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Dr. KANTA HALDER Resident (MD;Phase A)

BICH

Particulars of the patient

Name: Abdullah. Age: 1 month 7 days. Sex: Male. Address: Shonir akhra, Dhaka. Date of Admission: 12.03.2016. Date of Examination: 13.03.2016.

Chief Complaints

Generalized swelling of whole body for 20 days. Respiratory distress for 1 month.

History of present illness According to the statement of mother, her

child developed respiratory distress since his 10th day of life. For this complaints, he was admitted in a local hospital and treated with some injectable medications. During the course of treatment, he also developed swelling of whole body for last 20 days which first appeared in the face, then gradually became generalized.

Cont.. For these complaints, several investigations

were done & then the baby was referred to Dhaka Shishu Hospital for further evaluation and better management. He had no H/O reddish urine, convulsion or same type of illness previously.

History of Past illness She had no significant past illness.

Treatment History He was treated with some injectable

medication in a local hospital, but mother could not mention the name.

Birth History Antenatal : Mother was on regular antenatal

check up and was normotensive & nondiabetic. She had history of fever with rash during her pregnancy period.

Natal : Baby was delivered normally at term at a local clinic with average birth weight.

Postnatal : Uneventful.

Feeding History He is on exclusive breast feeding.

Developmental History He is developmentally age appropriate.

Immunization History Immunization is not yet started.

Familly History He is the only issue of his non-consanguineous

parents.

Socio-economic History He came from a low socio economic

background.

General Examination Appearance: Puffy face.Anaemia: Moderate.Jaundice: Cyanosis: Absent.Clubbing: Dehydration:Oedema: +++

Cont..Skin: BCG mark absent.Lymphnode: Not palpable.Ear:Nose: NormalThroat:Bedside Urine Albumin: +++

Cont..Vital Signs:

Pulse: 124/min.Respiratory Rate: 36/min.Temperature: 98°F.Blood Pressure: 80/40 mmHg.

Anthropometry:

Cont..

Weight: 4 kg. Length: 50 cm. LAZ: - 2 SD (moderately stunted).WLZ: - 0.8 SD (normal).OFC: 34 cm (-2.3 SD).

Systemic ExaminationAbdomimal Examination: Inspection:

Abdomen is distended.Flanks are full.

Umbilicus is centrally placed with transversely slit.

Cont.. Palpation :

Liver: Not palpable. Spleen: Not palpable.

Kidneys: Not ballotable. Renal angle: Not evaluated. Fluid thrill: Absent.

Cont..Percussion: Shifting dullness: present.Auscultation:

Bowel sound: present.Genitalia: Normal.

Cont.. Respiratory system :

Inspection : Respiratory rate: 36/min. Shape of the chest is normal. Movement is bilaterally symmetrical. Chest indrawing : Present.

Cont..Palpation : Trachea is centrally placed. Apex beat is in left 4th ICS medial to the

midclavicular line. Chest expansion : Normal. Vocal fremitus is normal in mid clavicular, mid

axillary & post. scapular line.

Cont..Percussion: Percussion note is resonant in MCL, MAL &

PSL in both lung field.Auscultation: Breath sound is vesicular and vocal resonance

is normal in MCL, MAL & PSL in both lungs. Crepitations is present in both lung fields.Other Systemic examination: No abnormality.

Salient feature Abdullah, 1 month 7 days old boy presented

with anasarca for 20 days and respiratory distress for 1 month. He had no H/O same type of illness previously or no H/O maternal fever with rash during her pregnancy period. He was moderately pale, having puffy face with generalized oedema, bed side urine albumin was +++. Abdomen was distended with signs of ascites without organomegaly.

Cont.. Crepitation was present in both lung fields

along the mid clavicular, mid axillary & post scapular line. Vitals were within normal limit.

Provisional Diagnosis

Congenital Nephrotic syndrome with pneumonia.

Differentinal Diagnosis

TORCH infection.

Investigations Urine R/M/E:

Color: Straw.Appearance: Clear.Albumin: +.RBC: 6-8/HPF.Pus cell: 5-8/HPF.

Spot protein creatinine ratio: 3.88. Urine C/S: No growth .

Cont.. S. Albumin: 21 gm/L. S. Cholesterol: 162 mg/dl. S. Electrolytes:

Na+: 146.5 mmol/L.K+: 3.1 mmol/L.

Cl-: 110.1 mmol/L. S. Creatinine: 28.5 µmol/L. B. Urea: 2.9 mmol/L.

Cont.. Complete Blood Count :

• Hb: 8.1 gm/dl.• WBC: Total count: 13,500/mm3. Differential count:

o Neutrophil: 55%o Lymphocyte: 35%o Monocyte: 07%o Eosinophil: 03%o Basophil: 00%

Cont..

o RBC: Normocytic normochromic.o WBC: Mature with above

distribution.o Platelet: Thrombocytopenia.

• Platelet: 43,000/mm3.• PBF:

Blood C/S: No growth.

Cont.. USG of W/A: Renal parenchymal change

with free fluid collection in peritoneal cavity. HBsAg: Positive. HbeAg: Negative. Anti HBc IgM: Negative. S. TSH: 8.60 µIu/ml.

Cont..Torch Panel : Toxoplasma : IgG – 15.2 IU/ml. IgM - <100 U/ml. Rubella : IgG - <2 IU/ml. IgM - <2 U/ml. CMV : IgG - 207.5 U/ml (Positive). IgM - <5 IU/ml. HSV type 1 : IgG - <10 U/ml. IgM - <10 U/ml. HSV type 2 : IgG - <10 U/ml. IgM - <10 U/ml.

Final Diagnosis Congenital Nephrotic Syndrome with

Pneumonia in a HBsAg (+ve) baby.

ManagementCounseling to the parents.

General treatment:• Exclusive breast feeding.• Calcium & Vit-D supplementation: (250 mg of

elemental Calcium + 200 IU of D3 ) daily.• Correction of anemia: Fresh whole blood

transfusion.

Cont.. Control of edema: Inj. 20% Human Albumin. To decrease proteinuria: Tab. Enalapril (5mg) - ¼ tab BD. Treatment of Pneumonia: Inj. Ceftriaxone 250 mg once daily. Inj. Amikacin 30 mg 12 hourly. Thyroxine supplementation: Tab. Thyroxine Sodium(50µgm) - ¼ tab daily

as single morning dose.

Follow up on 22.03.2016

Patient was afebrile.Heart rate – 110/min.Respiratory rate – 38/min.Lungs – Clear.Bed side Urine albumin – Nil for 7 days.Oedema – Absent.

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