General medicine case 3

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

Date of admission : 10th September 2021

A 14 year old male came with the complaint of 

- involuntary movements since one day

- vomitings since one day 

 History of present illness : 

- The patient was apparently asymptomatic 20 days back then he noticed facial swelling and pedal edema which was treated by local doctor.

- After few days the patient developed fever for which he was given symptomatic treatment and the condition subsided.

- He had 4 episodes of vomiting on 9th september with increased blood pressure and involuntary movements.

- The patient also noticed reddish urine output

 History of past illness : 

- The patient is not a known case of hypertension, diabetes, tuberculosis, epilepsy, asthma.

Personal history :

- The patient has no loss of appetite

- He takes mixed diet

- He has proper bowel and bladder movements

- No sleep disturbances

- No addictions 

Family history :

- There are no similar complaints in the family members

Treatment history :

- The patient has taken medications for fever and pedal edema associated with facial puffiness

- He is not a known case of drug allergy.

General examination :

- Patient is conscious, coherent, cooperative at the time of joining

- No pallor

- No icterus

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- No pedal edema

Vitals : temperature - afebrile

              Pulse rate - 78 bpm

              Respiratory rate - 18 cycles per minute

              BP - 130/90 mm Hg

Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry us normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- bowel sounds heard

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Provisional diagnosis : Acute glomerulonephritis

Investigations : 

Hemogram :

Complete urine examination : 

ECG : 

TPR chart :

Urine microscopy : 

Serology : Negative

ESR : 25 mm Hg

Renal function tests :

Urea : 40

Creatinine : 1.0

Calcium : 8.8

Phosphate : 3.6

Sodium : 139

Pottasium : 4.3

Chlorine : 102

Liver function tests : 

AST - 22

ALT - 19

Final diagnosis : Acute glomerulonephritis

Treatment : 

Inj. Zofer 4 mg IV

Tab. PCM 650 mg

Inj. Optineuron 10 mp in 100 ml NS IV

Tab. Sodium valproate 500 mg OD

Inj. Pantop 40 mg IV

Fluid restriction < 1.5 litre/day

Salt restriction < 4 g/day

1. What are the causes of acute glomerulonephritis?

2. Differential diagnosis for acute glomerulonephritis ?

3. Why did the patient have involuntary movements ?

4. When can the condition be diagnosed as secondary to streptococcal infection? 

5. What are the features of nephritic disease?