CAGAYAN STATE UNIVERSITY
COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City
PEDIATRICS WARD I
Submitted by: Occas, Sheryl Jane
Robles, Roane Crispina
Unipa, Ma. Clarissa Mae
3rd Year Medical Students- PRELIMS GROUP
Submitted to: GRANDELEE TAQUIQUI, MD
PEDIA LABORATORY PRECEPTOR
PATIENT PROFILE
NAME (INITIALS) : Ian Battung
AGE : 18
GENDER : Male
ADDRESS : San Gabriel, Tuguegarao City
RELIGION : Roman Catholic
DATE OF ADMISSION : August 12, 2019
TIME OF ADMISSION : 10:00pm
DATE OF INTERVIEW : August 13, 2019
TIME OF HISTORY : 3:00pm
TAKING
INFORMANT : Patient and his Father
RELIABILITY : 85%
NUMBER OF : none
ADMISSIONS:
CHIEF COMPLAINT : Headache and Fever
HEALTH HISTORY
HISTORY OF PRESENT ILLNESS:
Four days PTA, the patient experienced abrupt onset of frontal headache (PS 5/10) and high fever
with slight dizziness while at his work. The patient went home to rest and took paracetamol. The next day the
patient still presents headache and fever. His father also reported that the patient experienced vomiting and
loss of appetite. He chose to stay at home and took paracetamol but the pain did not subside.
One day PTA, the patient experienced body weakness and abdominal pain in epigastric area (PS 6/10)
and due to the constant headache and intermittent fever, the father decided to bring him to CVMC for check-
up hence admitted.
PAST MEDICAL HISTORY:
(+) Chickenpox (3 years old)
The patient had only 2 vaccinations. (BCG and Hep B)
1 | Page
No known allergies.
No known history of trauma, fall, serious illnesses and previous hospitalization.
PERSONAL AND SOCIAL HISTORY:
The patient is the youngest in their family. His father, 61 years old is a farmer while his mother 56
years old is a housewife. He is living with his family in a bungalow house with 2 rooms and source of
drinking water is a pump well. He finished high school and decided to work in San Gabriel as a meat
delivery boy since July 30, 2019. The patient is a non-smoker but admits that he occasionally drinks 5 shot
glass of ginebra.
FAMILY HISTORY:
PATERNAL/MATERNAL
HPN -
DM - -
Cancer - -
Heart Disease - -
Asthma -
Tuberculosis - -
BIRTH HISTORY:
The patient was born to a 38-year old G3P3 (3003) in their house in San Gabriel. His father cannot
recall patient’s birth weight.
PRENATAL HISTORY:
His father claimed that his wife regularly attends her pre-natal check-up in Holy Infant. He can’t
recall if his wife had regular intake of vitamins during pregnancy. The mother does not have any history of
measles or any disease during her pregnancy.
POSTNATAL HISTORY:
His father claimed the patient has good cry and suck after the delivery. No jaundice and other signs
and symptoms of distress was noted.
NUTRITIONAL HISTORY:
The patient was breastfed up to 3 months and was bottle-fed up to 2 years old. Complimentary
feeding of “lugaw” was started at 1st year of age.
The patient current diet mainly consists of meat, noodles and rice. Occasionally with vegetables and
fruits if available. He eats three times a day.
DEVELOPMENTAL MILESTONES:
2 | Page
REVIEW OF SYSTEMS
Constitutional:
HEENT:
Head: (-) headache, (-) neck pain, (+) facial edema
Eyes: No changes in visual field, blurring and pain
Ears: No dizziness, (-) hearing impairment, (-) otalgia, (-) otorrhea
Nose: No nasal discharge and congestion
Throat: No difficulty in swallowing, no ulceration, bleeding and hoarseness
Integumentary System: (-) pruritus, (-) rash (+) wounds
Central Nervous System: (-) seizure, (-) drowsiness, (-) confusion
Respiratory System: (+) productive cough, (-) colds, (-) hemoptysis, (-) dyspnea
Cardiovascular System: (-) chest pain, no palpitations
Gastrointestinal System: (-) vomiting, (-) diarrhea, (-) constipation, (-) nausea
Genitourinary System: (-) hematuria, (-) nocturia, (-) polyuria
Musculoskeletal System: (-) body weakness, (-) paralysis on upper and lower extremities, (-) muscle pain
Endocrine system: (-) sweating, (+) fever, (-) polydipsia, (-) polyphagia
PHYSICAL EXAM
General: The patient is lying on bed, awake,
conscious, coherent and oriented to time and
place. The patient has thin body built.
Vitals signs:
Temperature: 37.5 degrees Celsius, axillary
(afebrile)
Respiratory: 30 bpm (Normal)
Heart rate: 135 bpm (Normal)
02 saturation: 96%
Anthropometric measurements:
Height: .96 m
Weight: 15 kg
BMI: 16.3
3 | Page
Skin: (-) pallor; warm to touch; good skin turgor; (-) rashes, (-) cyanosis; (-) jaundice; (-) petechiae, (-)
hematoma, (+) scars, (+) fresh cuts and wounds
HEENT:
Head: Normocephalic with no lesions or masses, (+) facial edema
Eyes: Non-icteric sclerae. Pinkish palpebra. Normal pupillary reflex
Ears: symmetrical. (-) ear infection and discharge
Nose: (-) deformities and masses, (-) nasal discharge
Mouth: (-) neck engorgement, no bleeding gums
Neck: (-) masses, (-) enlargement of lymph nodes, (-) hypertrophy of tonsils
Chest and Lungs: Symmetrical on chest expansion, clear breath sounds, (-) chest retraction, (-) wheezes
Heart: Adynamic precordium, Normal rate and regular rhythm, no murmur
Abdomen: protuberant, round, normoactive bowel sounds, tympanic upon percussion, soft and no
abdominal mass
Extremities: Non pitting edema, no gross deformities, non-cyanotic, with a capillary refill time of 1-2
seconds, (+) peripheral pulses with muscle strength of 5/5 on all extremities, normoreactive deep tendon
reflexes
NEUROLOGICAL ASSESSMENT
Mental Status: Active and awake, coherent and oriented to time and place
Cranial Nerves:
CN I: able to smell
CN II: not done
CN III, IV, VI: pupils are equally reactive to light and accommodation; pupil size approximately 2-3mm
CN V: can move jaw
CN VII: (+) facial sensation no facial asymmetry
CN VIII: able to hear
CN IX, X: patient able to swallow
CN XI: turns head from side to side, shrugs shoulder
CN XII: (+) movement symmetry of tongue
REFLEXES: (-) Kernigs sign, (-) Brudzinki’s sign
SALIENT FEATURES
A patient presenting with a history of fresh and old skin lesions with oliguria, facial edema followed
with upper and lower extremity edema.
INITIAL IMPRESSION
TO CONSIDER ACUTE POST STREPTOCOCCAL GLOMERULONEPHRITIS
DIFFERENTIAL DIAGNOSIS
NEPHROTIC SYNDROME
Nephrotic syndrome is the clinical manifestation of glomerular diseases associated with heavy
(nephrotic-range) proteinuria. Nephrotic range proteinuria is defined as proteinuria >3.5 g/24 hr. or a urine
4 | Page
protein: creatinine ratio >2. The triad of clinical findings associated with nephrotic syndrome arising from
the large urinary losses of protein are hypoalbuminemia, edema, and hyperlipidemia.
RULE IN RULE OUT
Generalized edema
Oliguria
POST-INFECTIOUS GLOMERULONEPHRITIS (NON-STREPTOCOCCAL GN)
AGN infection of either viral etiologic agents (influenza, mumps), bacterial agents (S. viridans, leptospirosis)
and parasitic agents (malaria and schistosomiasis)
RULE IN RULE OUT
Generalized edema
(-) Non streptococcal infection
Oliguria
IgA NEPHROPATHY/BERGER’S DISEASE
Glomerulonephritis that presents with gross hematuria within 1-2 days after the onset of an apparent
viral upper respiratory tract infection and typically resolves within 5 days.
RULE IN RULE OUT
Generalized edema Loin pain
Oliguria Gross hematuria
MEMBRANOPROLIFERATIVE GN
Are most commonly associated with subacute and chronic infection, including hepatitis B and C,
syphilis, subacute bacterial endocarditis, and infected shunts, especially ventriculo-atrial shunts. MPGN is
most common in the 2nd decade of life. Patients present in equal proportions with nephrotic syndrome, acute
nephritic syndrome (hematuria, hypertension, and some level of renal insufficiency), or persistent
asymptomatic microscopic hematuria and proteinuria.
RULE IN RULE OUT
Generalized edema Most common in the 2nd decade of life
Oliguria
CASE DISCUSSION: APSGN
Is the prototype of post-infectious glomerulonephritis and is associated with a previous skin or throat
infection.
Common in children and can lead to the postinfectious complication of acute glomerulonephritis
5 | Page
A classic example of the acute nephritic syndrome characterized by sudden onset of gross hematuria,
edema, hypertension and renal insufficiency.
EPIDEMIOLOGY
Epidemics and clusters of household cases occur throughout the world
97% of cases occur in less-developed countries
Acute Post-Infectious Glomerulonephritis rank first in pediatric renal and urologic disorders in Jan-
Dec 2017 (21% of all cases)
Post-streptococcal GN commonly follows streptococcal pharyngitis during cold weather months and
streptococcal skin infections or pyoderma during warm-weather months.
CLINICAL MANIFESTATIONS
Most common in children ages 5-12 year and uncommon before the age 3 years old.
Typical patient develops an acute nephritic syndrome 1-2 weeks after an antecedent streptococcal
pharyngitis or 3-6 weeks after a streptococcal pyoderma.
History of a specific infection may be absent, because symptoms may have been mild or have
resolved without patients receiving specific treatment or seeking the care of a medical provider
From asymptomatic microscopic hematuria with normal renal function to gross hematuria with acute
renal failure.
Manifests with edema, hypertension and oliguria.
Risk for developing encephalopathy and heart failure due to hypertension and hypervolemia.
6 | Page
PATHOPHYSIOLOGY
7 | Page
DIAGNOSIS
Urinalysis- demonstrates red blood cells, red blood cell casts, proteinuria and polymorphonuclear
leukocytes
Mild normochromic anemia from hemodilution and low-grade hemolysis
Serum C3- reduced in >90% of patients in the acute phase and returns to normal 6-8 weeks after
onset.
C4 is most often normal
Confirmation of diagnosis requires clear evidence of prior streptococcal infection
- Positive throat culture report
- Rising antibody titter to streptococcal antigens (confirms recent streptococcal
infection)
- ASO titer, commonly elevated after a pharyngeal infection, but rarely increases
after a skin infection
Clinical diagnosis
- Quite likely in a child presenting with acute nephritic syndrome
- Evidence of a recent streptococcal infection and a low C3 level
TREATMENT AND PATIENT MANAGEMENT
Adequate rest and limitation of physical activities
Dietary sodium restriction
Control of dietary protein and potassium.
Fluids are limited to insensible water loss replacements (usually 20 ml/kg/day under baseline
conditions) plus volume for volume replacement of urine output in the preceding 24 hours, minus a
planned weight loss. IVF usually regulated at KVO
All fluids should be given orally when tolerated, preferably as nonelectrolyte preparations initially.
Loop diuretics -furosemide (1mg/kg/day) through IV
Penicillin - To eradicate residual foci of streptococcal infection, given either orally or parenterally,
the former route being preferred if tolerated. In case of penicillin hypersensitivity, erythromycin is
substituted. Penicillin dosage= 25,000 units/ kg
Antihypertensives if patient presents with increased blood pressure. ACE inhibitors may be given
such as Captopril, 2.5-6mg/kg/day divided in 3 doses (q8)
Prednisone 0.14- 2mg/ kg/ day divided in 3 doses.
COMPLICATIONS
Acute complications usually result from hypertension and acute renal dysfunction
Hypertension in 60% of cases and associated with hypertensive encephalopathy.
Intracranial bleeding, heart failure, hyperkalemia, hyperphosphatemia, hypercalcemia, acidosis,
seizures and uremia.
Acute renal failure
PREVENTION
Antibiotics do not prevent PSGN from developing in persons with acute streptococcal infections.
Good hand hygiene and respiratory etiquette
People with group A strep pharyngitis or impetigo should stay at home from work, school or daycare
until they are afebrile or at least 24 hours after starting appropriate antibiotic therapy.
8 | Page
PROGNOSIS
PSAGN is regarded a self-limiting disease.
Streptococcus-related asymptomatic proteinuria disappeared after 3 months and most cases of
asymptomatic microhematuria, after 6 months.
The prognosis of PSAGN is usually guarded if the age at onset is below 2 or above 15 years
REFERENCES
Kliegman, R., Stanton, B., St. Geme, J. W., Schor, N. F., & Behrman, R. E. (2016). Nelson
textbook of pediatrics (Edition 20.). Phialdelphia, PA: Elsevier.
Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J.
(2015). Harrison's principles of internal medicine (19th edition.). New York: McGraw Hill
Education.
2017 Census Report on Pediatric Renal and Urologic disorders (https://pps.org.ph>PNSP-Renal-
Registry
9 | Page
