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Preceptor:dr. Ulinar M., Sp.A
Compiled by:
Michael S. Rampangilei07120080106
FACULTY OF MEDICINE UNIVERSITY OF PELITA HARAPANDEPARTMENT OF PEDIATRICS CLINICAL CLERKSHIPBHAYANGKARA TK. 1 R. SAID SUKANTO HOSPITAL
DECEMBER 23RD-MARCH 1ST2014 PERIOD
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IDENTITY
Name : NGender : Male
Age : 10 Years 6 MonthsAddress : CigudegWeight : 29kgHeight : 130cmDate of admission : 22ndDecember 2013Date of examination : 22ndDecember 2013
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ANAMNESIS
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Chief and additional
complaints Auto- and alloanamnesis to the patient and his
mother
Chief Complaint
Hip pain since 9 days before hospital admission
Additional Complaint
Abdominal pain, nausea, vomiting, fever,constipation, both eyes swollen
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History of the present illness The patient complained of a dull pelvic pain that started 9 days before
being admitted to the hospital. The pain radiates towards the frontcentral torso. 6 days before hospital admission, the patient woke up withboth eyelids swollen and complained of a blurry vision. Patient was takento RS MISI diagnosed with Acute Glomerulonephritis and undefined eyeillness. The patient consulted with an ophthalmologist but no pathologieswere discovered. During urination, the color was dark tea like, no pain isevident. The patient has also experienced nausea and frequent vomiting4- 5x/day since the initial symptom. A day before the pelvic pain, thepatient endured a constant fever recorded by the mother at 38,8C, thatwas relieved by consuming paracetamol temporarily. The last time thepatient defecated was 3 days before being admitted. The patientsuffered a cough and runny nose 2 days before hospital admission.
The patient said that he didntconsume any drugsbefore the onset of hissickness and he doesnt have any allergy to some food or medicine.There werentany patientsfamily, relatives, or friends who had the same
symptoms.
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Past diseases history Pharyngitis/tonsillitis: (+)
Bronchitis : (-)
Pneumonia : (-)
Morbili : (+)
Pertussis : (-)
Varicela : (-)
Diphteriae : (-)
Malaria : (-)
Polio : (-)
Enteritis : (-)
Basilar dysentriae: (-)
Amoeba dysentriae : (-)
Typhoid Abdomen : (-)
Parasite : (-)
Operation : (-)
Brain injury : (-)
Fracture : (-)
Medicine Allergies : (-)
Others : -
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Family History Parents married: once for a mother, once for a
father
Patients father is healthy
Patients mother is healthy
People surrounding the patient is healthy
History of siblings
YearGestational
ageMethod ofdelivery
Sex Birthweight
2003 9 months Normal Male 3000 gram
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Past obstetric state Prenatal care
Antenatal care is done regularly at the local clinic
Sickness while pregnant: -
Pregnancy history
Gestational age: 40 weeks (normal)
Born at Home
Delivered by a midwife
Born by normal delivery, cried directly afterdelivery
Weight: 3000 gram (normal: 2500-4000 gram)
Height: 49cm (normal: 45-54 cm)
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Vaccination BCG : 1x
Varicella : 0x
DPT : 3x
Polio : 4x
Hepatitis B : 3x
Measles : 2x
Other vaccinations : -
Patients been given fundamentalvaccination according to thegovernments law.
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Food intake Breastfeeding since born until 9 months old
Started be given formula milk since the age of10 months. The milk was dancow.
Fruits have been given since the age of 10months (banana and papaya)
Vegetables been given since the age of 10months (carrot and celery)
Condensed food been given since the age of1,5 year old (rice, egg, beef meat, chickenmeat, and fish).
Quantity and quality of the food intake, inoverall is considered as sufficient
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PHYSICALEXAMINATIONDone on December 22rd2013 (1st day of medical care)
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Vital signs General condition : Patients looks moderately ill
Level of consciousness :Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 150/80 mmHg
Pulse Rate : 90x/minute, regular, adequate
Respiratory Rate : 22x/minute
Axillary temperature : 36,7C
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Nutritional status Weight : 29 kg
Height : 130 cm
Weight for Age : 29/30= 96,67%
Height for Age : 130/137 =94,90%
Weight for Height : 29/ 27= 107,41%
Interpretation : Normoweight
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General examination Head :
Normocephaly
Deformity (-)
Eyes : Pale conjunctiva-/-
Icteric sclera -/-
Secretions -/-
Pupil is rounded, isochore 3mm/3mm
Direct light reflex +/+
Indirect light reflex +/+
Edema Palpebra +/+
Nasal:
Septum is in the middle, deviation (-)
Secretions-/-
Nasal flaring -/-
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Ear: External acoustic meatus +/+
Timpanyc membrane is intact +/+
Cerumen -/-
Secretions -/-
Mouth: Wet lips
Oral mucous is wet, kopliksspot (-)
Tongue is wet, coated tongue (-)
Pharyx is hyperemic (+) Tonsil is T2/T3
Neck : Intact trachea in the middle
Mass (-)
Enlarged lymph nodes (-)
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Thorax
Pulmo Inspection: symmetrical breathing movements
Palpation: Stem fremitus on the right and the left wereequivalent
Percussion: Sonor in both lungs field
Ausculation: Vesicular breath sound +/+, wheezing -/-
, rhonchi -/- Cardio
Inspection: Ictus cordis was unseen
Palpation : Ictus cordis was palpated on the 5thintercostal left midclavicular line
Percussion: Cardiomegaly (-)
Auscultation: S1 and S2 regullar, gallop (-), murmur (-)
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Abdomen
Inspection: Flat abdomen
Auscultation: Bowel sound (+) 2-3x/minute Palpation: Tenderness (-), hepatomegaly (-),
splenomegaly (-), muscular defense (-)
Percussion: Timpany on all abdominal region
Extremities:
Warm
Capillary refill time < 3 seconds
Edema (-)
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LABORATORY
SEXAMINATION
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December 18th2013Examination Result Unit Normal Value
Hematology I
Hemoglobin 10,7 g/dl Boy : 13-18; Girl : 12-16
Hematocrit 31 % Boy : 40-58; Girl : 37-43
Leukocyte 9,200 /L 5.000-10.000
Thrombocyte 242.000 L 150.000-500.000
SGOT 23 /L
SGPT 10 /L
Hitung Jenis
Basophil 0 % 0-1
Eosinophil 0 % 1-3
Batang 0 % 2-6
Segmen 63 % 50-70
Limfosit 25 % 20-40
Monosit 12 % 0-1
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December 22nd2013Examination Result Unit Normal Value
Hematology I
Hemoglobin 11,5 g/dl Boy : 13-18; Girl : 12-16
Hematocrit 33 % Boy : 40-58; Girl : 37-43
Leukocyte 7.600 /L 5.000-10.000
Thrombocyte 361.000 /L 150.000-500.000
Erythrocyte 4.38 Million/ul 4.5-5.5
Examination Result Unit Normal Value
Clinic Chemistry
Ureum 125 mg/dl 10 - 50
Creatinine 2,2 mg/dl 0,51,5
Random Blood Glucose 114 mg/dl
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December 23rd2013
Examination Result Unit Normal Value
Complete Feces Exam
Color Brown
Consistency Soft
Mucus - -
Blood - -
Microscopic
Leukocyte +1-2 Negative
Erythrocyte 0 - 1 Negative
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Examination Result Unit Normal Value
Hematology III
Hemoglobin 10,7 g/dl Boy : 13-18; Girl : 12-16
Hematocrit 30 % Boy : 40-58; Girl : 37-43
Leukocyte 7,700 /L 5.000-10.000
Thrombocyte 342.000 L 150.000-500.000
LED 60 %
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December 26th2013
Examination Result Unit Normal Value
Hematology IHemoglobin 10,4 g/dl Boy : 13-18; Girl : 12-16
Hematocrit 31 % Boy : 40-58; Girl : 37-43
Leukocyte 13.600 /L 5.000-10.000
Thrombocyte 284.000 /L 150.000-500.000Ureum 47 Mg/dL 10 - 50
Creatinine 0,9 Mg/dL 0,5 1,5
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26thof December 2013
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A 10 years 6 months old boy patient, came to theemergency department of Polri Hospital onDecember 20th 2013 with the chief complaint of adull pelvic pain that started 9 days before being
admitted to the hospital. The pain radiates towardsthe front central torso. Both of the patients eyelidsswollen and caused a blurry vision. The patientsurine color was dark tea like. The patient has alsoexperienced nausea and frequent vomiting 4-5x/day since the initial symptom. A fever recordedby the mother at 38,8C, that was relieved by
consuming paracetamol temporarily. Patient alsopresented with constipation. The patient suffered acough and runny nose 2 days before hospitaladmission.
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Physical examination on December 23rd2013:
General condition : Patients lookedmoderately ill
Level of consciousness :Compos Mentis, GCS 15(E4M6V5)
Blood Pressure : 150/80 mmHg
Pulse Rate : 90x/minute, regular,adequate
Respiratory Rate : 22x/minute
Axillary temperature : 36,7C
Further examination:
Laboratory shows hyperurecemia, increased LFT, micro
hematuria, proteinuria, Hypertryglyceride
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DIAGNOSIS A 10 years 6 months old boy patient,
with weight 29 kg, and height 130 cm,been sick for 8 days, and receiving his
4th day of medical care, with workingdiagnosis of:
Acute Glomerulonephritis withSecondary Hypertension
Acute Tonsillopharyngitis
Growth and development isappropriate with age
Fundamental vaccination have beencompletely given
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TREATMENT IVFD Ringer Lactate maintenance 2000
cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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FOLLOW-UP2 day of medical care
S Fever (-), eyelids are still swollen and still the complain of nausea
O General condition : Patient looked moderately ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 140/90 mmHg (Normal: 100-120/60-75)
Pulse Rate : 90x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 22x/minute (Normal: 16-20x/minute)
Axillary temperature : 36,8C
A 10 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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3 day of medical care
S Fever (-), eyelids are still swollen, fullness of the abdomen
O General condition : Patient looked moderately ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)Blood Pressure : 130/80 mmHg (Normal: 100-120/60-75)
Pulse Rate : 70x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 20x/minute (Normal: 16-20x/minute)
Axillary temperature : 36C
Extremities : Swollen lower extremities
A 11 day of acute glomerulonephritis
P Released from the hospital IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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4 day of medical care
S Fever (-), eyelids are still swollen, fullness of the abdomen, shortness of breath
O General condition : Patient looked moderately ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 110/70 mmHg (Normal: 100-120/60-75)Pulse Rate : 88x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 28x/minute (Normal: 16-20x/minute)
Axillary temperature : 36,5C
Abdomen : Shifting Dullness (+)
A 12 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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5 day of medical care
S Fever (-), eyelids are still swollen,
O General condition : Patient looked moderately ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 100/60 mmHg (Normal: 100-120/60-75)
Pulse Rate : 80x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 24x/minute (Normal: 16-20x/minute)
Axillary temperature : 36C
A 13 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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Albumin 20% 50cc
6 day of medical care
S Headache and Fatigued
O General condition : Patient looked moderately ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 160/90 mmHg (Normal: 100-120/60-75)
Pulse Rate : 84x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 20x/minute (Normal: 16-20x/minute)
Axillary temperature : 37C
A 14 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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7 day of medical care
S Headache
O General condition : Patient looked mildly ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 130/80 mmHg (Normal: 100-120/60-75)
Pulse Rate : 80x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 20x/minute (Normal: 16-20x/minute)
Axillary temperature : 36,6C
A 15 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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8 day of medical care
S -
O General condition : Patient looked mildly ill
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)Blood Pressure : 120/90 mmHg (Normal: 100-120/60-75)
Pulse Rate : 76x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 20x/minute (Normal: 16-20x/minute)
Axillary temperature : 36C
A 16 day of acute glomerulonephritis
P IVFD Ringer Lactate maintenance 2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg
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9 day of medical care
S -
O General condition : Patient showed substantial improvement than the day before
Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)
Blood Pressure : 110/80 mmHg (Normal: 100-120/60-75)
Pulse Rate : 88x/minute, regular, adequate (Normal :60-100x/minute)
Respiratory Rate : 20x/minute (Normal: 16-20x/minute)
Axillary temperature : 36,3C
A -
P Released from the hospital
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AcuteGlomerulonephritis
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Background
Definition:
The failure of kidneys to process and regulate its physiological function due to the immunologicmechanism that triggers inflammation and proliferation of glomerular tissue which in turn resultin the damage to the basement membrane, mesangium, or capillary endothelium.
Hippocrates originally described the manifestation of back pain and hematuria,
which lead to oliguria or anuria. With the development of the microscope, Langhans
was later able to describe these pathophysiologic glomerular changes.
Acute GN is defined as the:
Sudden onset of hematuria Proteinuria, and
Red Blood Cell (RBC) casts
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Fundamental Kidney Anatomyand Function
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8 fundamental function of the Kidneys:
Excretion of Metabolic Waste and ForeignSubstances
Regulation of Water and Electrolyte Balance Regulation of Extracellular Fluid Volume
Regulation of Plasma Osmolality
Regulation of Red Blood Cell Production
Regulation of Vascular Resistance
Regulation of Acid-base Balance
Regulation of Vitamin D Production
Gluconeogenesis
Eti l
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Etiology
Infectious
Streptococcusspecies (ie, group A, beta-hemolytic)
Serotype 12 - upper respiratory infection
Serotype 49 - skin infection
Staphylococci
Mycobacteria
Brucella suis
Treponema pallidum
Corynebacterium bovis
CMV
EBV
Non-Infectious
Primary Renal Disease
MembranoproliferativeGlomerulonephritis
Berger Disease
Pure Mesangial Proliferation
Systemic Disease
HSP
Vasculitis (Wegener Granulomatosis)
SLE
Polyarteritis nodosa
Goodpasture Syndrome Miscellaneous Disease
Guillain-Barr syndrome
Irradiation of Wilms tumor
Diphtheria-pertussis-tetanus (DPT)vaccine
P th h i l
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Pathophysiology
fPSGN
NPSGN
Formationof ImmuneComplexes
GlomeruliDeposition
50% KidneyEnlargement
Inflamation of
Glomerulartufts
Increased number
of cells inGlomerular tufts
Endothelial,Epithelial,
Mesangial CellularProliferation
Extracapillary
Endocapillary
Glomeruli
Deposition
GlomerularBasement
Thickening
Hyalinization/Scl
erosis
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DIAGNOSIS
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Disease Presentation
HISTORY
Identification of an underlying systemic disease (if any) or recentinfection. Use of intravenous medications
Triad of sinusitis, pulmonary infiltrates, and nephritisWegener
granulomatosis Nausea and vomiting, abdominal pain, and purpura,Henoch-
Schnlein purpura
Arthralgias, associated with systemic lupus erythematosus (SLE)
Hemoptysis, occurring with Goodpasture syndrome or idiopathic
progressive glomerulonephritis Skin rashes, observed with hypersensitivity vasculitis or SLE
Ri k F t M l d 2 14 h dd l d l ffi f th
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Risk Factor: Male, aged 2-14 years, who suddenly develops puffiness of theeyelids and facial edema in the setting of a poststreptococcal infection.
Urine:
Dark and scanty
Blood pressure may be elevated.
Nonspecific symptoms:
Weakness,
Fever
Abdominal pain
Malaise
Onset and duration of the illness:
Symptom onset is usually abrupt.
The onset of nephritis within 1-4 days of streptococcal infection
Assess the consequences of the disease process (uremic symptoms):
Inquire about loss of appetite,
Generalized itching and tiredness,
Nausea
Easy bruising
Nosebleeds
Facial swelling
Leg edema
Shortness of Breath
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Inquire about symptoms of acute glomerulonephritis, including thefollowing:
Hematuria(smoky-, coffee-, or cola-colored urine)
Oliguria Edema (peripheral or periorbital) - This is reported in
approximately 85% of pediatric patients; edema may be mild(involving only the face) to severe,
Headache - This may occur secondary to hypertension; confusion
secondary to malignant hypertension may be seen in as many as5% of patients.
Shortness of breath or dyspnea on exertion - This may occursecondary to heart failure or pulmonary edema; it is usuallyuncommon, particularly in children.
Possible flank pain secondary to stretching of the renal capsule
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PHYSICAL EXAMINATION
Patients present with a combination of edema, hypertension,and oliguria.
The physician should look for the following signs of fluidoverload:
Periorbital and/or pedal edema
Edema and hypertension due to fluid overload (in 75% of patients)
Crackles (ie, if pulmonary edema)
Elevated jugular venous pressure
Ascites and pleural effusion (possible)
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The physician should also look for the following: Rash (as with vasculitis, Henoch-Schnlein purpura, or lupus nephritis)
Pallor
Renal angle (ie, costovertebral) fullness or tenderness, joint swelling, ortenderness
Hematuria, either macroscopic (gross) or microscopic Abnormal neurologic examination or altered level of consciousness (from
malignant hypertension or hypertensive encephalopathy)
Arthritis
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Other signs include the following: Pharyngitis
Impetigo
Respiratory infection Pulmonary hemorrhage
Heart murmur (possibly indicative of endocarditis)
Scarlet fever
Weight gain
Abdominal pain
Anorexia
Back pain
Oral ulcers
Progression of Disease
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Progression of Disease
Progression to sclerosis is rare in the typical patient 0.5-2% of patients with acute GN, the course progresses toward renal failure,
resulting in kidney death in a short period.
Abnormal urinalysis (ie, microhematuria) may persist for years.
Marked decline in the glomerular filtration rate (GFR) is rare.
Pulmonary edema and hypertension may develop.
Generalized anasarca and hypoalbuminemia may develop secondary tosevere proteinuria.
End-organ damage in the central nervous system (CNS) or the
cardiopulmonary system can develop in patients who present with severehypertension, encephalopathy, and pulmonary edema. Thosecomplications include the following: Hypertensive retinopathy
Hypertensive encephalopathy
Rapidly progressive GN
Chronic renal failure
Nephrotic syndrome
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Workup Complete Blood Count
Urinalysis and Sediment
Blood Urea Nitrogen
Serum Ureum andCreatinine
Electrolytes
ErythrocyteSedimentation Rate
Ultrasonography
Streptozyme Tests
Blood and Tissue Culture
NAPR
Renal Biopsy
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Differential Diagnosis
The following 4 renal syndromes commonly mimic
the early stage of acute glomerulonephritis (GN): Anaphylactoid purpura with nephritis
Chronic GN with an acute exacerbation
Idiopathic hematuria
Familial nephritis
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Immunoglobulin A (IgA) nephritis
The latent period between infection and onset of nephritis is 1-2 days
Nephritis may be concomitant with upper respiratory tract infection
Lupus nephritis
Gross hematuria is unusual in lupus nephritis.
GN of chronic infection
Manifest as acute nephritis Unlike PSGN, in which the infection may have resolved by the time
nephritis occurs, patients with nephritis of chronic infection have anactive infection at the time nephritis becomes evident.
Circulating immune complexes play an important role in the
pathogenesis of acute GN in these diseases.
M t
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Management
Key ConceptSUPPORTIVE THERAPY.
Pharmacological Agents
Antibiotics
Diuretics
Antihypertensives/Vasodilator Drugs
Glucocorticoids
Diet and Activity
Sodium and fluid restriction
Protein restriction for patients with * no evidence of no malnutrition
Bed rest is recommended until signs of glomerular inflammationand circulatory congestion subside.
A tibi ti
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Antibiotics
Penicillin V(500 mg PO q12hr or 250 mg PO q6hr for 10 days)
250 mg of penicillin V = 400,000 U of penicillin.
Cephalexin (25-50 mg/kg/day PO divided q6-8hr for 10 days; 4 g/daymaximum)
The recommended dosing schedule of erythromycin may result in GI upset,causing one to prescribe an alternative macrolide or to change to thrice-dailydosing. Erythromycin covers most potential etiologic agents, includingmycoplasmal species.
Erythromycin (Mild-to-moderate infections: 30-50 mg/kg/day PO dividedq6-12hr, Severe infection: 60-100 mg/kg/day PO divided q6-12hr)
In children, age, weight, and severity of infection determine the proper dosage.When twice-daily dosing is desired, half the total daily dose may be taken every12 hours. For more severe infections, double the dose.
Erythromycin has the added advantage of being a good anti-inflammatory agentby inhibiting the migration of polymorphonuclear leukocytes.
Loop Diuretics
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Loop Diuretics
Loop diuretics decrease plasma volume and edema by causingdiuresis. The reductions in plasma volume and stroke volume associatedwith diuresis decrease cardiac output and, consequently, bloodpressure. Furosemide (Lasix)
Initial Dosage: 12mg/kg/hr (PO/IV)
Increased Dosage: 12mg/kg/68hr (PO) OR 1mg/kg/ 2hr (IV)
Maximum Dose: 6mg/kg/day
Increases excretion of water by interfering with the chloride-bindingcotransport system, inhibiting sodium and chloride reabsorption in theascending loop of Henle and the distal renal tubule.
Rapidly absorbed from the gastrointestinal (GI) tract. The diuretic effect is apparent within 1 hour of oral (PO) administration and
lasts for 4-6 hours.
After intravenous (IV) administration, diuresis occurs within 30 minutes; theduration of action is about 2 hours
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Antihypertensives Amlodipine (6 years: 2.5-5 mg/day PO)
Labetalol (0.4-1 mg/kg/hr by continuous IVinfusion; not to exceed 3 mg/kg/hr)
Nifedipine (0.25-0.5 mg/kg/day (extendedrelease) PO in 1 or 2 daily doses initially; not toexceed 3 mg/kg/day (120 mg/day)
Hydralazine (Maximum dose in children: 7.5
mg/kg/day divided q12hr PO)
Nitroprusside 10 mcg/kg/min (6 mcg/kg/min inneonates)
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Prognosis Long-term studies on children with PSGN have
revealed few chronic sequelae
Long-term studies show higher mortality rates inelderly patients
Patients may be predisposed to crescentformation
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THANK YOU
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