Thursday, October 21, 2010

Acute Post-Streptococcal Glomerulonephritis

CP with Prof Wahab =)
(Im sooo happy that Prof Wahab likes my style of presentation *Elated mode* )

Its a simple case. But we know since our 3rd years Prof Wahab likes to emphasise on your style of presentation & always scrutinise the contents which I think is good. But I believe currently my way of presentation already mature compared to before. Thank you Allah =)

The case:-
9 years old Malay girl presented with fever for 5 days duration & facial puffiness 4 days which associated with hematuria. She also was diagnosed to have tonsilitis since 1 year ago. The last episode was 2 months ago.

On physical examination:- (day 4th of admission)
General - Alert, conscious, No facial puffiness, not pale, BP-normotensive, afebrile, fundoscopy not done (papilloedema), throat-no enlarge tonsils & throat not injected.

Other systems - (to find complications)
CVS - no signs of failure
Respiratory - no signs of pulmonary edema
CNS - Alert, conscious, GCS 15/15, normal tone, power 5/5, reflex normal & sensation intact

Provisional diagnosis:- Acute Post-Streptococcal Glomerulonephritis

Do you think the cause is due to tonsilitis??
May or may not be since the last episode was 2 months ago which post-streptococcal is acute presentation& should manifest earlier. But I could not find any other source of infection.

What complications must you anticipate in this patient?
Acute renal failure
Fluid overload -Heart failure & pulmonary edema
Hypertensive encephalopathy

What investigation you would like to do??
1) urine
- gross examination to confirm the dark color urine
-urinalysis & culture - RBCs, RBCs cast, proteinuria can be negative/trace

2) confirmatory test
- ASOT titre - Normal- >200 (this patient 1600IU/ml)
- complement levels - reduced in C3, normal in C4

3) other supportive investigations
- FBC - Hb - Patient had hematuria & by history the mother said the child is pale
(patient - Hb on admission 12, D4 - go down to 7)
- RP - urea & creatinie - looks for any renal impairment (high in this patient)
- BUSE - looks for hyperkalemia - also for renal impairment (patient:normal)

How do you treat this patient??
- Monitor this patient blood pressure & put her on BP chart
- Put her on ROF - 400mls/day - to avoid for any fluid overload
-monitor her input & output strictly
- advice to avoid salt intake

What you want to restrict the childs fluid??
Patient came with facial puffiness & high blood pressure
The pathology behind it is due to hypervolemia
So I would like to prevent complication such as fluid overload in this patient.

Prof added- but make sure you look at her input output first. Some patient might already be in diuresis when admitted to the ward

What is the cause of hypervolemia??
sodium & water retention due to reduced GFR

How do you know patient in diuresis??
when no longer has facial puffiness & her BP normalise
This we can allow her free fluid intake

Treat her BP - diuretics - can treat her hypervolemia & her hypertension as well
Treat the infection - IV Penicillin

I wasnt given any questions anymore.
But actually I expect Prof to give more scenarios like CP in real exams =) Anyhow, I still appreciate that Prof was very satisfied with my presentation....

But I would like to highlight the points you must know in this case:
1) Pathophysiology of AGN & how the complications occurs
2) Definition & causes of hypertension in paeds (like what Dr Zain taught us)
3) Types of hypertensive medications
4) Reasons behind the treatment given & why the drug is the choice of treatment
5) Try to remember normal values of important investigations & simple2 drug dose

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