INTRODUCTION:

As a part of our clinical experience posting in Nirmal Hospital Surat, I took

care of Master. Yuvika who was diagnosed as acute post streptococcal glomerulonephritis
from 02/01/17 to 05/01/17. I selected this case in order to use this knowledge in my day to
day clinical practice.

BASE LINE DATA:-

Name : yuvika bikash behani

Age : 5 year, 9 month

Sex : female

Address : 202 vaishali APPT. bhatar road, surat

Religion : Hindu

Informant : Mother and Father

Diagnosis : Acute Post Streptococal glomerulonephritis

CHIEF COMPLAINTS:-

The child was suffering from hematuria, vomiting and also throat paining.

PAST HISTORY OF ILLNESS:-

The child has been no any surgical procedure perform and no any
serious medical condition occur;

PRESENT HISTORY:-

In present child have suffering from passing red colored urine (hematuria)
since 2 days, vomiting since 2 days, throat pain since 2days and back pain since 7-8 days.
FAMILY HIISTORY:

SL. NAME AGE SEX Relationship with EDUCATION OCCUPPATION HEALTH

No. patient
1. Mr. BIKASH 42 M Father Graduate Business Healthy

2. Mrs. GEETA 39 F Mother Graduate Housewife Healthy

In the family history, persons are not suffering from any disease condition and no any hereditary
disease is there and in past no any surgery will be performed.

SOCIO-ECONOMIC HISTORY:-

They belong to a good and middle class family in which father have own
business. They live in nuclear family and has their own house.

PERSONAL HISTORY:-

In the personal history

Diet pattern:- child is taken food ownself.

Elimination pattern:- the child has good bowel pattern but in bladder some time irritation will be
there.

Best and sleep:- the child sleeps for most of the time.

BIRTH HISTORY:-

ANTENATAL HITORY:- Mrs. Geeta had regular antenatal checkup and completed the course of
tetanus toxoid, folic acid and iron supplements.
INTRANATAL HISTORY:- The baby was delivered in hospital. Mother had normally delivered the baby.

POSTNATAL HISTORY:- the baby easily cry after delivered. Baby had spontaneous respiration. An no
any deformities seen in the baby after delivey.

DIETARY HISTORY:- In dietary child’s taken normal food during Illness, child have all type of food
,and also child have fast food before admit in the hospital.

GROWTH AND DEVELOPMENT:-

IMMUNIZATION:-

AGE VACCUNE PATIENT PICTURE

BCG
DPT
OPV
Vit.K
Hip.B
Measelas
Vit.A

PHYSICAL ASSESSMENT

A. General Observation
Child looks pale, moderately built, cooperative
B. Anthropometric Measurements
Height : cms
Weight : kgs
Head circumference : cms
Chest circumference : cms
Mid arm circumference : cms
C.Vital Signs
Temperature : 1020F
Pulse : beats/min
Respiration : breaths/min
Blood pressure : mm/hg

D.Skin And Mucus Membrane

Color : Pale brown
Integrity :
Edema : Absent
 Moisture : Dry
E.Head
Skull : No abnormality noted
Suture : Normal, no overlapping
Hair : Present
Movements of head : All ROM possible
F.Face
Appearance :
Color : Rose coloured skin
Symmetry : Symmetric
G.Eyes
Expression : Normal
Eye brows : Equal
Eye lids : No lesions
Lacrimation : Clear fluid
Conjunctiva : Normal
Sclera : White
Cornea : Moist
Iris :
Pupil : Reacting to light
H.Ears
Appearance : Normal
Hearing : Present
I.Nose
Appearance : Normal nasal septum
Discharges : Normal discharges
Patency : Patent
Sense of Smell : Good
J. Mouth And Throat
Lips : Normal pink lips
Tongue : Pink and moist
Teeth : Absent
Gums and buccal mucosa : Pink and moist, no lesion
Palate and tonsils : Normal
Taste : Normal
 K.Neck
Trachea : Normal centrally placed trachea
Lymph Nodes : No enlargement
Thyroid Glands : Feels smooth and firm
Cysts and Tumors : Not palpable
L .Chest And Respiratory System
Inspection : Size and shape is normal,
chest expansion equal in both sides and respiration is
normal.
Palpation : No local swelling, no lymph node enlargement
Percussion : Normal resonance in both lungs
Auscultation : Breath sounds are normal, respiratory rate is 30
breaths/min.`
M.Cardio Vascular System
Inspection : Size and shape is normal
Palpation : No tenderness present
Percussion : No fluid accumulation present
Auscultation : S1 and S2 heard..
N.Abdomen
Inspection : No abnormalities detected.
Palpation : No organomegaly.
Percussion : Normal resonance.
Auscultation : Bowel sounds are heard.
O.Back
Spine, Curvature : No abnormalities noted
Movements : Possible
Tenderness : Absent
P. Genitalia : No abnormality noted
Q. Upper Extremities:
There is no deformity, edema and enlargement present. Normal range of movements.
R. Lower Extremitie:
Normal movements and posture.
S. Nervous System
Birth Injuries : Absent
Speech : Normal
 Cranial nerve function : Normal
Sensory function : Normal
Reflexes : Normal
Gait : Normal
U. Urinary System
Urinary Tract Infections : present
Any Abnormalities : hematuria
V. Gastro-Intestinal System
Diarrhea : Present
Constipation : Absent
Bleeding : Absent
Worm Infestation : Absent
Vomiting : Present

Laboratory investigations

Sl. Investigation Patient values Normal Remarks

No. values
1. Hemoglobin 11.1gm/dl 9 – 14 gm/dl
2. TC 27900cells/cum 6.0- 17.5×100
cells/mm3

Phagocyte P-
3.
L-25-33%
Lymphocyte
E- 1-3%,
Erythrocyte
M
monocyte

4. ESR 160
5. S. Creatinine 0.6
6. SGPT 7

7 UREA 34

8 Na++ 139

K++ 4.7
9
Cl- 101
10

URINE :-
Protein 3

RBC 5-6

WBC 200-250

STOOL:-

WBC

EPI 1.2

TREATMENT

NAME DOSAGE FREQUENCY ACTION

1. Inj. 1gm BD
Augmentin

2. Inj. Pantop 20mg BD

2 ml SOS Anti emetic

3. Inj. Emset

4. Tab. 10mg
TDS Anti hypertensive
Nefidipine

5. Inj. lasix OD Diuretic

1ml
GENERAL APPEARANCE:

POSTURE:-

BODY BUILT:

SKIN:-

COLORS:

TEXTURE:

JURGOR:

VERNIX CASEOSA:

LANUGO:

HEAD:-

SIZE:

SHAPE:

ANTERIOR FONTANELLE:
POSTERIOR FONTANELLE:

CAPUT SUCCEDENUM:

CEPHAL HEMATOMA:

FUSED SUTURES:

WIDENED SUTURES AND FONTANELLES:-

SCALP:

EYES:-

LIDS:

IRIS COLOR:

FIXATION ON OBJECTS:

ABILITY TO FOLLOW MIDLINE:

SCLERA:

SUBCONJUCTIVAL HAEMORRAHAGES:

EPITHELIAL FOLDS:

CONGENITAL CATRACT:

EAR:-

PINNA IN LINE WITH EYES:

PATENT EAR CANAL:

PINNA FLEXIBLE:
CARTILAGE PRESENT:

HAIRY LOSS:

NOSE:

PATENT NOSTRIL:

NASAL DISCHARGE:

NASAL SEPTAL DURATION:

LARGER PHILTRUM:

FLORING OF EARS:
MOUTH & EXTERNAL OBSERVATION:

THROAT:

NECK:

CHEST:

STERNAL RETRACTION:

XIPHOID PROCESS EVIDENT:

BREAST ENGORGMENT:

WIDE SPACED NIPPLES:

SUPERMUMERARY NIPPLES;

LUNGS:

HEART:

ABDOMEN:

DISTENED ABDOMEN

FEMORAL PULSE:

DISTENDED:

CORD BLEEDING:

BOWEL SOUND:’

PALPABLE LIVER :

VISIBLE PERISTALTIC WAVES:

FEMALE GENITALIA :
IMMUNZATION

AGE VACCINE PATIENT PICTURE