This document summarizes the medical case history of a 3-year-old boy named Jubayer who was admitted with generalized swelling for 15 days and scanty urination for 10 days. He had a previous episode of nephrotic syndrome 10 months ago. On examination, he was found to have puffy face, distended abdomen, and moderate pallor. Laboratory tests showed urine protein of 4+ and normal kidney function. The provisional diagnosis was nephrotic syndrome first relapse, most likely minimal change disease. The management plan included supportive care, prednisolone treatment, and counseling.

1. Welcome

2. Clinical Meeting

3. Dr. Shubhra Prakash Paul
MD (Ped) Part II
Bangladesh Institute of Child Health

4. Particulars of the Patient
Name Jubayer
Medical Case History
Age 3years
Sex Male
Address Panchagar
Date of Adm. 10/04/2012
Date of 12/04/2012
Exam.

5. Presenting Complaints with Duration
Generalized swelling for 15 days
Case History
Scanty Micturition for 10 days

6. History of Present Illness
According to his mother, Jubayer was quite
well 15 days back. Then there developed
generalized swelling starting from face.
Mother complained also of scanty micturition
Case History
for last 10 days. There is no history of sore
throat or skin infection prior to this illness.
There was no chest pain, breathlessness ,
headache during the courses of illness.

7. History of Past Illness
Jubayer suffered from same type of illness
i.e. generalized swelling starting from face,10
months back and diagnosed as a case of
nephrotic syndrome first attack and treated
Case History
accordingly in Rangpur Medical College
Hospital and subsequently at Dhaka Shishu
Hospital with Tab. Cortan and syp. Neotack.

8. History of Past Illness
He was completely relieved from 1st attack
of Nephrotic syndrome and completed the
alternate day steroid for adequate duration.
There was no history of breathlessness,
Case History
chest pain, headache, passage of high color
urine through out his illness. He suffered
from occasional cough and cold.

9. Treatment History
He was treated with optimum dose of Tablet
Prednisolone and Syrup Ranitidine for
optimal duration.
Birth History
Case History
He was delivered at term at home without
any perinatal untoward event. His mother
was on irregular antenatal check-up.

10. Immunization History
He is immunized as per EPI schedule
Feeding History
Case History
He was on exclusive breast feeding up to 6
months of age, after that complementary
food is introduced and tolerated. Now he is
on family diet.

11. Developmental Milestones
His mile stone of development is age
appropriate
Family history
Case History
He is the third issue of his non-
consanguineous parents. Other sibs are
healthy. All of his family members are
healthy.

12. Socioeconomic History
Jubayer belongs to a lower socioeconomic
family; father being a farmer and mother
housewife.
Housing and Sanitation history
Case History
He lives in a kacha house with his family
members and drinks tube well water and
uses sanitary toilet.

13. Physical Examination
General Examination
Appearance Playful but having puffy face
and distended abdomen
Built Average
Nutrition Average
Case History
Co-operation Co-operative
Pallor Moderate
Jaundice Absent
Cyanosis Absent
Clubbing Absent

14. Physical Examination contd.
General Examination contd.
Koilonychia
Leuconychia Absent
Dehydration
Edema Present (bilateral pedal)
Case History
Temperature 990F
Pulse 98 /min.
Resp. rate 24/min
Blood Pressure 95/50 mm of Hg

15. Physical Examination contd.…..
General Examination contd..
Skin BCG mark present, no skin lesion
is present
Sign of Absent
meningeal
Case History
irritation
Lymphnode Accessible nodes are not
s enlarged

16. Physical Examination Contd.
Case History
Marked area (arrow) Bilateral pedal edema

17. Physical Examination Contd.
Case History
Marked area (arrow) indicates Puffy face and Ascites

18. Physical Examination contd.
General Examination contd.
HEENT Normal
Bed side urine (++++)
albumin
Others IV cannula placed on
Case History
right hand

19. Physical Examination contd.
Anthropometry
Height Cm
Weight 13 Kg
Weight for Age + 2 SD
Case History
Height for Age + 0.8 SD
Weight for SD
height
Body Surface 0.71 m2
area

20. Physical Examination Contd.
Per abdominal Examination
Inspection
Abdomen is distended, flanks are full, umbilicus is
centrally placed and everted with transverse slit.
Penis and both scrotum are normal.
Palpation
Case History
Abdomen is soft and non tender. There was no
organomegaly. Both kidneys are not bimanually
ballotable.

21. Physical Examination Contd.
Per abdominal Examination
Percussion
Percussion note is dull. Shifting dullness present
Auscultation
Bowel sound is present.
No hepatic, renal or aortic bruit is detected
Case History

22. Physical Examination Contd.
Examination of Cardiovascular System
No abnormality detected
Examination of Respiratory System
Case History
No abnormality detected
Examination of Alimentary System
No abnormality detected

23. Timeline of illness
Regular ANC -----No illness----
No drug, -
radiation -----------Immunization--------
NVD at term at home
Complementary
Breast feeding Swelling,
Puffiness of face
untoward event
Scanty micturition
Case History
feeding
No perinatal
6 mo. 3 years

24. Timeline of illness
< 7 days > < 14 days > < 2 mo. > 07/12/11-
01/01/12
Swelling Swelling Swelling Swelling
Tab. Frulac Tab. persist Decreased
Deltasone Tab. Deltasone Tab. Cortan
Syp. Gepin Syp. Gepin Syp. Neotack
and frulac
Case History
Panchagar Rangpur Home DSH
Medical
College
3 years

25. Timeline of illness
22/03/12 26/03/12 < 15 days > 10/04/12
Dose of Swelling Swelling, Admission
Steroid Reappear puffiness
complete ed Scanty
d micturition
Case History
Home Home Home DSH
3 years

26. Salient Features
Jubayer , 3 years old boy, 3rd issue of his non-
consanguineous parents from Panchagar was
admitted with the complains of generalized
oedema for 15 days and scanty micturition for
10 days. He suffered from nephrotic syndrome
1st attack 10 months back and was treated
accordingly with prednisolone at optimal dose
Case History
and duration. There was no history of skin
infection or sore throat prior to this illness. There
is no history of chest pain, breathlessness,
headache, hypertension or passage of high
colour urine.

27. Salient Features
On examination Jubayer was found playful,
oedematous, moderately pale. Vital signs are
found within normal limit i.e. HR- Resp. Rate-
Temp. 0F and blood pressure mm of Hg. Skin
survey revealed presence of BCG mark and
absence of any skin lesion. There is no
Case History
lymphadenopathy. Bed side urine protein was
4+. Systemic examination revealed presence of
ascites without hepatosplenomegaly.
Examination of respiratory , cardiovascular and
other system revealed no abnormality.

28. Provisional Diagnosis
Nephrotic Syndrome
(1st relapse) most
Case History
probably Minimal
change disease

29. Differential Diagnosis
Nephrotic syndrome
other than minimal
Case History
change disease

30. Laboratory Investigations
1. Urine routine and microscopic examination (10/04/12)
Appearance
Color Straw
Albumin +++
Microscopy
Pus cell 1 - 2/HPF
Case History
RBCs Nil
Epithelial cells 1 - 2 /HPF
Spot protein creatinine ratio 3.5
II. Urine culture (10/04/12)
No growth

31. Laboratory Investigations
II. Biochemical Parameters (on 11/02/2012)
Serum Creatinine 33.2 µmol/L
Blood urea 2.2 mmol/L
Serum Albumin 7.5 gm/dL
Serum electrolytes
Sodium 138.9 mmol/L
Potassium 3.3 mmol/L
Case History
Chloride 101.8 mmol/L
SGPT 38 IU/L
Serum calcium 1.79 mmol/L
C- Reactive Protein (CRP) 3.7 mg/L

32. Laboratory Investigations
III. Complete Haemogram (10/04/12)
Hemoglobin 10.1 gm/dL
ESR 125 mm in 1st hour
Total WBC Count 16,400 /cumm
Differential count of WBC
Neutrophil 60 %
Case History
Lymphocytes 35%
Monocytes 02 %
Eosinophil 03 %

33. Final Diagnosis
Nephrotic Syndrome (1st
Case History
relapse)

34. Management
A. General Supportive
• Normal diet
• Daily monitoring of Blood pressure, Weight,
Bedside urine albumin, recording of intake
and output, abdominal girth.
B. Specific
Case History
• Tab. Prednisolone 60 mg/m2/day for 4 - 6
weeks followed by 40 mg/m2 every alternate
day for 4 – 6 weeks.

35. C. Counseling
Case History

36. Thank you