abdominal examination + nephrotic syndrome

Tag: Physical examination + discussion on Nephrotic syndrome

Abdominal examination with Dato’ Abdullah zawawi

Case: Relapse Atypical nephrotic syndrome(9 years old)

In any P.E, apply these steps for introduction before proceed with P.E

 I(intro)

P(permission)

E(explaination)

P(position)

E(exposure)

Before you start, please bear in your mind that you are about to examine a HUMAN, so do communicate with her/him throughout the examination.

Start with GENERAL INSPECTION at the end of the bed, head to toe, side by side for;

alertness, consciousness, general body built, hydration and nutritional status, attachment(s):in this case there is branula attachment that connect with medication(steroid i think)

Then go nearer, proceed  with general examination(start with periphery a.k.a hand la, org melayu kannn???:Dr fadzil, then proceed with head to toe)

in this case

hand: look for clubbing, cyanosis, pallor, palmar erythema(polycythemia due to steroid toxicity) skin infection; tenia vesicolor(due to steroid)

head & neck: cushing’s feature(moon face, bufflo hump, central obesity n others, please add kJ

foot: ankle edema

After that continue with SYSTEMIC EXAMINATION

inspection: ayat biase abdominal examination la.. for this case look for abdominal distension, scrotal swelling, scar for biopsy(at the back), bed sore, fullness of flank, moving with respiration, central obesity(cushing’s).. n ade lg rasenye, bley tambah k..sila comment nt ble aku post!!!

Palpation: superficial & deep.. always look at patient’s face! Don’t forget to communicate with patient k..:) look for any tenderness(in this case peritonitis can occur due to pneumococcal infection, thats why we give PENICILLIN V as prophylaxis n Tx), organomegally n masses. Measure the liver span. Ballot the kidney

Percussion: shifting dullness(tilt the patient properly) & fluid thrill, trout space

Auscultation: abdominal sound n bruit.

Lastly end with PER RECTAL EXAMINATION!!

  

DDX:

1.       AGN

2.       Atypical NEPHROTIC

3.       Lupus nephritis

INVESTIGATION:

BLOOD

1.       FBC(HB, leucocyte count for infection(viral or bacterial)

2.       Liver profile( total protein, albumin, liver enzyme(exclude liver causes of edema i.e. liver failure, hepatitis & malaria(in orang asli!)

3.       Lipid profile

4.       Renal profile(urea n creatinine)

5.       Serum C3/C4 to exclude AGN

6.       BFMP to exclude malaria in orang asli or endemic area case.

7.       ANA antibody to exclude lupus.

8.       C & S

9.       Add some more please!!!

URINE:  

1.       24hr urine collection and protein: more than 1g/m2/day or 40mg/m2/hour

2.       UFEME for leucocyte in case of infection, heamaturia in case of nephrotic nephritis sx and also to exclude AGN

3.       Urine cast(x ingat lah aku, tolong2)

IMAGING(U/S ABDOMEN)

1.       Number of kidney!;)

2.       Edematous kidney in nephrotic sx

3.       Kidney shrinkage & scarring in kidney failure

4.       Minimal fluid accumulation

5.       Stone or others

RENAL BIOPSY:

Indication: renal impairment, steroid resistant, frequent relapse

MANAGEMENT:

1.       Admit the patient la..hehe

2.       Firstly treat the symptoms & proceed with the specific treatment for nephrotic

3.       Check the vital signs! & stabilize it.. in this case patient can come with HPT(nefidipine), SOB(O2), & FEVER(penicillin V). Don’t give gentamycin or other nephrotoxic antibiotic.

4.       Maintain ABC. Patient can present with SOB in case of pleural effusion, so maintain the air way. Give albumin;(to restore the heamodynamic imbalance n correct the colloid prseure so that edema will be reduce) and diuretics such as frusemide;(to wash out the 3^rd space fluid lost and to avoid fluid overload if albumin is given alone)

5.       Specific management: 60mg prednisolone for 4 weeks in divided dose every day, then tapper down to 40mg prednisolone for 4 weeks in divided dose alternate day, & tapper 25% of dose(40mg) for 4 months(tapper every month la.) every day jgk rasenye..ni yg aku ingt td la..hehe.. malas nk check..

6.       If ade masalah dgn prednisolone bley tukar dgn cyclophosphamide

7.       Give prophylaxis PENICILLIN V

8.       Then give follow up every month for disease progression & steroid complication

COMPLICATION OF STEROID:

Acute=severe septicaemia, pneumococcal peritonitis

Chonic= cushing’s syndrome, osteoporosis, cataract, hypertension, hrperglyceamia n others.. tolong add kat komen k..