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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 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 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%) 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 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: ________________________________