Case Management Conference (04/04/19)

Dr. Monakil
Post-Graduate Interns:
Calimbahin, Mark
Iglesias, Marianne
Neyra, Coleen
Stehmeier, Mark
Villareal, Lejan

Clinical Case:
Patient K.B., a 4-year-old male, Filipino, Roman Catholic, currently residing in Silang, Cavite, who
was brought to DLSUMC-OPD with a chief complaint of tea-colored urine. One month prior to
consult, the patient had a wound at the 1st digit of the right foot, secondary to trauma (nail cutter).
Progression in size of the wound was noted, and no medications nor consult was done. Eleven
days prior to consult, the patient was noted to have undocumented fever, associated with facial
swelling. No noted other associated symptoms such as cough, colds, dysphagia, throat pain,
rashes, diarrhea, nor vomiting noted. No consult was done and no medications were given. Ten
days prior to consult, persistence of intermittent fever prompted consult at a nearby health
facility. The informant was unable to recall the diagnosis but was given paracetamol (unrecalled
dose), phenylephrine Hcl +chlorphenamine maleate and co-amoxiclav 27mg/kg/day. Compliance
only lasted for three days. One week prior to consult, intermittent fever persisted, now
associated with presence of tea colored urine, not associated with oliguria, dysuria nor changes
in bowel and bladder habit. Five days prior to consult, the patient was noted to develop cough
and colds, still with persistence of other accompanying symptoms. Patient was brought to
another health facility where a urinalysis was done which showed presence of protein (+1), pyuria
(wbc 28-30) and hematuria (too numerous to count). Patient was given cefixime of unrecalled
dose, with noted relief of fever, cough and colds, but persistence of hematuria. One day prior to
consult, the informant noted slight periorbital edema and decrease in urinary output. Persistence
of symptoms prompted consult.

Past Medical History:

Patient is a known case of G6PD, and was noted to have one hospital admission due to
pneumonia (2015). Patient was also diagnosed with hand-foot mouth disease 1 month prior to
consult. Given unrecalled cream which provided relief of lesions. No medications were being
taken prior to initial presentation of symptoms. No allergies present. No previous history of
surgery nor accidents noted. No previous occurrence of current symptoms observed. Complete
immunization based on WHO EPI according to informant.

Family Medical History:

Patient’s father is noted to have T2DM. No other relatives with similar symptoms.
Nutritional History:
Patient was breastfed until 4 months old. Complementary feeding started at 6 months and table
food introduced at 12 months. Patient is a non-picky eater with no noted preference for food.
No noted food intolerance.

Personal Social:
The Father is a 27-year-old electrician while the mother is a 24-year-old housewife. Exposure to
gadget (mobile phone) is unregulated, >5 hours per day. The patient currently lives with his father,
his mother, his grandparents, his 3 aunts, and his uncle. His primary caregiver is his mother, aunt
and grandmother, since his father works during the day. No pets at home but stray dogs around
the community were noted. Patient is also fond of playing outside with his friends.

Environmental History:
The patient is exposed to cigarette smoke. Garbage collected weekly. Drinking water comes from
tap water.

Developmental history:
No noted lapses with regards to development, (gross, fine, language and personal).

Birht and Maternal:

The patient was born to a 19-year-old G2P2 (2002) mother and a 22-year-old father. Complete
prenatal check, with no maternal illnesses nor complications noted. Born term at 38 weeks via
vaginal spontaneous delivery, with no NICU admission nor complications. However, G6PD was
noted upon new born screening,

Review of Systems:
General: -change in activity; -loss of appetite, -weight loss/gain
Skin and Lymph - +skin lesion, 1st digit, right foot, -erythema, +scaling –tenderness, -warmth, -
rashes,
HEENT - +CLAD, +periorbital swelling, -headaches, -concussions, -conjunctivitis, -visual problems,
-hearing, ear infections, -draining ears, +cold –epistaxis, +dysphagia, -ulcers
Cardiac - -cyanosis -dyspnea, -heart murmurs, -chest pain, -palpitations
Respiratory +cough -hemoptysis,-difficulty of breathing, - shortness of breath
GI -diarrhea, -constipation, -vomiting, -hematemesis, -jaundice, -abdominal pain,
GU – decreased frequency, -dysuria, +hematuria, -discharge, -abdominal pains, -polyuria,
Musculoskeletal -joint pains -swelling, -weakness, -injuries, -gait changes

Impression: POST-STREPTOCOCCAL ACUTE GLOMERULONEPHRITIS (OLIGURIC PHASE)

At the OPD:
BP 130/90mmHg, HR 82 bpm, RR 24cpm, T 36.0
Patient was noted to be awake, conscious, coherent and not in cardiorespiratory distress. No
signs of dehydration was noted. No pallor, no jaundice, no CLADS but with slight periorbital
edema (bilateral). Non-hyperemic, non-hypertrophic tonsils noted. Clear breath sounds, normal
rate, regular rhythm with no observed murmurs. Abdomen was soft, non-tender. No edema of
extremities, no limitation of ROM. +1x1 scaly non-erythematous, tender lesion at the 1st digit of
the right foot noted. Normal mental status and no motor and sensory deficits noted. Patient is
initially given nifedipine; a repeat BP showed decrease in BP of 110/70 mmHg.

Course in the Wards

On the first hospital day, the patient was noted to be on his 12th day of illness. He still had
productive cough with whitish nasal discharge. Urine was noted to be tea-colored. On PE, the
patient was hypertensive upon taking his blood pressure on the lower extremities. He had clear
breath sounds and slightly distended abdomen. A 1x2 cm wound was noted on the first digit of
his right foot, described as a solitary lesion that was hypopigmented with erythematous border
and is slightly swollen. Patient had negative fluid balance with an output of 1.06cc/kg/hr which
is still adequate. The following diagnostic tests were done: CBCPC, ASO, C3, BUN, Crea, Serum Na,
Cl and KUB UTZ. For the therapeutics, patient was given the following: Penicillin G 225,000u IV
Q6, Furosemide 18mg IV Q12 (1mkday), and Nifedipine 5mg/cap, 1 capsule Q6 for BP >= 110/70.
Daily monitoring of Abdominal circumference and weight was done

On the second hospital day, patient still had productive cough and tea-colored urine. One episode
of pinkish urine was noted as well as an increase in urine output. Patient still had hypertensive
episodes. Weight was noted to decrease as well as the abdominal circumference. Lesion on the
right big toe was assessed as an infected ingrown and wound cleaning was done using Betadine.
Penicillin was discontinued and Furosemide was shifted to oral medication. Nifedipine was given
RTC and PRN basis to control the hypertension.

On the 3rd hospital day, persistence of cough and tea-colored urine were still noted. No
hypertensive episodes. There was decrease in abdominal circumference. RTC Nifedipine was
discontinued.

On the 4th hospital day, cough and colds resolved but still with occasional tea-colored urine.
There was also decrease in erythema of the lesion on the right foot. Furosemide was discontinued.

On the 5th hospital day, patient still had occasional tea-colored urine. No hypertensive episodes.
Patient was sent home.

Pertinent Laboratory Findings:

KUB ULTRASOUND (03/19/19)

Both kidneys have relatively increased parenchymal echogenicity. The right kidney measures 7.5
x 3.4 cm (NV = 5.86 to 7.86 cm) with a cortical thickness of 0.4 cm, while the left kidney measures
8.0 x 4.4 cm (NV = 6.26 to 8.34 cm) with a cortical thickness of 0.4 cm. Both central echo
complexes are intact. No renal lithiasis seen.
The urinary bladder is adequately filled, with smooth walls and no internal echoes seen. The total
amount of urine in the bladder is approximately 315 cc, which was reduced to 8 cc on post-void
scan.

IMPRESSION:
- CONSIDER DIFFUSE RENAL PARENCHYMAL DISEASE, BILATERAL
- RESIDUAL URINE VOLUME OF 8 cc

URINALYSIS

AMORPHOUS
CHARACTER

EPITHELIAL

OXALATES
BACTERIA
ALBUMIN

THREADS

CALCIUM
GRAVITY
SPECIFIC

URATES
MUCUS
COLOR

SUGAR

CELLS
DATE

WBC

RBC
PH

Dark
3/13/19 Turbid 1.030 6.0 1+ Negative 28-30 TNTC - Few - - -
yellow
Dark
3/17/19 Turbid - 6.5 2+ Negative TNTC TNTC - Few - - -
yellow

CHEMISTRY
CREATININE

CHLORIDE
SODIUM
DATE

BUN
ASO

C3

3/18/19 200 6.7 61.6 140 108 195