Case 3-A long case

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.

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 .

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

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

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 .

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.

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

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.

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