COMPREHENSIVE

CLINICAL CLASS
Mentor: Dr.CHETHANA
Pediatric Nephrologist
Indira Gandhi Institute of Child Health.

Presenter: Dr.Ashray S Patel

1st year MD Pediatrics
BMCRI, Bengaluru.
GENERAL INFORMATION:
• Name: XYZ
• Age: 2 years, 11 months.
• Sex: Male
• First born to 3rd degree consanguineous parents.
• Address: Doddaballapur
• Religion: Hindu
• Informant: Mother(Reliable)
• Date of Admission: 31.08.20
• Date of Examination: 2.09.20
CHIEF COMPLAINTS:
• Puffiness of eyes & face for 1 month.
• Swelling of lower limbs & upper limbs for 3 weeks.
• Abdominal distension & external genitalia swelling for 2 weeks.
• Reduced urine output for one week.
HISTORY OF PRESENTING
ILLNESSES:
• 3 year old male child 1st born to third degree consanguineous
marriage, was brought with complaints of puffiness around the eye &
face for one month, insidious in onset, gradually progressive, from
initially involving the peri-orbital region to the whole of face, more
during morning hours and then decreases as the day progresses.
• Then mother noticed swelling of bilateral lower limbs after 5-7 days,
insidious in onset, gradually progressed from feet to knee, then in the
upper limbs from hands upto elbow; more during morning hours and
then decreases as the day progresses.
• After 4-5 days, mother noticed generalised abdominal distension,
insidious in onset, gradually progressive which later went on to
involve the external genitalia. There was no associated pain abdomen.
• Mother has noticed reduction in both frequency & the amount of
urine passed since a week, initially used to pass 6-8 times per day and
presently passing 3-4 times in reduced amounts, high coloured urine
was present & she noticed frothing of urine.
• No history of breathlessness on exertion, chest pain, recurrent
respiratory tract infection, decreased physical activity, altered
appetite, failure to thrive, jaundice, vomiting blood, blood in stools.
• No history of cola coloured urine, headache, blurring of vision.
• No history of recurrent infections, weight loss, bony pain, blood
transfusion, skin lesions, rashes, joint pain, drug intake.
• No history of crying during micturition, urgency, increased frequency
of micturition.
• No history of pain abdomen, vomiting, reduced appetite, loose stools,
cough, hurried breathing, chest in drawing, fever.
• No history of headache, altered sensorium, seizures.
PAST HISTORY:
• Child was apparently normal 6 months back, when he had similar
complaints of puffiness of eyes & face progressing to involve lower &
upper limbs followed by abdomen genitalia. He went to a local clinic,
was admitted for 3 days where he was given IV Medications, then oral
medications were advised for 4 months, but he discontinued after 2
months as the swelling subsided within two weeks.
• After that the child was asymptomatic for 3 months.
• No history of tuberculosis.
TREATMENT HISTORY:
• The child was not on any regular medications.
Antenatal History:
The child is of 1st born out of 3rd degree consanguineous marriage.
The mother is a registered case and history is as follows:

1st trimester:
• No h/o of fever, rash.
• Dating scan was done
• Folic acid was taken
• No other drug intake or radiation exposure.
• No alcohol/tobacco/substance abuse.
2nd Trimester:
• Quickening felt at 18 weeks.
• 2 doses of Tetanus toxoid taken 1 month apart.
• Iron, folic acid & calcium taken.
• Anomaly scan done and no abnormality noted.
• No h/o Headache, swelling of feet, blurring of vision, pedal edema,
documented hypertension.
• No h/o of Polyuria, Polydipsia & OGTT was done and was normal.
3rd Trimester:
• Appreciated fetal movements well.
• No h/o maternal fever, diarrhoea, UTI.
• No bleeding per vaginum, leaking per vaginum, foul smelling liquor,
premature rupture of membranes.
Birth History:
• Place: Doddaballapur
• Mode: Normal Vaginal Delivery
• Period of gestation: 39 weeks of gestation
• Baby cried immediately after birth.
Neonatal History:
• Birth weight: 2.9kg.
• Full term
• Cried immediately after birth
• Breastfeeding started 30 mins after delivery.
• Breast feeding was done adequately on demand at day and night, no
feeding problems was noticed.
• No respiratory difficulty, jaundice, cyanosis or seizures.
Developmental history:
• All developmental domains achieved till date.
Immunization History:
• Immunised upto date according to National Immunization schedule.
• BCG scar present.
• Optional vaccines not taken.
Diet history:
The child was exclusively breastfed till 6 months of age. Complimentary feeds was started at 6 months of age with Ragiseri. Breastfeeding stopped by 1 and half years of
age.

24 hour recall method:

Time Food Items Amount Calorie(kcal) Protein(g)

Morning Dosa 1 100 4
Chutney ½ cup 70 1.5
Afternoon Rice 1 cup 170 4
Sambar ½ cup 110 4
Curd ½ cup 35 1.5
Evening Biscuit 5 100 0
Night Ragimudde ½ 100 1.5
Sambar ½ cup 110 4
• Non veg: chicken 50g once a week.
• Not taking food items such as salted snacks, cheese, pickle.

• Calories:
Consumed: 770kcal
Required: 1200kcal
Deficit: 430kcal (35%)

• Protein:
Consumed: 20.5g
Required: 26g
Deficit: 6.5g (30%)
Family history:
• Type: Extended family
• Members: 6 (Grand parents, Parents & 2 kids)
• Sibling: 11 month old healthy boy child.
• No abortion or stillbirths.
• No history of tuberculosis contact, similar complaints, early death due
to congenital disorders.
Pedigree:
Socioeconomic Status:
• House: 2 room Pucca house, with a kitchen, separate bathroom and
toilet, with adequate sanitary measures & clean water supply.
• Hand hygiene: poor
• Father occupation: tractor driver(10-15k per month), education till 9th
standard.
• Mother occupation: House wife, education till 10th standard.
• Kuppuswamy scale: Lower middle class
Summary:
• 2 years 11 months old child of birth order 1, born of 3rd degree
consanguineous marriage, Full Term Normal Vaginal Delivery, belonging
to Class 3 Kuppuswamy Scale, all developmental domains achieved &
fully immunized with dietary deficit of 35% calories & 30% protein was
bought to OPD with complaints of puffiness around eyes and face for 4
weeks, progressing to involve bilateral lower and upper limbs since 3
weeks, abdominal & external genitalia swelling for 2 weeks.
• With this would like to consider that the child is suffering from 1st
relapse of idiopathic nephrotic syndrome, most probably MCNS, with
no obvious complications.
General Examination:
• Child was alert, playful, Well looking, lying on the mother’s lap.
• Examined in supine position.
• Anasarca was present.
Vitals:
• Temperature: 98.6 degree Fahrenheit
• PR: 98bpm, good volume, regular, no delay, all peripheral pulses felt.
• RR: 32/min
• CFT<3 seconds
• BP: 85/50 mmHg(50-90th centile)
Head to Toe Examination:
• Head: normal in size and shape.
• Hair: hypopigmented, lustreless, thin
• Face: peri-orbital puffiness, facial puffiness.
• Oral Cavity: no ulcers, fissures at the angle of the mouth & lips, no cleft lip &
palate, gum bleeds. Dentition normal, no dental carries, tonsils & throat normal.
• Eyes: Pallor present, no icterus, cataract, microcornea, buphthalmous, bitot spots,
ulcer, scar, corneal neovascularization, conjunctivitis, conjunctival haemorrhages.
• Ears: no discharge.
• Nose & nasal cavity: normal.
• Neck: no rashes around neck.
• Chest: ribs are prominent, no Rachitic rosary, Harisson’s sulcus, pigeon
chest.
• Umbilicus: normal position & stretched.
• Abdomen: distended
• Genitalia: scrotal & penile edema
• Spine: normal
• Extremity: bilateral pitting edema upto knees & elbow
• Skin: shiny over edematous region.
• Skeletal system: no valgus or Varum deformity, anterior tibial Bowing.
• No cyanosis, clubbing, lymphadenopathy.
Anthropometry:

Observed Expected Inference

Weight(wet) for age 10.8kg 14.2kg -2 to -3SD

Length for age 86cm 95.4cm -2 to -3SD

HC 48cm 49.4cm At -1SD

MUAC 12.5 Malnutrition

Wt for Lt -1 to -2SD
SYSTEMIC EXAMINATION:
GIT: examined in supine position

Inspection –
• Abdomen distended Uniformly, flanks full
• Corresponding quadrant move equally with respiration
• Umbilical central, stretched.
• No scars
• Superficial dilated veins present
• No Visible peristalsis, pulsations.
• Hernial orifices are normal
• External genitalia: scrotal & penile edema present
Palpation –
• No local rise of temperate and Tenderness, pitting edema present.
• On deep palpation liver ,spleen, kidney are non palpable; no
tenderness
• Abdominal Girth:53cm
Percussion
• Shifting dullness present
Auscultation
• Normal Bowel sounds are heard
Other systems:

• RS – Normal vesicular breath sounds heard, Bilateral equal air entry

no added sounds

• CVS- S1 S2 heard, no murmur

• CNS - No focal neurological deficit

DIAGNOSIS:
• 1st relapse of idiopathic nephrotic syndrome, most probably MCNS,
without any complications, along with nutritional anemia, Protein
Energy Malnutrition.
INVESTIGATIONS:
URINE ROUTINE
• protein 4+
• Sugar: nil
• WBC: 6-8
• RBC: 0-15
• epithelial cells: 1-2

Interpret the report?

INVESTIGATIONS
• Serum Albumin: 1.3
• Total Cholesterol: 400
INVESTIGATIONS
CBC
• Hb: 11g%
• PCV: 40
• TC: 15,300
• N: 80%
• Platelets: 6,00,000
INVESTIGATIONS
ELECTROLYTES
• Na: 130
• K: 3.6
• Cl: 100

RENAL FUNCTIONS
• Urea: 134
• Serum creatinine: 0.7
CASE SCENARIO 1
• Pulse : 120/min, low volume
• RR : 34/min
• BP: 70/40mmHg
• CFT prolonged

• What will you do?

CASE SCENARIO 2
2 month old girl with swelling of entire body since 1 week, on
examination has generalised edema,investigations
• urine albumin 4+
• serum albumin 0.8
• Total cholesterol 450

• Diagnosis?
CASE SCENARIO 3
7 year old child with Nephrotic syndrome diagnosed at the age of 4
years, initially had 1 episode per year,but last year he has had
relapses in January 2019, June 2019,October 2020 and February 2020

Diagnosis?
Treatment?
CASE SCENARIO 4
• 6 year old girl with Nephrotic syndrome, initially had a IFRNS course
• Last episode : 7/9/2020- was started on 2mg/kg of wysolone
• Urine albumin monitoring was done at home
• on 16th,17th and 18th September, urine albumin was nil

• you see the child on 19th- What will you do?

Continued
• Today, 28/9/2020, child has come with edema and urine albumin in is
4+

• What will you do?

• What is your Diagnosis?
CASE SCENARIO 5
• 5 year old boy diagnosed to have first episode nephrotic syndrome in August
2020
• weight 20kg
• Has received 40mg Wysolone tablets daily for 1 month

He has no edema, but urine albumin on 3 consecutive mornings is 3+

Diagnosis?
What additional investigations?
CHILD XYZ
• First episode was treated only for 2 months -improperly treated first
episode Nephrotic Syndrome
• Now with first relapse
• How will you treat?
THANK YOU