Short Case Final: 22 year old female with decreased urine output and edema

Neha Pradeep

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This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

I’ve 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 22 year old female patient was brought to the OPD, with complaints of decreased urine output since 5 days and generalized edema since 5 days.

She is a daily wage labourer by occupation and is a resident of Miryalaguda.

History of Presenting Illness:

Patient was apparently asymptomatic 12 years ago when she was taken to the hospital with complaints of fever, increased frequency of micturition and increased appetite. She was diagnosed with diabetes. She was prescribed oral hypoglycemic agents for one year after diagnosis. Then she was shifted to insulin.

Around 3 years ago, she was taken to the hospital due to altered sensorium, with a hyperglycemic episode. Her insulin dosage was increased.

20 days ago, she was brought to the OPD, with complaints of decreased urine output, and generalized edema. She was given dialysis 5 times and one unit of transfusion of blood was given. After this she was discharged.

She was returned with the same complaints.

There is a decrease in urine output since 15 days, which has progressively decreased since 5 days. Not associated with hematuria, loin pain or any suprapubic pain.

The edema is insidious in onset and progressive. It began around the eyes and has progressed to the whole body.

No history of fever or sore throat.

PAST HISTORY :

Patient is a known case of diabetes since 12 years and hypertension since 1 year. She is on regular medication.

• T Telma 40mg

• T Nicardia 20mg

No history of Tuberculosis, Epilepsy, or Asthma.

No previous surgical history

FAMILY HISTORY :

No history of diabetes or hypertension in the family

No similar history in the family.

PERSONAL HISTORY:

Diet - mixed diet

Appetite - decreased appetite since 6 months

Sleep - adequate

Bowel movements - regular

Bladder movements - normal before 20 days

No addictions

No food or drug allergies

MENSTRUAL AND OBSTETRIC HISTORY :

Attained menarche at the age of 11 years

Regular cycles - 5/30

No pains, No clots

Married 1 year back

Three months ago, she had 2 months of amenorrhoea. On ultrasound, pregnancy was confirmed but there was no detectable cardiac activity of the fetus. Abortion was induced.

After which she has had no menstrual cycles.

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking the necessary informed consent.

She is conscious, coherent and cooperative.

Well oriented to time, place and person.

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - present, putting type

She has generalized edema (anasarca)

VITALS:

• Pulse: 88 beats per minute, regular in rhythm.

• Respiratory rate: 20 cycles per minute

• Blood pressure: 130/80 mm of hg, measured in the right arm in supine position

• Temperature: Afebrile

• Spo2: 96% at room air

• GRBS: 203 mg/dL

SYSTEMIC EXAMINATION :

Cardiovascular System:

INSPECTION:

-Chest wall: bilaterally symmetrical

-Apical impulse and pulsations cannot be seen.

-No dilated veins, scars, sinuses.

PALPATION:

-Apical impulse is felt on the left 5th intercoastal space, 2cm lateral from the midline.

-No parasternal heave, thrills were felt.

PERCUSSION:

-Right and left heart borders percussed.

AUSCULTATION:

- S1 and S2 heard, no added thrills and murmurs heard

Central Nervous System:

No neurological deficit, patient's higher mental functions are intact.

Abdominal Examination:

INSPECTION:

• Abdomen is distended

• Flanks are full

• Umbilicus is normal in shape and position

• No visible scars or sinuses

• No visible gastric peristalsis

• No distended veins

PALPATION:

• No local rise of temperature

• No tenderness

• Organs couldn't be palpated

PERCUSSION

• Fluid thrill present

AUSCULTATION

• Bowel sounds normal

Respiratory Examination:

Examination done in sitting position.

INSPECTION:

Inspection of Upper Respiratory Tract:

- Normal

Inspection of Lower Respiratory Tract:

- Trachea is central in position

- Chest is symmetrical in shape

- Movement of the chest is equal

- Thoraco- abdominal type of breathing

PALPATION:

- Trachea is central in position.

- Chest is expanding symmetrically.

- Vocal fremitus decreased in inframammary, infraaxillary and infrascapular areas bilaterally.

PERCUSSION:

- Stony dull note in inframammary, infraaxillary, infrascapular areas bilaterally.

- All other areas were resonant.

AUSCULTATION:

- Bilateral air entry present.

- Normal vesicular breath sounds.

- Decreased breath sounds in inframammary, infraaxillary, infrascapular areas bilaterally.

PROVISIONAL DIAGNOSIS:

A case of nephrotic syndrome or diabetic nephropathy (depending on further investigation) causing chronic kidney disease, with a history of diabetes since 12 years, hypertension since 1 year and bilateral pleural effusion.

INVESTIGATIONS:

Blood urea: 127mg/dL

Serum creatinine: 6.7mg/dL

Serum electrolytes :

• Sodium : 136 mEq/L

• Potassium: 3.5 mEq/L

• Chloride: 97 mEq/L

10/06/22

Hemogram: