Preskas GNA PPT

8/13/2019 Preskas GNA PPT

1/67

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


2/67

IDENTITY

Name : NGender : Male

Age : 10 Years 6 MonthsAddress : CigudegWeight : 29kgHeight : 130cmDate of admission : 22ndDecember 2013Date of examination : 22ndDecember 2013


3/67

ANAMNESIS


4/67

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


5/67

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.


6/67

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 : -


7/67

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


8/67

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)


9/67


10/67

Vaccination BCG : 1x

Varicella : 0x

DPT : 3x

Polio : 4x

Hepatitis B : 3x

Measles : 2x

Other vaccinations : -

Patients been given fundamentalvaccination according to thegovernments law.


11/67

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


12/67

PHYSICALEXAMINATIONDone on December 22rd2013 (1st day of medical care)


13/67

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


14/67

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


15/67


16/67

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 -/-


17/67

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 (-)


18/67

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 (-)


19/67

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 (-)


20/67

LABORATORY

SEXAMINATION


21/67

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


22/67


23/67

December 22nd2013Examination Result Unit Normal Value

Hematology I



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


24/67

December 23rd2013


Complete Feces Exam

Color Brown

Consistency Soft

Mucus - -

Blood - -

Microscopic

Leukocyte +1-2 Negative

Erythrocyte 0 - 1 Negative


25/67


Hematology III



Leukocyte 7,700 /L 5.000-10.000

Thrombocyte 342.000 L 150.000-500.000

LED 60 %


26/67


27/67


28/67

December 26th2013


Hematology IHemoglobin 10,4 g/dl Boy : 13-18; Girl : 12-16


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


29/67

26thof December 2013


30/67


31/67

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.


32/67

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


Further examination:

Laboratory shows hyperurecemia, increased LFT, micro

hematuria, proteinuria, Hypertryglyceride


33/67

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


34/67

TREATMENT IVFD Ringer Lactate maintenance 2000

cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg


35/67


36/67

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)


A 10 day of acute glomerulonephritis

P IVFD Ringer Lactate maintenance 2000 cc/24jam


Lasix tablet 1x30mg

Captopril 2 x 5mg


37/67

3 day of medical care

S Fever (-), eyelids are still swollen, fullness of the abdomen


Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)Blood Pressure : 130/80 mmHg (Normal: 100-120/60-75)



Axillary temperature : 36C

Extremities : Swollen lower extremities


P Released from the hospital IVFD Ringer Lactate maintenance 2000 cc/24jam


Lasix tablet 1x30mg

Captopril 2 x 5mg


38/67


S Fever (-), eyelids are still swollen, fullness of the abdomen, shortness of breath



Blood Pressure : 110/70 mmHg (Normal: 100-120/60-75)Pulse Rate : 88x/minute, regular, adequate (Normal :60-100x/minute)



Abdomen : Shifting Dullness (+)




Lasix tablet 1x30mg

Captopril 2 x 5mg


39/67


S Fever (-), eyelids are still swollen,










Lasix tablet 1x30mg

Captopril 2 x 5mg


40/67

Albumin 20% 50cc


S Headache and Fatigued










Lasix tablet 1x30mg

Captopril 2 x 5mg


41/67


S Headache

O General condition : Patient looked mildly ill









Lasix tablet 1x30mg

Captopril 2 x 5mg


42/67


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)







Lasix tablet 1x30mg

Captopril 2 x 5mg


43/67


S -

O General condition : Patient showed substantial improvement than the day before






A -

P Released from the hospital


44/67

AcuteGlomerulonephritis


45/67

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


46/67

Fundamental Kidney Anatomyand Function


47/67

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


48/67

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


49/67

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


50/67


51/67

DIAGNOSIS


52/67

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


53/67

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


54/67

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


55/67

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)


56/67

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


57/67

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


58/67

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


59/67

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


60/67

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


61/67

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


62/67

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


63/67

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


64/67

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


65/67

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)


66/67

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


67/67

THANK YOU

Preskas GNA PPT

Documents

Transcript of Preskas GNA PPT