Acute Glomerulonephritis (AGN)

• The text is a question bank for an MBBS Nigerian Professional Exam standard, organized into topic-based clinical scenario segments and integrated cross-topic clinical scenarios.

Acute Glomerulonephritis (AGN)

• AGN is exemplified by a 9-year-old boy presenting with dark urine, periorbital edema, and mild hypertension following a sore throat.
• Low serum C3, elevated ASO titers, and microscopic hematuria are key laboratory findings.
• Low serum C3 levels are a characteristic finding.
• A history of recent streptococcal throat infection supports a diagnosis of post-streptococcal glomerulonephritis.
• In post-streptococcal AGN, complement level (C3) typically declines within 6–8 weeks.
• Red blood cell casts are the expected urinary finding.
• Confirmation of diagnosis is achieved through urinalysis, ASO titer measurement, and serum complement levels.
• The immunopathogenesis involves immune complex deposition activating complement, leading to inflammation and glomerular injury.
• Edema is an expected clinical sign.
• Aggressive antibiotic treatment is not required once AGN is established.
• The presence of RBC casts in the urine is an important clue for glomerular inflammation.
• Hypertensive encephalopathy, nephrotic syndrome, and chronic kidney disease are complications.
• Management involves supportive care, diuretics for edema, and antihypertensive agents.
• A renal biopsy is not routinely indicated in all cases of post-streptococcal glomerulonephritis.
• Most children recover completely over several weeks with follow-up needed to monitor blood pressure and renal function.
• "Subepithelial humps" are a classically described histopathological finding.
• Resolution of complement abnormalities generally correlates with clinical recovery.

Nephrotic Syndrome

• Nephrotic syndrome is shown by a 7-year-old girl presenting with generalized edema, weight gain, and frothy urine.
• Laboratory results reveal heavy proteinuria (>40 mg/m²/hr), hypoalbuminemia, and hyperlipidemia, suggesting minimal change disease.
• Heavy proteinuria is most characteristic.
• Hypoalbuminemia is responsible for the edema.
• In minimal change disease, electron microscopy reveals effacement of podocyte foot processes.
• Corticosteroids are the first‑line treatment for minimal change disease.
• The clinical picture includes hyperlipidemia, massive proteinuria, edema, and hypoalbuminemia.
• Loss of albumin triggers hepatic lipoprotein synthesis, resulting in hyperlipidemia.
• Minimal change disease is the most common cause in children.
• Nephrotic syndrome does not always present with hypertension.
• The use of diuretics is essential in managing symptomatic edema.
• A common risk is thromboembolism.
• Minimal change disease has an excellent steroid response, a high relapse rate in some patients, and complete recovery is common.
• Albumin infusions are not the definitive treatment.
• Management includes steroid therapy, edema management with diuretics, monitoring for infections and thromboembolism, and follow‑up assessments.
• Marked hematuria is not typical.
• Most children with minimal change disease show rapid improvement with corticosteroid therapy.

Cerebral Palsy

• Cerebral palsy is indicated by a 3-year-old boy with a history of perinatal asphyxia presenting with delayed motor milestones, spasticity, and difficulty with fine motor skills.
• Spastic diplegia is the most suggested type.
• Perinatal asphyxia is a recognized risk factor.
• Early intervention aims to improve motor outcomes.
• MRI of the brain is most useful in confirming the diagnosis.
• Multidisciplinary management includes physiotherapy, occupational therapy, speech therapy, and family counseling.
• Long-term challenges include motor disability, communication difficulties, feeding problems, and social integration issues.
• Increased muscle tone is expected in spastic cerebral palsy.
• Cerebral palsy is not a progressive disorder.
• Early intervention programs are most effective when started before 1 year of age.
• Epilepsy is commonly seen.
• Physiotherapy improves motor function, prevents musculoskeletal deformities, enhances balance and coordination, and reduces spasticity through stretching.
• There is a role for surgical intervention.
• Family support helps in coping, adherence to therapy, and overall improved quality of life.
• White matter injury around the ventricles is typically associated with periventricular leukomalacia.
• Management includes both rehabilitative and supportive care.

Shock

• A 6-year-old child with severe diarrhea and vomiting presents with tachycardia, cold clammy skin, delayed capillary refill, and low blood pressure.
• Hypovolemic shock is the most likely type.
• Rapid fluid resuscitation is essential in hypovolemic shock.
• The child is most likely to have metabolic acidosis due to poor perfusion.
• Serum lactate measurement is most useful in assessing severity.
• Management includes a rapid fluid bolus with isotonic saline, vasopressor support if needed, monitoring vital signs closely, immediate antibiotic therapy (if septic shock is suspected), and oxygen supplementation.
• Loss of circulating volume leads to decreased tissue perfusion, anaerobic metabolism, and acidosis in hypovolemic shock.
• Delayed capillary refill is most consistent with shock.
• In shock management, serial reassessments of the patient’s response are necessary.
• The administration of isotonic fluids is the cornerstone of resuscitation in hypovolemic shock.
• Elevated lactate is most expected.
• Monitoring modalities include continuous heart rate and blood pressure, urine output measurement, serial blood gas analysis, and frequent neurological checks.
• The use of inotropic support is indicated if fluid resuscitation fails.
• Fluid resuscitation should be initiated promptly but cautiously in patients with signs of overload or cardiac dysfunction.
• Overaggressive fluid administration can result in pulmonary edema, cerebral edema, and cardiac overload.
• The primary goal is to restore intravascular volume.

Diphtheria

• A 10-year-old unvaccinated child presents with a sore throat, low-grade fever, and a grayish pseudomembrane on the tonsils, along with a “bull neck” appearance.
• Pseudomembrane formation is the hallmark clinical feature.
• The “bull neck” appearance is due to cervical lymphadenopathy and soft tissue edema.
• The causative organism is Corynebacterium diphtheriae.
• The Elek test is most useful for confirming the diagnosis.
• Management steps include administration of diphtheria antitoxin, initiation of erythromycin, airway management, and isolation of the patient.
• The toxin inactivates elongation factor‑2, leading to inhibition of protein synthesis and cell death.
• Unvaccinated children are most at risk.
• Prophylactic antibiotics are given to close contacts.
• The toxin works by inhibiting protein synthesis.
• Myocarditis is most concerning.
• Universal DPT vaccination is recommended, booster doses are needed, vaccine coverage reduces outbreak risk, and immunization should begin in infancy.
• Diphtheria is no longer a public health concern in areas with high vaccine coverage.
• Strategies include high immunization coverage, booster campaigns, public awareness, and prompt case isolation.
• Positive culture for C. diphtheriae is most characteristic.
• Treatment should be initiated immediately once the diagnosis is suspected.

Febrile Seizures

• A 2-year-old boy develops a generalized seizure lasting 3 minutes during a high fever (39.5°C) from an upper respiratory tract infection.
• A simple febrile seizure is most likely.
• Febrile seizures occur most commonly between 6 months and 5 years of age.
• Febrile seizures are generally benign.
• Ensuring the airway is protected is the most important initial management step.
• Febrile seizures are usually self‑limiting, there is no need for long‑term antiepileptic therapy, parental reassurance is important, and evaluation for central nervous system infection is considered in certain age groups.
• Temperature range between 38–40°C is most commonly associated with febrile seizures.