 2145 H , BP – 146/87 mmHg. Child is active, alert ,
conscious and comfortable. Not tachypnoiec ,
tachycardic. Improve facial puffiness. No other acute
complains
Plan- Tab. Nefidipine 10mg BD 0.2 mg/kg/dose
DAY 3 ( 5/12/2011)
BP range : systolic 115-125 mmHg
diastolic 88-104 mmHg
According mother, child complaint of headache. No
nausea, vomiting, blurring of vision.
On examination respitaroty rate, pulse rate and
temperature are within the normal range.
Cardiovascular system
Respiratory system Normal
Abdomen
Repeated BP – 147/95 mmHg.
Glucometer stat – 7.8 mmol/L ( at 1545 H )
Treatment plan –-Tab. Nefidipine 10mg BD 0.2 mg/kg/dose
-Tab prednisolone 80 mg OD ( 40 mg –morning +
40 mg-night )
-Penicillin 500 mg OD
-Trace urine protein creatinine ratio.
DAY 4 (6/12/2011)
On examination:
Child is well, comfortable,
no headache,abdominal pain / discomfort.
no nausea and vomiting
Reduced pedal oedema
Tolerating oral well
Loss 1 kg ( 63 kg )
Vitals are stable ( temperature – 37 ̊̊ C; pulse rate 80
bpm; respiratory rate 20 breath per minute. )
BP range : systolic 127-134 mmHg
diastolic 74-81 mmHg
Planning for discharge after review by pediatric specialist
Educate child’s mother regarding the importance and
compliance of the medication.
Daily BP monitoring at nearby “ Klinik kesihatan” as well as
urine dipstick test.
Treatment on discharge : Tab. Nefidipine 10 mg
TDS for 1 week; Tab. Penicillin 500 mg BD for 5 days; Tab
prednisolone 40 mg ( 20 mg- morning ; 20 mg-night)
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