Download EVALUATION SHEET

EVALUATION SHEET
CASE 13: Edema and PSGN
Resident’s Name: _______________________
Year Level: __________
CASE
J.M., a 8-year-old female from Dasmariñas, Cavite who was admitted for the first time at
PGH due to edema.
HISTORY OF PRESENT ILLNESS: Three weeks PTA, patient had fever, cough, and
colds. She was given paracemtamol and carbocisteine which afforded temporary relief.
Three days PTA, the patient was noted to have facial edema and abdominal distention.
Patient complained of decreased urine output. Mother also noted tea-colored urine.
She was brought to a private MD for consult, diagnosis was unknown to the mother and
was given with unrecalled medications. There was no improvement of symptoms.
Persistence of edema prompted consult at PGH.
PHYSICAL EXAMINATION:
GENERAL: The patient was conscious, irritable, coherent, not in cardiopulmonary
distress.
VITAL SIGNS: HR 90/minute, RR 24/minute, weight 49 kg, height 152 cm, BSA 1.4
HEENT: Anicteric sclerae, slightly pale conjunctiva, with periorbital and facial edema
CHEST/LUNGS: Symmetrical chest expansion, harsh breath sounds
HEART: regular cardiac rate and rhythm, no murmur.
ABDOMEN: NABS, soft, no organomegaly, tenderness, or masses.
EXTREMITIES: Full pulses with grade II bipedal edema
Q1: Given the above information, what other historical data would you like to ask?
A. Diagnosis (70%)
General History (30%)
YES NO
Red
Comment
Flag
Yes
Previous Streptococcal Infection: Throat? Skin? the latent period is usually 10 to 14 days after
pharyngitis or 2 to 3 weeks after pyoderma.
(6%)
Yes
First episode of hematuria?
(6%)
Yes
Temporal pattern of appearance and progression of
edema?
(3%)
Yes
Family history of renal disease?
(6%)
Blood pressure on consult?
(3%)
Review of systems?
(6%)
 Headache
 Vomiting
 Blurring of vision
 Seizures
 Symptoms of cardiac causes: Chest pain,
orthopnea, nocturnal cough, paroxysmal
nocturnal dyspnea

Symptoms of liver causes: jaundice, melena/
hematochezia, pruritus, acholic stools
Nutritional history

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This is the patient’s first episode of hematuria
o Short latent period, recurrent episode of hematuria ( IgA nephropathy).
Edema noted mostly on waking up, mother noticed edema occurred suddenly
o Edema in GN is sudden usually more pronounced in the morning, while slow and
progressive in Nephrotic syndrome.
Family history – Hereditary nephritis, Alport syndrome – NOT PRESENT
Review of systems – occasional headache and vomiting the past few days, no blurring
of vision, no seizures, no orthopnea or paroxysmal nocturnal dyspnea, no jaundice or
acholic stools
Eats mostly fried foods
Q2: What parts of the physical examination would be pertinent in this case? What else
would you like to know regarding the physical examination?
Physical Examination (20%)
YES NO
Red
Comment
Flag
Yes
Anthropometrics/Vital Signs
Yes
Blood Pressure
General nutritional status
Yes
Periorbital and facial edema
Neck vein engorgement
Jaundice
Yes
Presence of skin lesions
Yes
Presence of pharyngitis
Dental carries
Otitis media
Pallor
Yes
Chest findings – crackles (3%)
Yes
Heart - rate and rhythm (rule out myocarditis, heart
failure)
Yes
Abdomen – check for ascites, masses, tenderness,
hepatomegaly
(3%)
Yes
Extremities - check for pallor, edema
(3%)
Additional physical examination
 Vital signs BP 140/90
 Fairly nourished child
 HEENT – no neck vein engorgement, multiple dental caries, no ear discharge
 Chest – minimal crackles bilateral lung fields
 Heart – adynamic precordium, no S3 gallop
 Abdomen – no hepatomegaly, flabby soft abdomen, no fluid wave
 Extremities – bipedal pitting edema, multiple wound lesions on bilateral
extremities, pink nail beds
Q3: What are your differential diagnosiGiven the additional information, what is your
diagnosis and differential diagnosis if any? Give the basis.
Diagnosis and Differentials (10%)
YES NO
Red
Comment
Flag
Yes
Post-infectious GN
(3%)
Yes
IgA nephropathy
(3%)
Lupus nephritis
(2%)
HSP nephritis
(2%)
Heart failure
Liver disease
Malnutrition



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Post-infectious Glomerulonephritis – edema more prominent on the face,
oliguria, hematuria, azotemia and hypertension, latent period of 1-2 weeks from
infection
IgA nephropathy – recurrent episodes of hematuria usually 1-2 days after a viral
respiratory or gastrointestinal infection/ synpharyngitic
Henoch-Schonlein purpura nephritis – appears within 3 months of onset of
palpable rash, joint pains and gastrointestinal complaints
Lupus nephritis – hematuria, proteinuria, hypertension with extra-renal
manifestations such as arthritis, malar rash, mucosal ulcers, alopecia, serositis,
hematologic , etc.
Heart failure – edema in cardiac disease is more prominent in the dependent
extremities and progresses upwar, no symptoms of failure such as PND, easy
fatigability, orthopnea. Normal PE of the heart with
Liver failure – noevidence of bleeding, no jaundice, no hepatomegaly, no
palmar erythema, ascites, visible ab veins
Q4: Given the above data, what initial diagnostic test would you request for?
Diagnostics (10%)
YES NO
Red
Comment
Flag
Yes
Urinalysis with RBC morphology
(2%)
Yes
ASO
(2%)
Yes
C3 level
(2%)
Electrolytes, BUN, crea
(1%)
CBC/PC
(1%)
CXR
(1%)
KUB-UTZ
(1%)
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Urinalysis with rbc morphology – to document proteinuria and hematuria and
determine the origin of bleeding
Dysmorphic rbcs with red blood cell casts – Glomerular origin
Normal rbc morphology – Non-glomerular origin
ASO – nonspecific marker for acute post-streptococcal GN;
- if <200, may be post-infectious
Complement level – decreased in acute postinfectious GN, lupus nephritis,
membranoproliferative GN, shunt nephritis and infective endocarditis
Electrolytes
CBC/PC
CXR – to check for pulmonary congestion and cardiomegaly
KUB-UTZ – not routinely done in most patients with acute post-infectious GN
Laboratory Examination showed:
Urinalysis: yellow, hazy, sp gr 1.010, ph 6.5, sugar (-), protein 2+, rbc innumerable, wbc 35 hpf,
cast negative, crystal negative, epithelial cells rare, bacteria rare, mucus threads negative, 47%
dysmorphic rbc 53 % normal rbc
ASO: >200 < 400 Iu/L
C3: 23.1 mg/dl (52.6-120 mg/dl)
Electrolytes: Na 136 mmol/L (140-148 mmol/L)
K 3.7 mmol/L (3.6-5.2 mmol/L)
Alb 26 g/L (34-50 g/L)
Phosphorus 1.65 mmol/L (0.81-1.58 mmol/L)
BUN 8.43 mmol/L (2.60-6.40 mmol/L)
Creatinine 90 mmol/L (53-115 umol/L)
CBC/PC: Hgb 100
Hct 0.24
Plt 388
Seg 0.80
Lym 0.18
CXR: infiltrates inner lung zones vs congestive changes considered
KUB UTZ: Kidneys are enlarged with increase in partenchymal echogenicity and fair
corticomedullary differentiation. The right kidney measures 13.2 cm x 6.6 cm x 4.6 cm. The left
kidney measures 14.4 cm x 7.3 cm x 8.7 cm. The central echo complexes are intact. No lithiasis
seen. Bilateral enlarged kidneys.
Q5: What is your present working impression?
Post-infectious Glomeulonephritis
Basis: History of previous upper tract infection 3 weeks ago , sudden onset of edema,
oliguria and tea-colored urine
PE: hypertension, facial and periorbital edema, and bipedal edema
Labs: microscopic hematuria with dysmorphism, hypocomplementemia
Q6: How will you manage this patient?
B. Management (20%)
YES
Fluid restriction
(10%)
Anti-hypertensive
Diuretics (Furosemide) and Nifedipine
(8%)
Antibiotics
(2%)
NO
Red
Flag
Yes
Yes
Comment
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Fluid restriction – most essential supportive therapy, oral fluid intake limited to
insensible water loss (400-500 cc/m2/day)
Furosemide – initial anti-hypertensive to be given due to volume overload
Nifedipine – rescue medication for blood pressure spikes
Antibiotics – no evidence that penicillin therapy affects the natural course of
PIGN only indicated if there are still signs of streptococcal infection
Q7: What advise will you give the patient and the family?
Patient Education (10%)
YES NO
Strict low salt diet
Fluid restriction
Course and prognosis
Red
Flag
Yes
Yes
Yes
Comment
Strict low salt diet – sodium intake less than 2 grams/ day in the latent period (2
weeks)
Fluid restriction – insensible water loss (400cc/m2/day) + previous urine output (2
weeks)
Patient education – complete recovery is the rule, important to discuss the resolution of
symptoms: gross hematuria nad hypertension 3 weeks, proteinuria 3-6 months, normalization of
c3 level 2-3 months and microscopic hematuria 12 months. Any deviation from the normal
course of the disease warrants a subspecialty referral.
OVERALL EASE and CONFIDENCE in taking the oral examination
1 – No self confidence whatsoever
2 – Showed very little confidence
3 – Showed little confidence
4 – Generally at ease and confident
5 – Impressive confidence
Examiner’s Name and Signature: ________________________________