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Dr. KANTA HALDER Resident (MD;Phase A)

BICH

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.

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.

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.

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.

History of Past illness She had no significant past illness.

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.

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.

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.

Developmental History She is developmentally age appropriate.

General Examination Appearance: Puffy face.Anaemia:Jaundice: Cyanosis:Clubbing: AbsentDehydration:Oedema: ++

Cont..Skin: BCG mark present.Lymphnode: Not palpable.Ear:Nose: NormalThroat:Bedside Urine Albumin: +++

Cont..Vital Signs:

Pulse: 100/min.Respiratory Rate: 32/min.Temperature: 98°F.Blood Pressure: 90/60 mmHg.

Anthropometry:

Cont..

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

Systemic ExaminationAbdomimal Examination: Inspection:

Abdomen is mildly distended.Flanks are full.

Umbilicus is centrally placed with transversely slit.

Cont.. Palpation :

Abdomen is non tender. Liver: Not palpable. Spleen: Not palpable.

Kidneys: Not ballotable. Renal angle: Not tender. Fluid thrill: Absent.

Cont..Percussion: Shifting dullness: present.Auscultation:

Bowel sound: present.Genitalia: Normal.

Cont.. Respiratory system :

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

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.

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.

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.

Provisional Diagnosis

Infrequent relapse Nephrotic syndrome.

Investigations Urine R/M/E:

Color: Straw.Appearance: Clear.Albumin: +.RBC: Nil.Pus cell: 0-2/HPF.

Urine C/S: No growth .

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.

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%

Cont..

o RBC: Normocytic normochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 304,000/mm3.• PBF:

Blood C/S: No growth.

Final Diagnosis Infrequent relapse Nephrotic syndrome

with Bronchopneumonia.

ManagementCounseling 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.

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.

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.

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

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

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