What discharge instructions should be given for a stable 13‑year‑old male who was hospitalized for tonsillitis, bilateral pedal edema, and rash and diagnosed with Henoch‑Schönlein purpura?

Discharge Instructions for a 13-Year-Old Male with Henoch-Schönlein Purpura

This patient requires structured monitoring for at least 6 months with weekly urinalysis and blood pressure checks initially, then monthly, because renal involvement is the key prognostic factor and the majority of nephritis manifests within 3 months of presentation. 1, 2

Immediate Post-Discharge Care

Symptom Management at Home

• Use acetaminophen (paracetamol) for pain control—avoid NSAIDs like ibuprofen or ketorolac (Toradol) because they can cause acute kidney injury, especially in patients with HSP who may have subclinical renal impairment. 2
• Rest and elevate legs to reduce swelling and discomfort from the purpuric rash. 3
• The disease typically resolves spontaneously within 4 weeks in 94% of children with supportive measures alone. 1

Activity Restrictions

• The patient may return to school and normal activities as tolerated, but avoid contact sports or activities that could cause trauma to areas with active purpura until the rash has completely resolved. 3
• Joint pain and swelling should improve within 1-2 weeks; if arthralgia persists beyond this, contact your physician. 1

Critical Monitoring Protocol

Weekly Monitoring (First 4-6 Weeks)

• Perform urinalysis with microscopy weekly to detect hematuria, proteinuria, red blood cell casts, or dysmorphic red blood cells. 1, 2
• Check blood pressure weekly because hypertension may indicate more severe renal involvement. 1, 2
• A normal urinalysis on day 7 has a 97% negative predictive value for normal renal outcome, but monitoring must continue because nephritis can develop later. 4

Monthly Monitoring (Months 2-6)

• Continue monthly urinalysis and blood pressure checks for at least 6 months after symptom resolution, since the majority of nephritis manifests within 3 months but can occur later. 1, 2
• If any urinalysis shows persistent hematuria or proteinuria beyond 3 months, initiate ACE inhibitor or ARB therapy. 1, 2

Long-Term Follow-Up

• Annual follow-up is required for any child who experienced nephritis during the acute phase, given the risk of later chronic kidney disease. 1
• In adolescents like this 13-year-old, renal involvement tends to be more severe and requires closer monitoring compared to younger children. 5

Red Flag Symptoms—Return to Emergency Department Immediately If:

• Severe abdominal pain that is not controlled with acetaminophen, especially if accompanied by vomiting or bloody stools (may indicate gastrointestinal hemorrhage or intussusception). 1, 6
• Blood in urine (visible hematuria) or cola-colored urine, which may indicate acute nephritis. 1, 2
• Facial or generalized swelling (edema), which may indicate nephrotic syndrome. 1
• Decreased urine output or no urination for >8 hours, which may indicate acute kidney injury. 1, 2
• Severe headache, confusion, seizures, or neurological symptoms (rare but serious CNS vasculitis). 1, 6
• Chest pain, palpitations, or syncope (rare cardiac involvement with arrhythmia). 6
• Testicular pain or swelling (may indicate testicular torsion, a urological emergency). 1
• Worsening or spreading purpuric rash after initial improvement, which may indicate disease recurrence. 1

Dietary Recommendations

• Limit dietary sodium to less than 2 grams per day to support renal health and reduce the risk of hypertension. 2
• Maintain adequate hydration with water; avoid excessive salt, processed foods, and caffeinated beverages. 2

Disease Recurrence and Prognosis

• Recurrence occurs in 30-40% of children, typically within 4-6 months of the initial episode, independent of whether steroids were used. 1
• If the rash, joint pain, or abdominal symptoms recur, contact your physician promptly for reassessment and repeat urinalysis. 1
• The overall prognosis is excellent: 94% of children achieve complete spontaneous resolution. 1
• Renal involvement is the key prognostic factor: approximately 2% progress to end-stage renal disease, and up to 20% of those with severe nephritis may require dialysis. 1

What NOT to Do

• Do not use prophylactic corticosteroids at home—moderate-quality evidence shows they do not prevent nephritis, do not reduce renal severity, and do not shorten disease duration in uncomplicated cases. 1, 2
• Do not use NSAIDs (ibuprofen, naproxen, ketorolac) for pain control due to the risk of acute kidney injury. 2
• Do not skip scheduled urinalysis appointments—failing to perform urinalysis at every clinical visit can lead to delayed detection of renal relapse. 2

Follow-Up Appointments

• Schedule a follow-up appointment with your primary care physician or pediatrician within 1 week of discharge for the first urinalysis and blood pressure check. 1, 4
• If proteinuria develops (>0.5 g/day per 1.73 m²), referral to a pediatric nephrologist is required for consideration of ACE inhibitor or ARB therapy. 1, 2
• If nephrotic-range proteinuria (>1 g/day per 1.73 m²), rapidly rising creatinine, or nephritic syndrome develop, immediate renal biopsy may be necessary. 1

Reassurance for Family

• HSP is a self-limiting disease in the vast majority of children, and your son is expected to recover fully with appropriate monitoring. 1, 7
• The purpuric rash may take several weeks to fade completely and may leave temporary brown discoloration, which will resolve over time. 3
• Most children return to normal activities within 4-6 weeks without long-term complications. 1, 8