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 Case 3-A long case

استعرض الموضوع السابق استعرض الموضوع التالي اذهب الى الأسفل 
كاتب الموضوعرسالة
Mohammad
مشرف قسم خمسه فرفشه
مشرف قسم خمسه فرفشه


ذكر

عدد الرسائل : 313

العمر : 30
العنوان : ]
العمل : ]
تاريخ التسجيل : 23/08/2008

مُساهمةموضوع: Case 3-A long case   الأربعاء يناير 14, 2009 7:35 am

(This case is based on real cases and events, and I was asked some of these questions in my Exam. It is a special gift to Dr Amani, as I know she is studying pediatrics now. I know it is very long, and it took me very long time to design it, but I think it is worth discussing.)



Nada Ahmad, a 5 year old female child, presented to the pediatric outpatient clinic in
SCU hospital with her mother.

The mother complained that her child had generalized body swelling.

HPI:
The condition started 6 days ago by periorbital puffiness, more in the morning.
Then the edema evolved in a descending manner over the following 2 days to involve
the whole face, upper limbs , trunk and the lower limbs. There was vulvar edema.

The mother noticed that her child's weight increased significantly during the illness (She did not weigh her, but she was no longer able to carry her ).

Review of the urinary system revealed oliguria, progressive in course over the previous 5 days. The mother noticed frothy urine on standing!

No hematuria or any other change of urine color, urgency , frequency or incontinence.

There was abdominal pain, gradual in onset and progressive in course developing over
the previous 2 days. No nausea, vomiting or diarrhea.

Otherwise, review of other systems was unremarkable.

Past history and family history: NAD (No abnormality detected)

Examination:
General:
Body Temp.: 37.5
Blood pressure: Normal?
Heart rate: Noraml?
Respiratory rate: Normal?
Body weight: 25kg

Chest Examination:
Right hemithoax:
Diminished chest expansion, with absent tactile vocal fremitus on the back.
Dullness of the right lung field detected on the back only
Diminished air entry on the back only.

Left hemithorax:
No abnormality detected.


Abdominal Examination:
Shifting dullness is evident on both sides.No organomegaly.



The pediatrician admitted the child to the hospital, and asked for the following
investigations:

-Urinalysis (urine analysis)
-Urinary 24 hour protein.
-BUN, Serum creatinine.
-AST-ALT
-CBC
-Serum C3 (complement 3)


In addition to these investigations he asked for an investigation which would be
performed on a single early morning urine sample, and claimed that it would be diagnostic !!!

When the results arrived, the pediatrician proposed the following plan of management.

-Hostacortin 5mg tab:
Five x 2 daily(to be dissolved in water before given)

-Mucogel syrup:
One teaspoonful after Hostacortin tablets.

-Lasix 20mg tab:
one x 2 daily.

Note:
Hostacortin, a popular trade name for prednisone,
Epicogel: Antacid.
Lasix: Furosemide

The following day, Dr Huda Atwa was reviewing the TTT plan of the inpatient cases. She was satisfied with the treatment plan of Nada, but she recommended the addition of a vaccine!!!

Questions:

1-What is the most probable diagnosis?

2-Give an explanation for the underlined data.

3-What are the normal levels of vital signs in this age group and in other pediatric age groups?

4-What is this curious investigation that can clench the diagnosis of this condition with reasonable accuracy from a single urine sample?

5-Do you agree with the daily amount and the division of doses of Hostacortin and Lasix?

6-Why did the physician add Mucogel to the treatment plan?

7-What can be the vaccine recommended by dr Huda Atwa




عدل سابقا من قبل Mohammad في الأربعاء يناير 14, 2009 9:04 am عدل 1 مرات
الرجوع الى أعلى الصفحة اذهب الى الأسفل
Mohammad
مشرف قسم خمسه فرفشه
مشرف قسم خمسه فرفشه


ذكر

عدد الرسائل : 313

العمر : 30
العنوان : ]
العمل : ]
تاريخ التسجيل : 23/08/2008

مُساهمةموضوع: رد: Case 3-A long case   الأربعاء يناير 14, 2009 8:09 am

Mucogel syrup

It is an antacid preparation produced by Eipico pharmaceutical company.It is a
leading national company.

Active ingredients: Mainly;

Aluminium hydroxide
Magnesium hydroxide

Both compounds neutralize gastric acidity, they are added to each other
because:

Alumunium hydroxide produces constipation, while Magnesium hydroxide produces
diarrhea, so, added together, bowel habit is less affected.



Logo of the company



Note: Take your TIME TO STUDY THE CASE.You don't have to answer all questions at the same time.


عدل سابقا من قبل Mohammad في الأربعاء يناير 14, 2009 5:17 pm عدل 2 مرات
الرجوع الى أعلى الصفحة اذهب الى الأسفل
Mohammad
مشرف قسم خمسه فرفشه
مشرف قسم خمسه فرفشه


ذكر

عدد الرسائل : 313

العمر : 30
العنوان : ]
العمل : ]
تاريخ التسجيل : 23/08/2008

مُساهمةموضوع: رد: Case 3-A long case   الأربعاء يناير 14, 2009 9:07 am

Lasix is produced by Aventis.

Sanofi Aventis was formed in 2004 when Sanofi-Synthélabo acquired Aventis.

Sanofi-Aventis headquartered in Paris, France, is a multinational pharmaceutical
company. The company is the world's fourth largest pharmaceutical company.

Logo of the company:



Active ingredient: Furosemide, also known as Frusemide (both are correct)

The name of Lasix is derived from lasts six (hours) -- referring to its duration of
action.

It is available as tablets 40mg, as well as ampoules 20 and 40 mg .



عدل سابقا من قبل Mohammad في السبت يناير 24, 2009 12:40 am عدل 1 مرات
الرجوع الى أعلى الصفحة اذهب الى الأسفل
snow white
عضو شرف
عضو شرف


انثى

عدد الرسائل : 13

العمر : 30
العنوان : الإسماعيلية حي السلام
العمل : طالبة
تاريخ التسجيل : 20/11/2008

مُساهمةموضوع: رد: Case 3-A long case   الأربعاء يناير 14, 2009 10:57 pm

السلام عليكم ورحمة اللع وبركاته
مبدئياً أحييك على الصياغة الرائعة وجزاك الله خيرا . انا هحاول أمشي فيها بس لو فيه أي حاجة فكرت فيها بطريقة خاطئة عايزة تعليق ماشي .
1) In my openion yhe most propablr diagnosis ie primary ( idiopayhic ) nephrotic syndrome .( The most common type of nephrotic syndrome in children is minimal change )

2) Explanation of the underlined data :
* oliguria isn't a main feature for diagnosis of nephrotic syndrome m but it may be present in the stage of edema .
* Frothy urine on standing is due to proteinuria
* Abdominal pain developed in the last 2 days with the propagation of the edema in descending manner till causing ascitis which is mostly the cause of the pain.
* Rt. hemithorax examination mostly indicate pleural effusion due to the absence of TVF , dullness , diminished air entery and chest expantion . As the causes of absent TVF is pleural effusion , collapse , pneumothorax . Collapse is excluded as in which there is impaired note not dullness , and so peumothorax that has tympanitic resonense . Pleural effusion occurs in the course of generalized edema in late stages .
* Shifting dullness is evedent due to the presence of ascitis .

3) Vital sugns in this age is :


Child vital signs (age 1 to 8 years)

Pulse

80 to 100 beats per minute

Blood pressure

80 to 110 mmHg systolic

Respirations

15 to 30 breaths per minute

in other pediatric ages

Infant vital signs (age 1 to 12 months)

Pulse

100 to 140 beats per minute

Blood pressure

70 to 95 mmHg systolic

Respirations

25 to 50 breaths per minute


Infant vital signs (age 1 to 12 months)

Pulse

100 to 140 beats per minute

Blood pressure

70 to 95 mmHg systolic

Respirations

25 to 50 breaths per minute
الرجوع الى أعلى الصفحة اذهب الى الأسفل
snow white
عضو شرف
عضو شرف


انثى

عدد الرسائل : 13

العمر : 30
العنوان : الإسماعيلية حي السلام
العمل : طالبة
تاريخ التسجيل : 20/11/2008

مُساهمةموضوع: رد: Case 3-A long case   الأربعاء يناير 14, 2009 11:43 pm

4) Few studies have shown that calculation of protein/creatinine ratio in a spot urine sample correlates well with the 24-hour urine collection. It avoids the collection errors and provides the information that is required for the diagnosis and follows-up of such cases . The normal value of protein/creatinine ratio was calculated to be 0.053 (S.E of mean±0.003
الرجوع الى أعلى الصفحة اذهب الى الأسفل
snow white
عضو شرف
عضو شرف


انثى

عدد الرسائل : 13

العمر : 30
العنوان : الإسماعيلية حي السلام
العمل : طالبة
تاريخ التسجيل : 20/11/2008

مُساهمةموضوع: رد: Case 3-A long case   الخميس يناير 15, 2009 12:24 am

5) السؤال دة محتاج وقت للبحث ممكن كمان يومين كدة

6) Mucogel for the side effects of steroid therapy .

7) children with nephrotic syndrome receive steroid with its immunosuppresor effect ( steroid senstive syndrome ) . some studies say that there is increased risk for varicella zoster virus so the vaccine that is recommended by dr Hoda is varicella vaccine .
الرجوع الى أعلى الصفحة اذهب الى الأسفل
Mohammad
مشرف قسم خمسه فرفشه
مشرف قسم خمسه فرفشه


ذكر

عدد الرسائل : 313

العمر : 30
العنوان : ]
العمل : ]
تاريخ التسجيل : 23/08/2008

مُساهمةموضوع: رد: Case 3-A long case   الخميس يناير 15, 2009 1:38 am

شكرا على الاستجابة السريعة والرائعة ، وطريقة تفكيرك منظمة ما شاء الله. وهذه تعليقاتي على الإجابات التي قدمتيها.

Q One: Your diagnosis is right. But take care, NEPHROTIC SYNDROME IS A CLINICAL
AND LABARATORY SYNDROME.....so DIAGNOSIS CAN'T BE MADE BASED ON
CLINICAL INFORMATION ONLY.

Q Two:
-You are right. Oliguria is not a feature of nephrotic syndrome, but it occurs due to
the contracted intravascular volume due to shift of fluid from the intravascular
space to the extravascular space.

-Frothy urine:Right, it is due to proteinuria. Differential diagnosis include
phosphaturia.

-Abdominal pain in this case may be due to: Mesentric hypoperfusion caused by
contracted intravascular volume (refer to Nsser Gamal,page 146)

But take care,always put Acute bacterial peritonitis (mostly pneumococcal
peritonitis in your mind). Peritonitis in the setting of nephrotic syndrome is

atypical and fever,rigidity and guarding may be minimal or absent,because all of
these may be blunted by corticosteroids.

Dr Ahmad Atef Said: Peritonitis is diagnosed in this case by HIGH INDEX OF
SUSPICION

-You are right. Pleural effusion is the cause the positive findings elicited by chest examination. BUT REMEMBER THESE FINDINGS ARE PRESENT ON THE BACK ONLY,WHICH DENOTE THAT THE LOWER LOBE IS THE SITE OF AFFECTION.

Now arise a question, why pleural effusion causes decreased TVF,while consolidation increases TVF?





-Vital signs:

Respiratory rate:According to IMCI, Less than two month:<60

Two to Twelv month: <50

One to five year: <40



Other vital signs are correct. But please review page 475 Nasser Gamal.



Q four-You are excellent. According to e-medicine:

· First morning urine protein/creatinine is more easily obtained than 24-hour urine

studies, possibly more reliable, and excludes orthostatic proteinuria.

· Urine protein/creatinine of more than 2-3 mg/mg is consistent with nephrotic-

range proteinuria



The normal value for protein/creatinine ratio is 0.2 (I am sure).



I was Asked this question by Dr Osama Zekry and Huda Atwa in my exam,and they were happy when I answered.




Q five: take your time

Q six: Excellent, prolonged corticosteroid therapy poses a risk of gastitis and peptic ulcer disease and the antacid is used to minimise this risk.

Q seven: Sorry. It is not the varicella vaccine.Take your time to search for
it.
الرجوع الى أعلى الصفحة اذهب الى الأسفل
snow white
عضو شرف
عضو شرف


انثى

عدد الرسائل : 13

العمر : 30
العنوان : الإسماعيلية حي السلام
العمل : طالبة
تاريخ التسجيل : 20/11/2008

مُساهمةموضوع: رد: Case 3-A long case   الخميس يناير 15, 2009 7:09 pm

السلام عليكم,
TVF referred to the palpable vibration transmitted through bronchopulmonary tree to the chest wall when the patient speaks , so it is affected when transmission of sound affected .
Dr/ Nancy in forth year said that factors affecting sound transmission are distance and media.
In pleural effusion there is separation between pleural surfaces by fluids so there is increased distance due to the separation and there isn't homogenous media for sound transmission ( fluids causes refraction)
But in consolidation there isn't anf effect on the distance tehre is only fluid in alveoli and transmisiion through fluids is easier than gases .
بس خلاص ولو في إضافة منكم نستفيد
الرجوع الى أعلى الصفحة اذهب الى الأسفل
snow white
عضو شرف
عضو شرف


انثى

عدد الرسائل : 13

العمر : 30
العنوان : الإسماعيلية حي السلام
العمل : طالبة
تاريخ التسجيل : 20/11/2008

مُساهمةموضوع: رد: Case 3-A long case   الخميس يناير 15, 2009 7:14 pm

Vaccine recommended by dr Hoda may be pneumococcal vaccine .The American Academy of Pediatrics released their recommendations for the prevention of pneumococcal infections with pneumococcal vaccines on June 5, 2000. It is recommended for who are at high risk, including children with an immune deficiency, sickle cell disease, asplenia (children without a working spleen), HIV infection, chronic cardiac conditions, chronic lung problems (including asthma), cerebrospinal fluid leaks, chronic renal insufficiency (including nephrotic syndrome) , diabetes mellitus, and children who are receiving immunosuppresive therapy (organ transplants, etc.).
There are two vaccine prevnar and 23PS , but in this age 23PS cheaper, provides good coverage against 23 subtypes of the pneumococcus and produces a good antibody response in children of this age, or they can receive the newer vaccine.
الرجوع الى أعلى الصفحة اذهب الى الأسفل
Mohammad
مشرف قسم خمسه فرفشه
مشرف قسم خمسه فرفشه


ذكر

عدد الرسائل : 313

العمر : 30
العنوان : ]
العمل : ]
تاريخ التسجيل : 23/08/2008

مُساهمةموضوع: رد: Case 3-A long case   الخميس يناير 15, 2009 8:57 pm

Excellent. Your explanation about TVF is completely right.

And the recommended vaccine is,as you mentioned, the pneumococcal vaccine.
And thank you for providing us with this valuable inforamtion about other
categories of patients who need this vaccine.

Gazakom Allah Khaira
الرجوع الى أعلى الصفحة اذهب الى الأسفل
 
Case 3-A long case
استعرض الموضوع السابق استعرض الموضوع التالي الرجوع الى أعلى الصفحة 
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