Presenting History
In children presenting with suspected Acute Glomerulonephritis (Nephritic Syndrome), systematically elicit the classic nephritic triad: hematuria, hypertension, and oliguria with edema, alongside the timeline of preceding infections.
- Macroscopic Glomerular Hematuria:
- Onset & Color: When did the urine turn abnormal? Is it characteristically dark, brownish, cola-colored, smoky red, or black-tea colored?
- Stream Characteristics: Is the discoloration present uniformly from the beginning to the end of urination (total hematuria)?
- Absence of Clots: Confirm absence of frank blood clots, gravel, or terminal burning pain (hallmark of glomerular vs lower urinary tract origin).
- Facial Puffiness & Edema:
- Did the swelling start around the eyes and face (periorbital and non-dependent)?
- Is it firm, non-pitting, and relatively stable throughout the day (unlike the dependent, pitting anasarca of nephrotic syndrome)?
- Oliguria & Fluid Retention:
- Quantify the reduction in urine frequency and daily volume ($<1\text{ mL/kg/hour}$ or $<400\text{ mL/m}^2/\text{day}$).
- Hypertensive Encephalopathy & Circulatory Congestion:
- Encephalopathy: History of severe persistent frontal/occipital headache, projectile vomiting, blurred vision, dizziness, or generalized convulsions.
- Congestion / Heart Failure: History of fast breathing, orthopnea, nocturnal cough, chest heaviness, or frothy pinkish sputum.
- Antecedent Infection (The Latent Period):
- Skin Infection (Pyoderma / Impetigo): History of crusted honey-colored sores, boils, or pustules over legs or face 3 to 6 weeks ago.
- Throat Infection (Pharyngitis / Tonsillitis): History of fever with sore throat, dysphagia, or painful neck glands 1 to 2 weeks ago.
Negative History (3C 1D Framework)
| Category | Pertinent Negative Question | Rationale / Significance |
|---|---|---|
| Causes | Recurrent Hematuria: No prior episodes of tea-colored urine with upper respiratory infections. Purpura: No history of palpable purpuric rash over buttocks or lower limbs. Malar Rash: No history of facial rash, photosensitivity, alopecia, or oral ulcers. Family Renal Disease: No family history of hematuria, dialysis, or early sensorineural deafness. | Synpharyngitic hematuria (<48-72 hrs) points to IgA nephropathy (Berger disease). Points to Henoch-Schönlein purpura (IgA vasculitis nephritis). Points to Systemic Lupus Erythematosus (Lupus nephritis). Rules out Alport syndrome (X-linked / AR type IV collagen defect). |
| Complaints (Differentiating) | Severe Flank Pain: No history of sudden, agonizing colicky flank-to-groin pain. Dysuria & High Fever: No history of high spiking fever with chills, burning micturition, or foul-smelling cloudy urine. | Rules out renal calculi / urolithiasis causing hematuria. Rules out acute bacterial pyelonephritis / urinary tract infection. |
| Complications | Hypertensive Emergency: No history of loss of consciousness, status epilepticus, or focal neurological deficits. Acute Pulmonary Edema: No history of acute respiratory distress, cyanosis, or pink frothy expectoration. Severe Uremia: No history of hiccups, intractable vomiting, metallic taste, or drowsiness. | Assesses severe end-organ neurological damage. Assesses left ventricular failure from acute afterload and hypervolemia. Assesses severe acute kidney injury requiring urgent hemodialysis. |
| Differentials | Trauma / Exercise: No history of recent blunt abdominal/flank trauma or strenuous marathon running. Drugs / Pigmenturia: No history of rifampicin, nitrofurantoin, or beetroot consumption. | Rules out traumatic renal injury and exertional myoglobinuria. Excludes non-hematuric drug- or dietary-induced discoloration. |
Other Relevant History
- Past Medical History: Inquire if child ever had blood pressure checked or documented renal disease in the past.
- Family History & Pedigree: Document three-generation pedigree; assess similar illness in siblings (streptococcal pyoderma often clusters among household contacts).
- Immunization & Drug History: Full immunization record; record any recent penicillin or antibiotic administration.
History Summary
"Master/Miss `Patient Name`, a `Age` old `male/female` child, `Birth Order` born of a `consanguineous/non-consanguineous` marriage from `City, State`, presented with a `Duration in days` history of periorbital and facial puffiness, cola-colored smoky hematuria, and oliguria, accompanied by `headache / vomiting / visual blurring`, following an episode of `pyoderma 3 weeks ago / pharyngitis 1-2 weeks ago`, without history of recurrent hematuria, purpuric skin rashes, or chronic renal disease in the family.
In view of the acute onset of hematuria, oliguria, hypertension symptoms, and antecedent streptococcal infection after an appropriate latent period, I would like to consider a provisional diagnosis of Acute Nephritic Syndrome secondary to Acute Post-Streptococcal Glomerulonephritis (PSGN), complicated by `Stage 1/2 Hypertension / Hypertensive Encephalopathy / Hypervolemic Circulatory Congestion`, currently in the oliguric phase."
General & Head-to-Toe Examination
- Child Behavioral State Assessment:
- Document Prechtl state (e.g., Prechtl State 3: quiet wakefulness, alert but photophobic, responding to verbal stimuli).
- Vitals:
- Pulse rate, respiratory rate (tachypnea), CRT ($<2\text{ s}$).
- Blood Pressure (Critical): Measure in right arm seated/supine with proper cuff. Categorize against pediatric BP tables based on age, sex, and height centile:
- Normal: $<90^{\text{th}}$ centile.
- Stage 1 HTN: $95^{\text{th}}\text{ centile}$ to $<95^{\text{th}} + 12\text{ mmHg}$.
- Stage 2 HTN / Emergency: $\ge 95^{\text{th}}\text{ centile} + 12\text{ mmHg}$ or $>140/90\text{ mmHg}$.
- Anthropometry: Current weight, height, BMI Z-score, and estimated fluid overload weight.
- Head-to-Toe Findings:
- Edema: Firm, non-pitting periorbital and facial puffiness; mild pretibial edema.
- Skin Examination: Meticulously inspect all skin surfaces (especially legs, shins, buttocks) for active crusted impetigo sores or post-inflammatory healed hyperpigmented scars.
- Fundoscopy: Mandatory to evaluate for hypertensive retinopathy (arteriolar spasm, flame hemorrhages, exudates, papilledema).
Systemic Examination
Cardiovascular System (CVS)
- Apex beat: Palpate for forceful, tapping or heaving apex beat.
- Auscultate: Normal $S_1$, loud accentuated aortic component of the second heart sound ($A_2$) in the right 2nd intercostal space; check for $S_3$ gallop or functional systolic murmur.
- JVP: Assess for elevated jugular venous pressure (hypervolemia).
Respiratory System (RS)
- Auscultate bilateral lung bases for fine end-inspiratory crackles (pulmonary congestion/edema).
Abdomen
- Palpate for tender congestive hepatomegaly (liver edge soft, tender, span increased due to systemic venous pooling).
- Spleen and kidneys not enlarged; no ascites (shifting dullness negative).
Central Nervous System (CNS)
- Sensorium, Glasgow Coma Scale, orientation, cranial nerves, motor tone, power, deep tendon reflexes, and meningeal signs.
Final Summary & Diagnosis
"A `Age` old `male/female` child presenting with acute nephritic syndrome characterized by macroscopic cola-colored hematuria, oliguria, periorbital puffiness, and hypertensive symptoms following a `3-week latent period post-pyoderma / 10-day latent period post-pharyngitis`, with examination revealing Stage 2 hypertension (`BP in mmHg`), accentuated $A_2$, tender congestive hepatomegaly, bilateral basilar crackles, and healed impetigo scars, in the absence of papilledema, gross anasarca, or focal neurological deficits.
My final diagnosis is Acute Post-Streptococcal Glomerulonephritis (PSGN / Post-Infectious GN), presenting with Hypertensive Emergency / Hypertensive Encephalopathy and acute hypervolemic circulatory congestion, in the acute oliguric phase."