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20/F with generalized swelling, decreased urine output

8/12/22


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A 20 year old female presented with generalised swelling of the body 

I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


CASE:

A 20 year old female presented to hospital with chief complaint of generalised swelling of the body. 

History of present illness:

Patient was apparently asymptomatic 5 months back then she developed rashes on both upper and lower limbs which were pruritic and are  healing with hyper pigmented lesions.
45 days ago she developed pedal edema - insidious onset, gradually progressed to entire body (anasarca) for which she used herbal medication - 9 days. Post which she visited other hospitals , and symptoms didn't subside. 
Presently she came with pedal edema- insidious in onset, gradually progressive pitting type (grade 2)

No H/O fever, shortness of breath, 

 Past history:

Not a k/c/o of DM, epilepsy, TB, CAD,CVD
Denovo HTN presently on Tab. NICARDIA
No past surgical history 



Personal history:

Appetite: Normal
Diet: Mixed
Sleep: adequate
Bowel and bladder: regular

Menstrual history:

Regular cycles, flow is for 4 days , no pain and clots

Marital history:

Age of marriage 2 years, non consanguineous 

Obstetric history:

 P1L1 - male child of 1 year age, normal vaginal delivery, immunized for appropriate age, milestones attained appropriately. 

Family history:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

Hyperpigmented lesions noted over both upper and lower limbs.

Pallor- present
Icterus- absent
Clubbing-absent
Lymphadenopathy- absent
Cyanosis- absent
Pedal edema - present (B/L grade 2)



VITALS: 

B.P:170/120 mmhg
P.R:96bpm
R.R: 16cpm
Temp:98 F
SPO2: 99%@ RA












SYSTEMIC EXAMINATION:


PER ABDOMEN:


Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 
          Hernial orifices- free.

Palpation -  
soft, non-tender
no palpable spleen and liver

Percussion - dull note heard over flanks

Auscultation- normal bowel sounds heard. 








CARDIOVASCULAR SYSTEM:

Inspection : 
  • Shape of chest- elliptical 
  • No engorged veins, scars, visible pulsations
  • JVP - raised
Palpation :
  •  Apex beat can be palpable in 5th inter costal space
  • No thrills and parasternal heaves can be felt
Auscultation : 

  • S1,S2 are heard
  • no murmurs


RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.


CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++


PROVISIONAL DIAGNOSIS:

NEPHROTIC SYNDROME UNDER EVALUATION WITH ANEMIA OF CHRONIC DISEASE & DENOVO HTN AND HYPERTROPHIC LICHEN PLANUS. 


INVESTIGATIONS:

CBP:
Hb - 9.8 gm/dl
TLC -  6500 cells/ cumm
RBC - 3.85 million
PLT -  3.21 lakh

CUE:

Colour- pale yellow 
Albumin- ++++ 
Sugars- negative 
Pus cells- 2-3 cells
Epithelial cells- 1 to 2 cells/ HPF


RFT

urea - 22 mg/dl
Creatinine - 0.7  mg/dl
Na  - 141 mEq/L
K - 4.3 mEq/L
Cl - 104 mEq/L 

LFT :

TB- 0.61 mg/dl
DB- 0.16 mg/dl
ALT - 17 IU/L
AST - 28 IU/L
ALP - 171 IU/L
TP - 6.8
albumin - 3.8 gm/dl

LIPID PROFILE:

TOTAL CHOLESTEROL- 151 mg/dl
TAG - 103  mg/dl
HDL- 37.6  mg/dl
LDL - 87.1 mg/dl
VLDL - 20.6 mg/dl

THYROID PROFILE:

T3 - 1.08 
T4 - 10.23
TSH- 6.39

URINARY PARAMETERS:

SPOT URINARY PROTEIN: 5.45
SPOT URINARY CREATININE: 21
RATIO: 0.25

24 HR URINARY PROTEIN- 436 mg/day
24 HR URINARY CREATININE- 0.8 gm /day
24 HR URINE VOLUME- 800 ml

COAGULATION PROFILE:

BT- 2.3 
CT- 4.3
PT- 14 sec 
APTT- 29 sec
INR- 1.0


CHEST X-RAY:




ECG




USG ABDOMEN:





ANA PROFILE:









Other reports:


























TREATMENT:

SALT  AND FLUID RESTRICTION 

TAB ENALAPRIL 2.5 MG PO/OD

TAB LASIX 40 MG PO/OD

MOMATE F CREAM L/A  OD

LIQUID PARAFFIN L/A BD




20/12/22

C/o generalised swelling of body


O
Pt is C/C/C

BP:130/90mmHg

PR:76bpm

RR:18cpm

SpO2:98% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly

A

NEPHROTIC SYNDROME UNDER EVALUATION WITH ANEMIA OF CHRONIC INFLAMMATION & DENOVO HTN AND HYPERTROPHIC LICHEN PLANUS


SALT  AND FLUID RESTRICTION 

TAB ENALAPRIL 2.5 MG PO/OD

TAB LASIX 40 MG PO/BD

MOMATE F CREAM L/A  OD

LIQUID PARAFFIN L/A BD

Vitals monitoring 4th Hrly

Plan for renal biopsy



Renal biopsy was done under strict aseptic conditions on 21/12/2022














Thank you Lasya for the blog

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