1. R. Francisco – J. Garimbao Dr. Balderas

2.  Identifying data EMA, an 8-year old, Filipino, Roman Catholic female, from Parang, Marikina

3. Chief Complaint  Fever of 13 days  Abdominal pain of 2 days

4.  History of Present Illness – 13 days prior to admission  Intermittent low grade fever (undocumented)  temporarily relieved by Paracetamol  No other symptoms were noted – 10 days prior to admission  still with fever  productive cough  swelling of the face  no decrease in activity

5. 6 days prior to admission  Red discoloration of urine 2 days prior to admission  Facial edema disappeared  Still with fever, cough, and reddish urine  Intermittent peri-umbilical pain Few hours prior to admission  Peri-umbilical pain worsened as well as her fever

6.  Past Health Prenatal  Mother is eclamptic Birth  Born full-term  Via normal spontaneous delivery, phyician assisted at Amang Rodriguez Hospital  BW= 4lbs  BL and APGAR=unknown

7.  Neonatal History  Had pneumonia during 2 nd week of life

8.  Immunization History  Complete vaccination obtained from the health center

9. Feeding History  solely breastfed for 1 month  introduced to formula at 2 months ( Bona with 1:1 dilution ratio, Bonakid from six months to 1 year and was then shifted to bear brand)  introduced to solid food at 6 months  no allergies to food

10.  Developmental History  Unremarkable

11.  Past Illnesses/Hospitlizations  No major illness/hospitalization/surgery/ history of allergic reactions prior to the current admission apart from pneumonia during 1 st week of life as stated above.

12.  Family History  Her grandmother in the paternal side had aplastic anemia

13.  Social and Environmental History  The patient lives in a 1-story house with 1 toilet along with 5 other occupants  Water for both drinking and household purposes are from the faucet.

14. General Survey Patient is awake, alert, and ambulatory but uncooperative and is not in any cardio-respiratory distress Vital Signs  PR:  BP:  RR:  Temperature:

15. Anthropometrics:  Length: 64in (162.56cm)  Weight: 49kg (108.03lbs)  BMI: 18.5

16. Skin  pink-pinkish red maculopapular rash distributed on all his extremities  red scar-like lesions on the back  warm to touch with normal turgor, nails pink with no signs of infection, pallor, cyanosis or clubbing

17.  HEENT Head  The skull was symmetric, atraumatic with well distributed black hair  no hair loss/infestations. Scalp without any masses, lesions, signs of trauma and pigmentations.  No facial asymmetry was noted.  Face have scars on the nasolabial line with red non pruritic patches on the cheeks (~0.5-3cm in diameter)

18. Eyes  Eyes are symmetrical, with no exopthalmos/enophthalmos or edema  anicteric sclera and pink conjunctivae  both pupils constricting on direct and indirect pupillary reflex test.  VA: OS= J2, OD=J1.  Fundoscopy: (+) ROR

19. Ears  Auricles are aligned  no gross deformities, lesions, swelling or masses or discharge

20. Nose  No gross deformities, swelling, bleeding, lesions, erosions, masses, infections.  Nasal septum at the midline

21. Mouth  Pink, moist lips with no deformities  with pustules (~1-2mm) on the buccal mucosa  uvula and tongue at the midline  with no tonsillar redness/enlargement

22. Neck  Trachea midline  thyroid is non palpable as well as lymph nodes

23. Thorax and Lungs:  Chest symmetrical with equal expansion and excursion and without gross abnormalities or respiratory lag.  No intercostal retractions, no use of accessory respiratory muscles.  No lesions, masses on anterior chest but with scars on the back  no tenderness noted  equal tactile fremitus.  Vesicular breath sounds with no adventitious sounds on auscultation

24. Cardiovascular:  Adynamic precordium with no deformities/palpable thrills or bruits.  Distinct S1 and S2 heard loudest at the 4 th -5 th ICS left parasternal border with regular rate and rhythm.  No murmurs or adventitious heart sounds noted

25. Abdomen  It was flat and symmetrical with no lesions/deformities/discolorations.  Normoactive bowel sounds with no bruits over all quadrants.  Quadrants were non-tender and tympanitic.

26. Musculoskeletal:  There were no gross deformities of joints and extremities  Normal tone and a muscle grade of 5/5 on all muscle groups with full range of motion and no crepitations.  No tenderness on joints and extremities.

27. MSE  the patient is awake, alert, and cooperative Cranial Nerves  Unremarkable

28. Reflexes  Deep tendon reflexes on biceps, triceps, knee and ankle have a grade of +2, (-) Babinski reflex  Sensory: pain perception is intact for all extremities Cerebellar: no babinski; intact

29. Differentials Henoch-Schonlein Purpura Urinary Tract Infection (UTI) Systemic Lupus Erythematosus (SLE) Membranoproliferative Glomerulonephritis (MPGN)

30.  Rule in  -Renal involvement  -Gross Hematuria  -Asian prevalence  -Occurs mainly in young children.  Rule out  -Typical anaphylactoid purpura ex: Henoch- Schonlein Purpura.  -Arthritis and/or arthralgia  -No fever  -Boys

31.  Rule in  -Hematuria  -Fever  -Female gender  Rule out  -No edema  -No increased blood pressure.

32.  Rule in  -Increased blood pressure  -Edema  -Dark urine  -Fever  -Female gender  -Asian  Rule out  -Butterfly skin rash  -Arthritis  -Most commonly 20-45 years of age (onset.)

33.  Rule in  -Blood pressure and GFR affected.  -(Some) Acute nephritis and hematuria.  -Edema  Rule out  -Young adults.  -Urinary abnormalities persist past time of expected resolution for acute poststrep. Glomerulonephritis.

34.  Acute poststreptococcal glomerulonephritis was considered as the primary diagnosis due to:  patient develops an acute nephritic syndrome 1–2 wks after a possible streptococcal pharyngitis ( fever and cough)  Hematuria  facial edema

35.  Diagnostics CBC ASO titer Renal Function Tests  BUN  Creatinine  Urinalysis

36.  Treatment  Treatment is supportive and focuses on control of hypertension and edema if present.  A loop diuretic (furosemide) should be given in order to remove excess fluid which reduced edema and also helps to correct hypertension.  Antibiotics for streptococcal infection such as penicillin should be given within the first 36 hours from the onset of symptoms