CASE PRESENTATIONIN PEDIATRICS

R. Francisco – J. GarimbaoDr. Balderas

PATIENT HISTORY Identifying data

EMA, an 8-year old, Filipino, Roman Catholic female, from Parang, Marikina

Chief Complaint Fever of 13 days Abdominal pain of 2 days

History of Present Illness– 13 days prior to admission Intermittent low grade fever (undocumented) temporarily relieved by Paracetamol No other symptoms were noted– 10 days prior to admission still with fever productive cough swelling of the face no decrease in activity

6 days prior to admission Red discoloration of urine2 days prior to admission Facial edema disappeared Still with fever, cough, and reddish urine Intermittent peri-umbilical painFew hours prior to admission Peri-umbilical pain worsened as well as

her fever

Past Health Prenatal

Mother is eclampticBirth Born full-term Via normal spontaneous delivery,

phyician assisted at Amang Rodriguez Hospital BW= 4lbs BL and APGAR=unknown

Neonatal History Had pneumonia during 2nd week of life

Immunization History Complete vaccination obtained from the

health center

Feeding History solely breastfed for 1 month introduced to formula at 2 months ( Bona

with 1:1 dilution ratio, Bonakid from six months to 1 year and was then shifted to bear brand)

introduced to solid food at 6 months no allergies to food

Developmental History Unremarkable

Past Illnesses/Hospitlizations No major illness/hospitalization/surgery/

history of allergic reactions prior to the current admission apart from pneumonia during 1st week of life as stated above.

Family History Her grandmother in the paternal side had

aplastic anemia

Social and Environmental History The patient lives in a 1-story house with 1

toilet along with 5 other occupants Water for both drinking and household

purposes are from the faucet.

PHYSICAL EXAMINATION

General Survey Patient is awake, alert, and ambulatory but uncooperative and is not in any cardio-respiratory distress

Vital Signs PR: BP: RR: Temperature:

Anthropometrics: Length: 64in (162.56cm) Weight: 49kg (108.03lbs) BMI: 18.5

Skin pink-pinkish red maculopapular

rash distributed on all his extremities red scar-like lesions on the back warm to touch with normal turgor,

nails pink with no signs of infection, pallor, cyanosis or clubbing

HEENTHead The skull was symmetric, atraumatic with well

distributed black hair no hair loss/infestations. Scalp without any

masses, lesions, signs of trauma and pigmentations.

No facial asymmetry was noted. Face have scars on the nasolabial line with red

non pruritic patches on the cheeks (~0.5-3cm in diameter)

Eyes Eyes are symmetrical, with no

exopthalmos/enophthalmos or edema anicteric sclera and pink conjunctivae both pupils constricting on direct and

indirect pupillary reflex test. VA: OS= J2, OD=J1. Fundoscopy: (+) ROR

Ears Auricles are aligned no gross deformities, lesions,

swelling or masses or discharge

Nose No gross deformities, swelling,

bleeding, lesions, erosions, masses, infections.

Nasal septum at the midline

Mouth Pink, moist lips with no deformities with pustules (~1-2mm) on the

buccal mucosa uvula and tongue at the midline with no tonsillar

redness/enlargement

Neck Trachea midline thyroid is non palpable as well as

lymph nodes

Thorax and Lungs: Chest symmetrical with equal expansion and excursion

and without gross abnormalities or respiratory lag. No intercostal retractions, no use of accessory

respiratory muscles. No lesions, masses on anterior chest but with scars on

the back no tenderness noted equal tactile fremitus. Vesicular breath sounds with no adventitious sounds on

auscultation

Cardiovascular: Adynamic precordium with no

deformities/palpable thrills or bruits. Distinct S1 and S2 heard loudest at the

4th-5th ICS left parasternal border with regular rate and rhythm.

No murmurs or adventitious heart sounds noted

Abdomen It was flat and symmetrical with no

lesions/deformities/discolorations. Normoactive bowel sounds with no

bruits over all quadrants. Quadrants were non-tender and

tympanitic.

Musculoskeletal: There were no gross deformities of

joints and extremities Normal tone and a muscle grade of 5/5

on all muscle groups with full range of motion and no crepitations.

No tenderness on joints and extremities.

MSE the patient is awake, alert, and

cooperative

Cranial Nerves Unremarkable

Reflexes Deep tendon reflexes on biceps,

triceps, knee and ankle have a grade of +2, (-) Babinski reflex

Sensory: pain perception is intact for all extremities

Cerebellar: no babinski; intact

PRIMARY IMPRESSION: ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS

DifferentialsHenoch-Schonlein Purpura Urinary Tract Infection (UTI) Systemic Lupus Erythematosus (SLE)Membranoproliferative Glomerulonephritis (MPGN)

HENOCH-SCHONLEIN PURPURA

Rule in -Renal involvement -Gross Hematuria -Asian prevalence -Occurs mainly in

young children.

Rule out -Typical

anaphylactoid purpura ex: Henoch-Schonlein Purpura.

-Arthritis and/or arthralgia

-No fever -Boys

URINARY TRACT INFECTION (UTI) Rule in -Hematuria -Fever -Female gender

Rule out -No edema -No increased blood

pressure.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Rule in -Increased blood

pressure -Edema -Dark urine -Fever -Female gender -Asian

Rule out -Butterfly skin rash -Arthritis -Most commonly 20-

45 years of age (onset.)

MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS (MPGN)

Rule in -Blood pressure and

GFR affected. -(Some) Acute

nephritis and hematuria.

-Edema

Rule out -Young adults. -Urinary

abnormalities persist past time of expected resolution for acute poststrep. Glomerulonephritis.

ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS

Acute poststreptococcal glomerulonephritis was considered as the primary diagnosis due to: patient develops an acute nephritic

syndrome 1–2 wks after a possible streptococcal pharyngitis ( fever and cough)

Hematuria facial edema

PLAN Diagnostics

CBCASO titerRenal Function Tests

BUN Creatinine Urinalysis

Treatment Treatment is supportive and focuses on

control of hypertension and edema if present.

A loop diuretic (furosemide) should be given in order to remove excess fluid which reduced edema and also helps to correct hypertension.

Antibiotics for streptococcal infection such as penicillin should be given within the first 36 hours from the onset of symptoms