nephrotic syndrome (1).pptx clinical meeting

Nephritic syndrome

1. WELCOME TO CLINICAL MEETING Dr. Minhajul Islam Medical officer Dept of Pediatrics KGH

2. Particulars of the patient Name : Arafat Age : 3 years 3 months Address : Vashantek , Dhaka. DOA : 10/02/25 DOE : 12/02/25

3. Chief complaints Generalized swelling of whole body for 16 days . Scanty micturation for 8 days. Cough for 8days .

4. History of present illness According to the statement of informant mother her child was reasonably well 16 days back. Then he developed swelling of whole body, which first appeared on face then gradually became generalized. Swelling was associated with scanty micturation for last 8 days.

5. History of present illness cont'd Mother also gave history of cough for 8 days, which was non productive with no diurnal variation. On query mother stated that, he had no history of similar type of illness before.

6. History of present illness cont'd He had no history of fever, loose motion, vomiting, abdominal pain, red colored urine, burning sensation of micturition, headache, convulsion, sore throat, skin infection, taking any offending drug, atopy or contact with TB patient. With above complaints he got admitted in KGH for further evaluation and better management .

7. Birth history Mother was on regular ante natal check up, she had no history of fever, rash, DM, HTN during pregnancy. He was delivered by NVD at term at hospital with average birth weight and her post natal period was uneventful.

8. Feeding history He was on Exclusive breast feeding for first 6 months, then complementary feeding was started appropriately along with breast feeding and now he is on family diet.

9. Immunization history Immunized as per EPI schedule

10. Developmental history Developmentally he is age appropriate.

11. Family history He is the second issue of his non consanguineous parents. No history of such type of illness in his family.

12. Socio economic history Father – Service holder Mother- Housewife Lives in kacha-paka house Use sanitary latrine Drinks boiled water

13. Treatment history He was treated with Inj Ceftazidime & Inj Amikacin from 30/01/25 to 04/02/25 then with Inj Ceftriaxone from 05/02/25 to 10/02/25 at Kishoregonj Medical College Hospital . But no improvement occurs.

14. General examination Appearance : Puffy face with periorbital edema Anemia : Absent Jaundice : Absent Cyanosis : Absent Clubbing : Absent Koilonychia : Absent Leukonychia : Absent Edema : Present (generalized)

15. General examination cont'd BCG mark : present Skin survey : Normal Lymhnode : Not palpable No sign of Meningeal irritation ENT : Normal Bed side urine for albumin (BSUA): +++

16. Vital signs Temp : 98 °F Pulse : 114 beats/min R/R : 48 breaths/min Blood pressure : 95/55 mmHg (systolic and diastolic between 50 th -90 th centile)

17. CDC HTN chart Centile Systolic BP Diastolic BP 50th 88 47 90th 102 62 95th 106 66 99th 113 74

18. Anthropometry Weight: 13kg, WAZ: - 2.00 Height: 92cm, HAZ: - 0.32 WHZ: -1.8 BSA: 0.57 m2

19. Gastrointestinal and genitourinary system examination Mouth and oral cavity : Healthy Inspection : Abdomen distended, flanks full. Umbilicus centrally placed, everted with transverse slit. Scrotal swelling present

20. Gastrointestinal and genitourinary system cont'd Palpation: Soft and non tender Liver :Not enlarged Spleen : Not palpable Kidney : Not ballotable Urinary bladder : Not palpable Fluid thrill : Present Renal angle tenderness : Absent

21. Gastrointestinal and genitourinary system cont'd Percussion: Shifting dullness : present. Auscultation: Bowel sound : present Renal bruit : absent

22. Respiratory system Inspection Size and shape of chest : normal Respiratory Rate : 38 breaths/min

23. Respiratory system Palpation: Trachea is centrally placed. Apex beat at left 5 th intercostal space, just medial to mid clavicular line. Chest expansibility symmetrical. Vocal fremitus : normal

24. Respiratory system cont'd Percussion: Resonant Auscultation: Breath sound vesicular , crepitation present on right lung field.

25. Salient feature Arafat , 3 years 3 months old boy ,immunized as per EPI schedule hailing from Vashantek , Dhaka, presented with the complaints of swelling of whole body, which first appeared on face then gradually became generalized for 16 days , scanty micturaion for 8 days. Cough for same duration.

26. Salient feature cont'd He had no history of fever, loose motion, vomiting, high colour urine, abdominal pain, headache and convulsion, sore throat, skin infection, taking any offending drug, atopy or contact with TB patient.

27. Salient feature cont'd On examination, he was conscious, oriented , having puffy face, vitals within normal limit, generalized edema was present and bed side urine albumin (BSUA) +++

28. Salient feature cont'd Abdomen was distended ,flanks full ,umbilicus centrally placed , everted with transverse slit. Ascities present evident by fluid thrill and shifting dullness . On auscultation of chest, crepitation was present on right lung field. Other systemic examination revealed nothing abnormity.

29. Provisional diagnosis Nephrotic syndrome (Initial Attack) with Bronchopneumonia

30. Investigations Complete blood count: Hb% 12 gm/dl White blood cell count : Total count : 11220/ cumm Differential count: Neutrophil : 34% Lymphocyte : 62% Monocyte : 2.5% Eosinophil : 0.8%

31. Investigation cont'd Chest X-Ray

32. Investigation cont'd CRP: 5.7 mg/L Urine R/M/E: Protein + RBC nil Pus cell 2-4/HPF Cast nil Urine C/S with colony count : No growth Blood C/S : No growth

33. Cont'd Serum Electrolyte : Na+: 141 mmol /L K+ : 3.5 mmol /L Cl- : 101 mmol /L Serum Creatinine : 0.4 mg/dl HBsAg : Negative

34. Cont'd Spot urinary protein creatinine ratio : Pending 24 hr UTP: 909mg/24hr S. Cholesterol: 459mg/dl Serum Albumin : 1.8 gm/dl

35. Treatment Counseling the parents about the nature of disease, treatment and prognosis. Normal family diet with adequate in protein(1.5-2 gm/kg/day) low fat and salt free diet. Fluid intake 230ml(400ml/m2)+ previous day output. Maintain intake - output chart and monitor weight ,blood pressure, abdominal girth, BSUA regularly.

36. Treatment Inj Albumin 25% -100ml Iv e inj Frusemide 1mg/kg Inf FFP -10ml/kg e inj frusemide 1mg/kg -3 unit For Scrotal Swelling: Elevation of scrotum with pillow

37. Treatment cont'd To control infection : Ongoing Broad spectrum antibiotic; Inj Meropenem 260mgm 8 hourly daily plus Inj Flucloxacillin 300mg 6 hourly daily. After control of infection , oral Prednisolone 60 mg/m2 single morning dose after meal upto 6 weeks followed by 40mg/m2 on alternate day for 6weeks

38. F/UP 11/02/25 Subjective Objective Assesment Plan No new complaints puffy face Pulse 112b/min R/R 44 br /min BP 100/55mmHg Temperature 99°F Edema present BSUA 3+ Lungs vesicular breath sound with crepitation on rt lung field. Output 250 ml Abdomen: abdominal girth 56cm, non tender,ascities present. bowel sound present. Static Continue treatment with inj ceftriaxone . Inj Albumin 20% 100ml

39. 12/02/25 Subjective Objective Assesment Plan No new complaints Facial puffynesss present Pulse 108b/min RR 52 br /min Temp 98°F BP 90/50 mmHg BSUA +++ Lungs vesicular breath sound e crepitation Intake 500ml Output 300ml Abdominal girth 55 cm, ascities present static Change antibiotic to inj Meropenem & inj Flucloxacillin Inf FFP 10ml/kg Total 3 unit in 3 consecutive day

40. F/UP 14/02/25 subjective Objective Assesment Plan No new complints Playful Pulse 96b/min BP 95/50 mmHg Temp 98°F BSUA + Edema present Weight 12kg Intake 1o00ml Output 800ml Abdominal girth 50cm improving Start oral prednisolone

41. F/UP 15/02/25 subjective Objective Assesment Plan No new complints Playful Pulse 96b/min BP 90/50 mmHg Temp 98°F BSUA nill Edema absent Ascitis present Weight 12kg Intake 1100ml Output 1000ml Abdominal girth 49cm improving continue oral prednisolone

42. Master Arafat after attainment of remission

43. Advised to come after 14 days outdoor follow up clinic to check- Albuminuria- BSUA Drug toxicities- steroid toxicity Complications- infection Renal function- S.createnine F/UP Discharge

44. Thank you