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CASE DISCUSSION

CASE DISCUSSION. RIVERA, JOANNA GRACE ASMPH BATCH 2013. OBJECTIVES. At the end of this case presentation, we should be able to do the following: Discuss a case of acute post-streptococcal glomerulonephritis Understand the natural course of APSGN

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CASE DISCUSSION

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  1. CASE DISCUSSION RIVERA, JOANNA GRACE ASMPH BATCH 2013

  2. OBJECTIVES • At the end of this case presentation, we should be able to do the following: • Discuss a case of acute post-streptococcal glomerulonephritis • Understand the natural course of APSGN • Understand the pathophysiology, diagnosis and management of APSGN

  3. GENERAL INFORMATION • JAL • Female • 2 4/12 years old • Filipino • Roman Catholic • Novaliches, Quezon City • Informant: Mother • Reliability: 90%

  4. CHIEF COMPLAINT Difficulty of Breathing (five days duration)

  5. HISTORY OF PRESENT ILLNESS Three weeks PTA • Erythematous, pruritic pustules on the lower extremities, trunk and some on the face • No associated fever, cough and colds • No medications taken • No consult

  6. HISTORY OF PRESENT ILLNESS • Edema • Periorbital area and on the lower extremities • Abdominal distention • No other associated symptoms Two weeks PTA

  7. HISTORY OF PRESENT ILLNESS • Productive cough – had difficulty of expectorating • Slight difficulty of breathing • No associated colds and fever Five days PTA

  8. HISTORY OF PRESENT ILLNESS • Sought consult in health center • Bronchopneumonia • Amoxicillin 7.5 ml every 8 hours • Salbutamol 4 ml every 8 hours Five days PTA

  9. HISTORY OF PRESENT ILLNESS • Decrease in the amount of urine • With associated tea-colored urine One day PTA DAY OF ADMISSION

  10. Review of Systems • General: (-) changes in weight, (-) sweats, (+) weakness, (-) fatigue • Skin: (-) itchiness, (-) color changes, (-) pigmentation, (+) rashes, (-) photosensitivity, changes in hairs and nails • Eye: (-) blurring of vision, (-) redness, (-) itchiness, (-) pain, (-) increased lacrimation

  11. Review of Systems • Ear: (-) deafness, tinnitus, discharge • Nose: (-) epistaxis, discharge, obstruction, postnasal drip • Mouth and throat: (-) bleeding gums, sores, fissures, tongue abnormalities, dental caries, • (-)sore throat, lump sensation • Pulmonary: (-) hemoptysis

  12. Review of Systems • Cardiac: (-) easy fatigability, orthopnea, nocturnal dyspnea, syncope, edema • GI: (-) retching, hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food intolerance, flatulence, (-)abdominal pain, (-) diarrhea, (-) vomiting, constipation, anal lesion

  13. Review of Systems • GU: (-) urinary frequency, urgency, hesitancy, nocturia • Musculoskeletal: (-) joint stiffness, pain, swelling, cramps, muscle pain, weakness, wasting • Endocrine: (-) heat-cold intolerance, polyuria, polydipsia

  14. Review of Systems • Hematopoietic: (-) abnormal bleeding, (-) bruising • Neurologic: (-) headache, seizure, mental status changes, head trauma

  15. PAST MEDICAL HISTORY • Denies previous history of recurrent throat infections • No other illnesses • No previous hospitalizations/surgeries • No known allergies to food and medications

  16. BIRTH AND MATERNAL HISTORY • Born full term via NSD to a 36 year old G6P6 in a lying in clinic attended by midwife • BW: 2.6 kg • Denies any perinatal or neonatal complications

  17. IMMUNIZATION HISTORY • EPI • BCG (1 dose) • DPT/OPV (3 doses) • Hep B (3 doses) • Measles (1 dose)

  18. NUTRITIONAL HISTORY • 24 hour : • Breakfast: 3 pandesals with half glass of chocolate milk (sometimes with egg) • Lunch: 1 cup rice with soup and vegetables (squash) • Dinner: 1 cup rice, soup and chicken • Loves eating chocolates, candies and junk foods • Can finish 2 glasses of softdrinks/day

  19. NUTRITIONAL HISTORY • Breastfed until 2 months • Formula fed with Nestogen (3 ounces/bottle) • Weaning age: 6 months (Cerelac); 9 months (rice)

  20. Developmental History FINE MOTOR 9 months: holds bottle 1 year and 3 months: can drink from cup 2 years old: can imitate a circle GROSS MOTOR 8 months: sits with support 10 months: stands with support 1o months: walks with support 15 months: walks well alone 2 years: runs well, can climb up and down stairs 2: jumps LANGUAGE 9 months: can speak mama and papa 1 and ½ year: can indicate needs; can speak three-word sentences 2 years old: can point to parts of the body and can follow directions LANGUAGE 2 years:can remove garment; toilet trained; uses spoon

  21. FAMILY HISTORY • Paternal • Hypertension (Father and grandfather) • Maternal • Asthma (grandmother) • TB (uncle)

  22. GENOGRAM Jeepney driver Housewife 38 37 10 1 4/12 15 12 6 3 2

  23. PERSONAL-SOCIAL HISTORY • Lives in a one-storey two-bedroom bungalow house. • Two older sisters are living in the province with their grandmother • Water source: Nawasa (most often, not boiled) • Garbage collected once a week • House is near factory of buttons and a cellular site.

  24. PHYSICAL EXAMINATION

  25. PHYSICAL EXAMINATION GENERAL APPEARANCE Alert, irritable, weak-looking, in respiratory distress VITAL SIGNS BP: 100/70 RR: 48O2 Sat (room air): 89% HR: 150 Temp: 36.7 ANTHROPOMETRICS: Height: 82 cm (-2) Weight: 11 kg (-2 to 0) BMI: 16.4 (0-1) Weight for Height: 0-1 HC: 46 cm (-1) CC: 53 cm AC: 51 cm

  26. PHYSICAL EXAMINATION SKIN dry but warm skin, good skin color and turgor, multiple macular and patches (1cm in greatest diameter), with some crusting on both lower extremities

  27. PHYSICAL EXAMINATION HEENT no lesions or matting of the eyelids, no eye discharge, periorbital swelling, anicteric sclerae, pale palpebral conjunctiva, facial swelling No tragal tenderness, no ear discharge, intact TM (+) alar flaring, nasal septum midline, with minimal nasal discharge dry lips, moist tongue, no buccal mucosal lesions, no TPC no masses in the neck, (-) CLAD, flat neck veins

  28. PHYSICAL EXAMINATION CHEST (+) Intercostal and subcostal retractions, symmetric chest expansion, crackles and wheezes on both lung fields HEART adynamic precordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, tachycardic, regular rhythm, good S1 and S2 sounds, (-) murmurs ABDOMEN globular, slightly distended, normoactive bowel sounds, no organomegaly, no tenderness

  29. PHYSICAL EXAMINATION EXTREMITIES full and equal pulses, Grade 2 bipedal edema, no atrophy/hypertrophy, no deformities GENITALIA Grossly female, no genital discharge, no lesions, no erythema NEUROLOGIC EXAMINATION Intact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus

  30. SALIENT FEATURES SUBJECTIVE OBJECTIVE • 2/F • history of skin infection • Difficulty of breathing with associated cough and fever, unrelieved by medications • Acute onset • decreased urine output • Edema • Tea-colored urine • Cardiorespiratory distress • Tachycardia, tachypnea • Alar flaring • Retractions • Crackles and wheezes • Periorbital and facial edema, • abdominal distention • Grade 2 bipedal edema

  31. PRIMARY WORKING IMPRESSION

  32. Differential Diagnosis • PCAP • IgA Nephropathy (Berger nephropathy)

  33. Management in the ER • NPO temporarily • IVF: D5LR 500 cc to run at 65cc/hr • O2 supplementation at 2LPM via nasal cannula • Diagnostic Test • CBC with APC • Therapeutics: • Ampicillin 275 mg/IV every 6 hours • Salbutamol nebulizaton every 15 minutes x 3 doses then every 2 hours

  34. Initial Laboratory Results

  35. 1st Hospital Day S/O> awake, irritable, still in respiratory distress tachypneic, afebrile facial and periorbitaledema (+) alar flaring, (+) retractions, SCE, (+) crackles and wheezes, both lung fields grade 2 bipedal edema A> Pneumonia, t/c Acute Post-Streptococcal Glomerulonephritis

  36. 1st Hospital Day P> Referred to PIDS, Nephro, Cardiology Repeat CBC, Urinalysis, ASO, C3, Blood CS, serum electrolytes, BUN, Crea, TPAG KUB ultrasound CKMB and 2D echo Shift antibiotics to Penicillin G 500,000 U IV every 6 hours Furosemide 10 mg/IV every 6 hours Famotidine 5 mg IV every 12 hours Maintain O2 at 10 LPM every 6 hours

  37. Laboratory Results

  38. CXR: pulmonary congestion • 2D Echo: Cardiomyopathy, mitral regurgitation, mild, pericardial effusion posterior (0.55-0.60 cm) • ABG: metabolic acidosis

  39. 2nd Hospital Day • S> Still with cough and difficulty breathing, tea- colored urine • O> Wt: 10 kg (from 11 kg), AC: 48 cm tachypneic, tachycardic decrease facial and periorbitaledema (-) alar flaring, (+) subcostal retractions, (+) crackles and wheezes slightly distended, NABS, soft abdomen decrease bipedal edema

  40. ASO: 200 IU/mL • UO: 3.5 mL/kg/hr • Repeat serum electrolytes • Na: 145 • K: 3.9 • Cl: 105 • Ca: 2.07

  41. 2nd Hospital Day A> APSGN, pulmonary congestion with associated bronchopneumonia P> Continue medications Fluid limit to 250 cc/day Start Low salt diet Start KCL syrup 10 mL TID

  42. 3rd Hospital Day S> (+) minimal cough, some episodes of DOB Dark-colored urine O> awake, not in respiratory distress normal vital signs Decreased facial and periorbitaledema (-) alar flaring, (+) slight subcostal retractions, (+) bibasal crackles AC: 46 cm, non-tender abdomen decreased edema

  43. Blood CS: no growth after 24 hours incubation • UO: 2.1 mg/kg/hr

  44. 3rd Hospital Day • A> APSGN, pulmonary congestion, resolving Bronchopneumonia • P> Same

  45. 4th Hospital day • S/O> Patient transferred to regular room Awake, ambulatory, not in respiratory distress Stable vital signs No periorbital or facial edemia SCE, crackles AC: 46 cm Labs: C3: 0.02 g/L (low) U/O: 3.2 mg/kg/hr

  46. A> Post-infectious glomerulonephritis, resolving • P> Decrease Furosemide to 20 mg/tab ½ tab every 12 hours Still for KUB-UTZ Discontinue fluid limit intake

  47. 5th Hospital Day • S> occasional cough with colds, lighter colored urine • O> awake, ambulatory, not in respiratory distress No facial or periorbitaledema (-) alar flaring, SCE, clear breath sounds (-) abdominal distention, (-) edema • A> APSGN, resolving; bronchopneumonia • P> May go home Take home medications: Co-Amoxiclav 250 mg/62 mg/5mL, 3mL every 8 hours for 10 days Furosemide 20 m/tablet, ½ tablet once daily for 3 days

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