SCHOOL OF MEDICAL SCIENCES UNIVERSITY OF SCIENCE MALAYSIA KUBANG KERIAN, KELANTAN
Paediatric Posting CLINICAL REPORT Written By
: Onn Azli Puade
Matrix Number
: 95793
Year
: 4
Clinical Group
: 5
Clinical Tutor
: Dr. Noorizan Abdul Majid
ONNAZLIPUADE
HISTORY TAKING Identification data Name - Aizat Khairi Aminuddin Baki Registration No – B493868 Age - 12 years old Race - Malay Sex – Male Address – Pasir Puteh th
Date of admission – 6 of june 2012 th
Date of clerking – 9 of June 2012 Informer – Patient and his mother, information is reliable
Chief complaint Facial puffiness 1 day prior to admission
History of Presenting Illness The patient with no known medical illness was apparently well until 2 weeks prior to admission when he was having low grade fever. The fever was gradual in onset, continuous throughout the day and was temporarily relieved by paracetamol. However there are no aggravating factors. The fever was associated with sore throat, and patient suffered from pain at the back of his mouth whenever he tried to swallow. But no history of runny nose or eye discharge. Patient also complained of skin lesion at his lower limb. Patient mother described the lesion as blisters, which distributed at the bilateral lower limb before specifically at the patient’s foot. As the blister breaks, there is clear yellow-colored fluid and there is itchiness at the blister site. As the patient able to tolerate the symptom, he did not seek for any treatment. There were no history of chills and rigors, symptoms of GIT infection such as vomiting and alteration in bowel habit, and no history of LRTI such as productive cough and shortness of breath 13 days later, which was about 1 day prior to admission, patient developed sudden onset facial puffiness. He mother noticed his face became puffy as soon as he woke up in the morning. It was reduced in the evening. It was associated with bilateral leg swelling until the level of knee. However there was no history of shortness of breath The symptoms were associated with tea colored urine. Patient described he noticed his urine increase in color intensity which the patient described as tea-coloured urine. But patient gave no history of reduction in urine volume, blood in the urine and painful micturition There was no history of jaundice, suprapubic pain, vomiting, history of passing cloudy urine or frothy urine and no symptoms to suggest connective tissue disease, history of insect bite and allergic reaction before Patient also complained of headache which was localized at the frontal area, gradually worsening throbbing in nature but no history of neck pain, visual disturbance, aura preceded the headache, projectile vomiting or photophobia. But there was no history of shortness of breath and cough His mother than brought the patient to the nearby klinik which the mother was told that her son’s blood pressure was high. He was then referred to HUSM for further management
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Upon further questioning, patient gave history of going to the beach with his family and Bachok 1 day before the onset of fever. There were no similar symptoms in his family.
Systemic review Cardiovascular System: no chest pain, palpitation, orthopnoea, PND, syncope Respiratory system: No SOB, wheezing, productive cough, night sweats, runny nose Gastro-intestinal System: no alteration in bowel habit, vomiting, abdominal pain Central Nervous System: +headache, loss of consciousness, seizure, and drowsiness Hematological System: no bleeding tendency Musculoskeletal System: no arthralgia, myalgia, limb weakness
Past Medical and surgical History This is the first time the patient had been hospitalized. Patient gave no history of hypertension, diabetes mellitus type 2, chronic chest infection, bronchial asthma and any contact with tuberculosis patient. There was no any surgical intervention done in the patient before
Paediatric History 1. Antenatal history His mother was diagnosed with anaemia in pregnancy at 22 weeks of POA and Gestational diabetes mellitus on diet control at 28 weeks period of amenorrhoea (after her MOGTT FBS 5.0, post prandial 8.9 mmol). She was prescribed with haematinics and claimed compliant to the medicationThe subsequent antenatal check up was uneventful.
2. Birth history He was delivered via spontaneous vaginal delivery at Hospital Pasir Puteh. His birth weight was 3.30 kg.
3. Postnatal history The period of postnatal was uneventful. There were no history of NNJ and admission to NICU
4. Immunization history He completed immunization at his age.
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5. Developmental Milestones According to his mother:
Gross motor
: patient able to sit unsupported at 9 months months old, started to stand
and cruising at the age of 11 months old, walk at 1 year old. Currently patient able to play sport (tennis – patient is Tennis Under 12 years o ld National Team)
Fine motor
: able to draw circles at age of 2 years old, writing at the age of 7
years old, currently able to draw scenery, house etc
Speech : started to talk at the age of 9 months old, able to talk in sentences (3-5 words) at the age of years old, currently able to read and talk fluently and read in English fluently
Social
: toilet trained at 4 years old, able to dress without supervision at the
age of 5 years old, currently mix well with his friends at school. Patient is an average student at his school with average academic perfomance. He was in the first class of standard 6 and his position in class was 16-18 out of 24 students.
6. Nutritional/Feeding history He is breastfed until the age of 2 years old. Weaning to semisolid food was started at the age of 6 months old and currently he was on adult diet
Family history
Diabetes Mellitus 2
Migraine
Diabetes Mellitus 2
Bronchial Asthma
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The patient was a product of non-consaguiness marriage and he was number 6 out of 7 siblings. His maternal grandmother and both of his paternal grandparents had been diagnosed to have DM 2 and requires oral medication for diabetic control. His maternal grandmother already passed away at the age of 70 years old due to kidney disease. Both of his parents were alive and healthy. His eldest sister was having a migraine and his brother had been diagnosed to have bronchial asthma at the age of 7 years old. There were no similar symptoms in the family and no other chronic illness running in the family such as hypertension, heart disease and dimorphism and congenital abnormalities in the family
Social history Patient stays with his other siblings, his parents and his grandmother at a well facilitated house. Both of his parents work as a secondary school teacher. The monthly household income was about RM5000. His father is a non-smoker. My patient attended primary school near his house and seldom absence from school. He was also active and did not have trouble attending school
Drug history Patient was not on any medication and there were no history of allergic to any known drugs
Diet history Patient was on normal adult diet and there were no history of allergic to foods
Summary Patient, a 12 years old Malay boy was admitted to HUSM with complained of fever associated with sore throat and skin lesion for 2 weeks prior to admission and he developed facial puffiness, ankle edema, headache and tea-colored urine 1 day prior to admission. Patient gave history o f recent travelling to beach at Bachok 1 day before the onset of fever.
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Physical examination (done 3 days after admission) General Inspection Patient was lying in supine position which is supported by one pillow. Patient was alert, conscious, and well oriented to time, place and person. the respiratory rate in this patient was 17 breath/minute and patient did not use accessory muscle for breathing, so patient was not in respiratory distress. Generally, patient hydrational and nutritional status was adequate.
Vital sign Pulse rate – 70 bpm regular rhythm, adequate volume, no radio-radial delay, no radio-femoral delay and all peripheral pulses presents Blood pressure – 138/98 mmHg (hypertension) Temperature – 37.5 (febrile)
Growth parameters th
th
Height – 132 cm, falls in between 25 to 50 percentile th
th
Weight – 36.8 kg, falls in between 50 to 75 percentile Head circumference – measured at 58.5 cm
Hand No clubbing in this patient, CRT was < 2 secs. His palm was moist and warm and pink. There is no tendon xantomata. There is no radio-radial delay in this patient and no collapsing pulse. There is also no scratch mark or brusing in this patient forearm
Eyes Face was puffy. There is no sclera icterus and the conjunctiva was pink. No malar rash can be seen. Funduscopy – no changes to support hypertensive retinopathy
Oral Oral hygiene was good, no evidence of central cyanosis. No enlargement of tonsils but the throat was injected
Neck No cervical lymphadenopathy and jugular venous pressure was not elevated
Lower limb There is pitting oedema up to the level of the ankle. There was presents of scarring of the skin at both of his feet, oval to round in shape with size about 3mm – 5mm, not elevated. No evidence of blister or rash and any discharge at his lower limb.
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SPECIFIC EXAMINATION
Abdominal examination Inspection
The abdomen was not distended, moved symmetrically with each respiration.
The umbilicus was centrally located and inverted.
There was no surgical scar, no dilated vein, no skin discoloration, no visible peristalsis or visible pulsation.
There was no presence of cough impulses in inguinal and femoral region.
Palpation Superficial palpation
The abdomen was soft and non-tender
Deep palpation
No mass palpable
Liver was not palpable
Spleen was not palpable
Kidneys was not ballotable
Percussion
No shifting dullness
Auscultation
Bowel sound was present
No renal bruits
Per rectal examination and examination of external genitalia was not done
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Respiratory examination Inspection
Chest wall moved symmetrically during respiration
No surgical scar
No skin discoloration
No gross deformity of the chest wall
No dilated veins, no visible pulsation
No increase in antero-posterior diameter of chest
No subcostal or intercostals recession
Palpation
Trachea was centrally located and no tracheal tug
Apex beat was palpable at left 5 intercostal space, 1 cm medial to mid-clavicular line
Chest expansion was equal on both sides
Vocal fremitus was equal and of normal intensity on both sides
th
Percussion
Resonant over both lung fields
Auscultation
Breath sound : Vesicular breath sounds, of normal intensity in both lungs
Vocal resonance equal and of normal intensity on both sides
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Cardiovascular examination Inspection
No precordial bulge
No visible pulsation
No surgical scar
No skin discoloration
No dilated vein
Palpation
th
Apex beat was palpable at left 5 intercostal space, 1 cm medial to mid-clavicular line
No parasternal heave
No palpable thrill
Auscultation
st
nd
1 and 2 heart sounds present
No gallop rhythm
No murmurs
No additional sounds
Nervous system examination Cranial nerve examination
All cranial nerves were intact
Sensory examination
All sensory were intact
Power
All of the limbs were grade 5/5 (MRC grading)
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PROBLEM LIST Symptoms
Signs
Low grade Fever Sore throat Skin infection Facial puffiness Bilateral leg swelling Tea colored urine Headache
Low grade fever Hypertension Facial puffiness Injected throat Bilateral pitting edema
DIAGNOSIS Provisional diagnosis Provisional diagnosis
Positive findings
Acute Post-streptococcus Glomerulonephritis
Negative findings
Symptoms Low grade Fever Sore throat and skin infection preceeded the symptoms Facial puffiness Bilateral leg swelling Tea colored urine Headache
Signs Low grade fever Hypertension Facial puffiness Injected throat Bilateral pitting edema
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Differential diagnosis Differential diagnosis
Positive findings
Negative findings
Nephrotic syndrome
Symptoms Facial puffiness Bilateral leg swelling Tea colored urine Headache Signs Hypertension Facial puffiness Bilateral pitting edema
Symptoms Fever Headache Tea coloured urine Signs Fever
No history of frothy urine No signs of generalized oedema (just mild oedema)
Urinary tract infections
Lupus Nephritis
Symptoms Low grade Fever Facial puffiness Bilateral leg swelling Tea colored urine Headache
No urinary symptoms to suggest urinary tract infections such as dysuria, cloudy urine No Vomiting (may be presents) No suprapubic pain/ no loin pain Sex of the patient is boy No other symptoms to suggest Systemic Lupus Erythematosus No other signs of Systemic Lupus Erythematosus
Signs Low grade fever Hypertension Facial puffiness Bilateral pitting edema
ONNAZLIPUADE
INVESTIGATIONS 1. Full blood count Taken on the day of admission
Result
Indication
Haemoglobin 11.7 g/dL
Interpretation
To assess anemic status of the patient as he had hematuria
White blood cell 9 9.67 x 10 /L Differential count
Platelet 9 350x 10 /L
Mean cell volume (MCV) and Mean cell haematocrit (MCH)
To assess pany pre-existing infection because patient had fever and post skin infection Should be done to give a clue about the types of infections presents in this patient whether bacterial (neutrophilia), viral (lymphocytosis) or parasitic (eosinophilia) To assess any bleeding disorder in this patient as he had hematuria Should be done to classify the types of anaemia into microcytic, normocytic or macrocytic and hypochromic, normochromic or hyperchromic
Slightly low. Normal haemoglobin is between 13 – 18 g/dL. Patient is not anemic. The result is may be due to hematuria Normal. Normal range is 4 – 11 9 x 10 /L. Currently, patient may be free of infection Not done
Normal (normal value is 150 9 400 x 10 /L) Not done
2. Renal function test st Taken on the day of admission (31 January 2012)
Results
Indication
Sodium 138 mmol/L
Nephrotic syndrome will cause sodium retention
Potassium 3.6 mmol/L
Acute renal failure can cause potassium retention due to reduce renal potassium secretion 1. To assess renal function as this patient’s condition may be due to renal failure 2. patient with acute glomerulonephritis may have azotemia
Urea 3.1 mmol/L
Interpretation Sodium level is normal. Normal range is 135 – 145 mmol/L. Edema in this patient is not due to sodium retention. Normal potassium level. Normal range is 3.5 5 mmol/L. Renal still can function to excrete the potassium. Normal urea. Normal range is 2.5 – 6.7 mmol/L. Urea will be high in renal failure and acute glomerulonephritis.
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Creatinine 79 µmol/L Calcium 2.23 mmol/L
To assess renal function as this patient’s condition may be due to renal failure Renal failure may cause hypocalcaemia
Phosphate 1.13 mmol/L
Renal failure can cause hyperphosphatemia
3. Liver function test Results
Total protein 75 g/L Albumin 39 g/L
Bilirubin 10 µmol/L
Alkaline phosphatase (ALP) 74 IU/L Aspartate aminotransferase (AST) 19 IU/L Alanine aminotransferase (ALT) - 43 IU/L
Creatinine is normal. Normal range range is 70 – 150 µmol/L. Creatinine will be high in renal failure but normal in acute glomerulonephritis. Calcium is normal. Normal range is 2.15 – 2.65 mmol/L. Renal can function to stimulate vitamin D production which aid in calcium absorption Normal serum phosphate. Normal range is 0.8 – 1.5 mmol/L. No renal dysfunction as renal can reabsorb phosphate
Normal range
Interpretation
In nephrotic patient, total protein will be reduce due to reduce albumin Nephrotic syndrome has low albumin
Normal total protein. Normal value is 64 – 82 g/L. Patient may not have nephrotic syndrome No hypoalbuminaemia. Normal range is 35 – 50 g/L. Nephrotic patient will have serum albumin less than 25 g/L Normal bilirubin level. Normal value is 3 – 17 µmol/L. Liver is not the cause of patient’s current condition
1. One of the cause of nephrotic syndrome is hepatitis 2. patient have generalized edema To assess liver function and as a part of liver function test To assess liver function and as a part of liver function test To assess liver function and as a part of liver function test
Normal ALP as the normal range is 50 – 136 IU/L. No liver damage Liver is functioning as the AST is normal between 15 – 37 IU/L ALT is normal. The normal value is 30 – 65 IU/L. No liver damage
4. Urinalysis Not done in this patient Indication 1) Patient had hematuria 2) Acute glomerulonephritis and nephrotic syndrome had proteinuria 3 component 1) Observation of urine colour and concentration 2) Chemical examination using urine dipstick (this is done in this patient) 3) Microscopic examination
5. Urine culture and sensitivity Culture reveals mixed growth
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6. Urine dipstick Done on the day of admission Result : protein +1 blood +1
7. Anti – streptolysin O titre Done 1 day after patient’s admission
Result
Indication
Present of antistreptolysin O – 800 units
8. Complement C3 and C4 Result
C3 – 0.26 (low) C4 – 0.28 (normal)
Interpretation
To determine whether patient had been infected with streptococci or not because one of the cause of nephritic syndrome is streptococcal infection
Indication
Acceptable value in children is less than 300 units. In this patient there is increase antistreptolysin O titre. This indicate that he had been infected by streptococci.
Interpretation
This patient is highly suspected of poststreptococcal glomerulonephritis. In postinfectious glomerulonephritis, his serum C3 is expected to be low while C4 is normal
With low c3 and normal C4, most likely diagnosis is poststreptococcus glomerulonephritis
9. Capillary blood sugar
Result
Indication
5.4 mmol/L
Diabetes mellitus is one of the cause of nephrotic syndrome
Interpretation Normal capillary blood sugar is <5.6 mmol/L. Patient does not have diabetes mellitus
10. Antinuclear antibody
Result
Indication
70 units
To determine any underlying autoimmune disease in this patient as systemic lupus erythematosus (SLE) can cause acute glomerulonephritis and nephrotic syndrome
Interpretation Patient does not have autoimmune disease as the antinuclear antibody is not elevated which is <95 units
11. Anti – double stranded DNA (anti-dsDNA)
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Not done in this patient because based on earlier result, patient had confirmed to have nephritic syndrome secondary to streptococcal infection It is a highly specific test for systemic lupus erythematosus (SLE)
12. Electrocardiogram Indications – hyperkalaemia may presents as a complications of nephritic syndrome
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FINAL DIAGNOSIS The most likely diagnosis in this patient based from history and physical examination Acute Post-
Streptococcus Glomerulnephritis
DISCUSSION From the history, my patient had mildedema which involved facial puffiness and bilateral leg swelling. Apart from t hat, he also had tea-colored urine. These symptoms may suggest acute glomerulonephritis or nephrotic syndrome. Patient had history of skin and symptoms to suggest upper respiratory tract infection based on symptoms of low grade fever and sore throat about 2 weeks before his symptoms developed. One of the cause of acute glomerulonephritis is streptococcal infection which may cause pharyngitis or impetigo such as skin lesion in my patient and post – infectious glomerulonephritis can cause nephrotic syndrome. If t he pathogen is still in the blood, patient may developed fever same like my patient. The symptoms of headache may be suggestive of complications of nephrotic or nephritic syndrome due to the sudden rise in blood pressure. Other complications may be need to considered such as acute pulmonary o edema (symptoms of shortness of breath, prodctive cough with pink frothy sputum, signs of tachypnoea, reduce air entry), hyperkalaemia (palpitation, syncope attack, seizure, signs of irregular heart rate) and uremic encephalopathy After performing physical examination in my patient, I found that he had hypertension. This findings can be found in acute glomerulonephritis. There were signs of injected throat with signs of post-infectious scar at both of his lower limbs. Patient also f acial puffiness and bilateral lower limb pitting edema. These findings correspond to patient’s history. From investigations result, patient is less likely to have renal failure as his kidney can still functioning based on the normal result of his renal function test. Nephrotic syndrome also can be excluded as patient’s albumin is normal. Eventhough there is +1 protein from the albustix test, thereis normal total protein in patient’s serum. In nephrotic syndrome, there is massive
proteinuria. Post – streptococcal glomerulonephritis is more likely to be the diagnosis in this patient because although he does not have azotemia, there is +1 protein and blood from the albustix test. Furthermore, the anti – streptolysin O titre is present more than 300 units. This indicate patient has post streptococcal infection Therefore, based on history, physical examination and investigation, my final diagnosis is post – streptococcal glomerulonephritis. Post – streptococcal glomerulonephritis is the most common cause of nephritic syndrome or acute glomerulonephritis. It is caused by group A beta-hemolytic streptococci ( Streptococcus pyogenes). This pathogen cause a latent period of days to 3 weeks of infection such as skin
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infection in this patient before patient developed nephritic symptoms. Patient may developed acute renal failure but most of the patient (more than 90%) recover fully with normal renal function
TREATMENT
General measures 1. Low salt diet with normal protein diet – avoid citrus fruits and fruit that contains hih level of potassium such as banana 2. Antibiotics - Penicillin for 10 days to eradicate the infecting streptococcus (shoul be given to the patient as there was still clinical evidence of active infection) 3. Fluid restriction - Allow insensible fluid loss of 400ml/ m2 body surface area/day - Add diuretics (e.g - frusemide) if patient still edematous despite fluid restriction Specific therapy 1. Treat the hypertension - Diuretics (e.g – frusemide) - Calcium channel blocker (e.g – nifedipine) 2. Treat the complication if present (acute renal failure) - Consider dialysis if there are o Acute pulmonary oedema o Hyperkalaemia Hyperuraemia o
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