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MB: the power puff girl

MB: the power puff girl. TMC: Department of Pediatrics. Identifying Information. Name: MB Age: 5 Gender: Female Nationality: Filipino Religion: Roman Catholic Status: Child Admitted: November 11, 2013 Information: ME (Patient’s Mother) with 70% Reliability. Chief Complaint.

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MB: the power puff girl

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  1. MB: the power puff girl TMC: Department of Pediatrics

  2. Identifying Information Name: MB Age: 5 Gender: Female Nationality: Filipino Religion: Roman Catholic Status: Child Admitted: November 11, 2013 Information: ME (Patient’s Mother) with 70% Reliability

  3. Chief Complaint “NamamagayungMukha” Facial swelling of 2 Days Duration

  4. History of Present Illness 2 Weeks PTC • Patient developed intermittent fever (Tmax 38°C) • Treated with Ibuprofen (Advil) 100mg/5ml at 5.88mg/kg/dose • Associated with the following symptoms: • Colds • Productive cough with yellowish phlegm • Moderate, intermittent, non-radiating RLQ pain • No consultations sought

  5. History of Present Illness 1 Week PTC • Patient afebrile • Developed loose, watery stools (3 episodes) • Non-foul smelling, non-mucoid, non-bloody • ½ cup per episode • No associated vomiting, headache, fatigue or weakness • Sought consult at OspitalngMaynila • Observation • Sent home with Oral Rehydration Solution

  6. History of Present Illness 4 Days PTC • Onset of facial swelling, decreased urine output and easy fatigability • Patient brought to Evangelista Clinic • CBC and Urinalysis were done Primary Impression: Post-infectious Glomerulonephritis ADVISED TRANSFER

  7. History of Present Illness 4 Days PTC • Onset of facial swelling, decreased urine output and easy fatigability • Patient brought to Evangelista Clinic • CBC and Urinalysis were done Primary Impression: Post-infectious Glomerulonephritis ADVISED TRANSFER

  8. History of Present Illness 1 Day PTC • Observed tea-colored urine • Brought patient to JRRMMC • Noted to by hypertensive at 130/90 • Had laboratory tests done: CBC, UA, C3, ASO titers and Electrolytes • Not retrieved by patient’s relative • Transferred to OsMak for further management and evaluation, hence consult and subsequent admission

  9. Review of Systems • General:(+) weight gain, (-) fever, (+) fatigue • Integument: (-) rashes • HEENT: • Head. (-) head injury, (-) tenderness, (-) changes in hair, (-) hair loss • Eyes. (-) blurring of vision, (-) diplopia, (-) spots or floaters, (-) loss of vision, (-) eye pain, (-) eye discharge, (-) conjunctival dryness, (-) excessive tearing • Ears. (-) tinnitus, (-) ear discharge, (-) ear pain • Nose. (-) colds, (-) sinusitis, (-) loss of smell, (-) epistaxis • Mouth. (-) mouth sores, (-) teeth problems, (-) tongue lesion, (-) tonsillar inflammation • Throat. (-) dysphagia, (-) sore throat

  10. Review of Systems • Respiratory: (-) shortness of breath • Cardiovascular:(-) chest pains, (-) palpitations • GI: (-) vomiting, (-) diarrhea, (-) constipation, (-) changes in eating habits, (-) pain or changes in defecation • GU:(-) dysuria • Hematopoietic: (-) anemia, (-) easy bleeding • Endocrine: (-) cold or heat intolerance, (-) excessive sweating, (-) increased thirst • Nervous: (-) memory impairment • Psychiatric: (-) changes in mood, (-) suicidal thoughts

  11. Past Medical History Previous Conditions Previous Hospitalizations, Surgeries or Procedures • None • None Asthma and Allergies • No known allergies or asthma

  12. Family History • Filipino descent, Makati City • Hypertension (maternal grandfather) • Bronchial Asthma (maternal grandmother, maternal uncles and younger sibling) • Household Members: • Paternal Grandmother • Paternal Aunts and Uncles • Parents • Younger sister • Genogram

  13. Birth/Maternal History • Birth: • Born full-term via NSD to an 18-year old G1P1 (1001) with a birth weight of 6lbs, unrecalled birth length • APGAR 9,9 • Maternal: • 6 prenatal check-ups at Dona Mapa Lying-In Clinic starting at 4 months AOG • 1 Ultrasound done at 4 months AOG • Took Ferrous Sulfate • UTI at 6 months AOG • treated with Amoxicillin 500mg OD for 4 days (no repeat UA) • Perinatal Complications: • Thickly meconium-stained

  14. Nutritional History • Breastfeeding Period: 0-1 week • Milk Formula: Bona until 6 months (1:1), Bonamil until 8 months (1:2), Alaska until 2yo (1:4) • Complementary Feeding: cereals and vegetables (7mo), meat and fish (1yo) • Food Restrictions: low-salt foods • 24-hour Diet Recall: • Breakfast: rice and fried chicken • Snacks: Hansel biscuit and bananas • Lunch and Dinner: rice and hotdog

  15. Child History Immunization History Developmental History • 1 dose of BCG • 3 doses of DPT and OPV • 3 doses of Hepatitis B • 1 dose of Measles • Sitting alone at 6 months, walks alone at 11 months • “Mama” at 7 months • Scribbling at 2 yo • Social Smile at 2 months, Stranger anxiety at 6 months

  16. Personal, Social and Environmental History Personal and Social History Environmental History • Patient is a Grade I student • Average performance • Likes dancing and singing • Dwelling: 1-floor wooden shanty with 2 windows • 12 inhabitants • Electricity: Meralco • Drinking Water Source: Maynilad Water Services • Waste Disposal: daily, not segregated • Exposure to tobacco smoke from both parents

  17. Stakeholder Analysis

  18. Physical Examination Vital Signs HR. 89bpm RR. 23bpm T. 36°C BP. 120/80 (p>95%) Anthropometrics Height. 102cm (p>-2) Weight. 17kg (p>-2) BMI. 16.3 (p>0) For a 5-year old female, systolic range is 107-113 and the diastolic range is from 69-73.

  19. Physical Examination • General: awake, alert, cooperative, not in cardiorespiratory distress • HEENT: • Head. Normocephalic head, closed sutures and fontanelle • Eyes. Symmetric eyes, no masses, lesions or discharge, (+) facial edema, (+) periorbital edema, anictericsclerae, pink palpebral conjunctivae, (+) ROR • Ears. Symmetric ears, patent canal, intact TM • Nose. Midline nasal septum, patent nares, (+) dried mucus at nasal opening • Mouth. Moist lips and buccal mucosa, non-hyperemic tonsils and pharynx • Neck. (+) submandibularlymphadenopathy, left

  20. Physical Examination • Respiratory: symmetric chest expansion, resonant in all lung fields, clear breath sounds • Cardiovascular:adynamicprecordium, normal rate, regular rhythm, no murmurs, heaves or thrills • Abdominal : round abdomen, no scars or lesions, umbilicus midline, NABS, tympanitic in all 4 quadrants, nontender, liver span 6cm • GU: grossly female • Extremities: • Upper: 5/5 motor, 100% sensory • Lower: 5/5 motor, 100% sensory • Integumentary: normal skin color, no cyanosis or pallor

  21. Salient Features History Physical Examination • 5-year old female • History of intermittent fever with productive cough and colds and RLQ pain • History of loose watery stools • 4 day history of facial swelling, decreased urine output and easy fatigability • 1 day history of tea-colored urine • Family history of HTN and BA • Born full-term and thickly-meconium stained via NSD to an 18yo G1P1 (1001) • Good nutrition and appetite, though on low salt and fluid diet • Exposed to tobacco smoke at home • Awake, alert, not in CR distress • Appropriate height and weight for age • Hypertensive (greater than 95th percentile) • (+) submandibularlymphadenopathy, left • Facial and periorbital edema • Dried mucous at the nasal opening

  22. Recommended Diagnostics • Complete evaluation of patient’s history and PE • Laboratory • Urinalysis • Electrolyte Levels • CBC • Serum Chemistries (e.g. BUN, Creatinine) • ASO Titers • Complement Levels • Imaging • Chest Radiograph (Plain) • Procedural • Renal Biopsy Indications for Renal Biopsy Persistently low C3 beyond 8 weeks Persistent heavy proteinuria after 6 months Atypical presentation (e.g. nephrotic syndrome, severe acute renal failure) Atypical course – failure of renal function to improve

  23. Primary Impression Acute Glomerulonephritis An inflammatory process affecting the glomerulus with infiltration and proliferation of acute immunologically-mediated inflammatory cells

  24. Differential Diagnoses

  25. Differential Diagnoses Primary Renal Diseases that manifest as Acute Glomerulonephritis

  26. Discussion Anatomy of the Kidney Etiology Pathophysiology Clinical Manifestations Therapeutic and Supportive Plan Prognosis

  27. Anatomy of the Kidney Kidney • Bean-shaped retroperitoneal organ • Measurements: 11-14cm in length, 6cm wide, 4cm thick • Supplied by the left and right renal arteries (receives 20% output); innervated by the renal plexus • Functions: • Filtration, reabsorption, and secretion; excretion of wastes; maintains body homeostasis; regulates acid-base balance, electrolyte concentrations, extracellular fluid volume; regulated blood pressure; produces endocrine hormones

  28. Kidney Anatomy Renal Pyramid Interlobular Artery Renal Artery Renal Vein Renal Hilum Renal Pelvis Ureter Minor Calyx Renal Capsule Inferior Renal Capsule Superior Renal Capsule Interlobular Vein Nephron Minor Calyx Major Calyx Renal Papilla Renal Column

  29. Etiology • Infectious (Bacteria, Parasite, Virus, Fungus) • Most commonly Streptococcus species, particularly serotypes 12 and 49

  30. Etiology • Non-Infectious

  31. Pathophysiology • Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes • Kidneys may be enlarged up to 50% • Histopathologic changes include mesangial proliferation and PMN infiltration • Immunofluourescence reveals a patter of “lumpy-bumpy” deposits of immunoglobulin and complement on the glomerular BM and mesangium

  32. Pathophysiology Structural Changes Functional Changes • Cellular proliferation  increased number of glomerular tufts • Proliferation may be endocapillary or extracapillary • Extracapillary proliferation leads to cresent formation • GBM thickening • Hyalinization/Sclerosis • Proteinuria • Hematuria • GFR reduction • Active urine sediment with RBCs and casts

  33. Pathophysiology Glomerulus appears enlarged and relatively bloodless and shows mesangial proliferation and exudation of neutrophils.

  34. Pathophysiology Electron micrograph show electron-dense deposits (D) on the epithelial cell (Ep) side of the glomerular basement membrane. A polymorphonuclear leukocyte (P) is present within the lumen (L) of the capillary. (BS) Bowman’s Space (M) Mesangium

  35. Clinical Manifestations • Common in children aged 5-12yo • Patient develops an acute nephritic syndrome 1-2 weeks after an antecedent pharyngitis, 0r 3-6 weeks after pyoderma. • Severity of kidney involvement varies from asymptomatic to acute renal failure • Edema, hypertension and oliguria • Risk for developing encephalopahty, heart failure, pulmonary edema • Nonspecific symptoms • Malaise, lethargy, abdominal or flank pain • Nephrotic syndrome develops in <5% of cases

  36. Symptom Timeline Acute phase generally resolves within 6-8 weeks.

  37. Therapeutic and Supportive Plan For this patient, the most important form of treatment is supportive since there is no specific treatment for Renal Disease

  38. Therapeutic and Supportive Plan Pharmacology Diuretics may be able to reduce congestive symptoms Antibiotics may be used to control local symptoms and prevent the spread of infection to close contacts This does not prevent the development of AGN

  39. Therapeutic and Supportive Plan Diet and Activity Sodium and Fluid Restriction Sodium: <2g/day Fluid (400ml/m2/day) Bed Rest is recommended until signs of glomerular inflammation and circulatory congestion subside Continuous Monitoring and Follow-Up

  40. Prognosis • 95% of cases follow a course ending in complete patient recovery • Mortality in the Pediatric Age Group: 0-7% • Other causes of AGN have outcomes varying from complete recovery to complete renal failure • Complications include renal failure, congestive conditions and hypersensitive encephalopathy

  41. Prevention • Hygiene • Early detection to prevent complications • Continuous monitoring to prevent chronic sequelae

  42. THANK YOU! Sources: Kliegmanet al. 2011. Nelson Textbook of Pediatrics, 19th Ed. Elsevier Saunders. p. 1785-1789. Parmar MS. 2013. Acute Glomerulonephritis. http://emedicine.medscape.com/article/239278-overview. Accessed on March 08, 2013.

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