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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
S
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
P
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
