Hello everyone, I'm a medicine intern and recently started my medical posting.This is a blog to share my experience and cases I came across during this period.

       70 year old woman from Chityal, a daily wage worker presented with the complains of
Bilateral pedal edema since
Abdominal distension since 4 days
Facial puffiness since 4 days
Dyspnea since 3 days 
She got married to a daily laborer who passed away few years back from a road traffic accident. She has 2 sons, the elder is a tailor and the younger son is a laborer. 
She was apparently alright 2 years back when she starting noticing purulent discharge from her left ear for which she visited an RMP who put her on eardrops. She has been experiencing left ear purulent discharge on and off for which she has been using ear drops. During her visit to the RMP she got diagnosed with type 2 diabetes for which she was put on tab Glimiperide and metformin 500mgs OD. She after an year started to experience body pains for which she started taking Ayurvedic medications and pain killers. She also tells a history of cough with mild expectoration since 1 year on and off for which she didn't use any medication. Over the last 5 days she developed bilateral pedal edema, pitting type extending upto knees later then she developed abdominal distension and facial puffiness. She also complains of dyspnea on exertion since 5 days and reduced urine output since 3 days, she also says she is feeling feverish since 1 day. 
 There were no complaints of fever, vomitings, burning micturition, PND, chest pain, palpitations and jaundice.
On examination - 
Her BP - 140/90mmhg
With a heart rate of 89 bpm
Rr -30/min
Spo2 -92%on RA
Pallor +
With bilateral pedal edema +
Jvp  mild elevated
Cvs - apex beat is present in 5th ICS at MCL
S1,s2 +
Lungs - on auscultation bilateral Fine inspitatory crackles present in IAA,ISA,MA
On abdominal palpation, there is a diffuse tenderness 
Bowel sounds heard .





Diagnosis:

  Bilateral pleural effusion (transudative type)
  Nephrotic syndrome 
  De novo HTN
 ?HFPEF 
  
Investigations:

 
RFT:
Urea: 77mg/dl
Creatinine: 1.1mg/dl —- 1.9 mg/dl (on 25/7/20)
Uric acid: 6.1mg/dl

CBP:
Hb: 8.3gm/dl
TC: 5400 cells/cumm
Platelets: 1 lakhs/cumm

FBS:70   PLBS:131   HbA1c:6.4

 Blood urea:77mg/dl

Spot urine protein: 160mg/dl
Spot urine creatinine: 73mg/dl
Ratio: 2.19

24hr urinary protein: 1083mg/dl

Serum LDH: 288

Serum electrolytes: 
Na+ 133mEq/L
k+ 3mEq/L
Cl- 96mEq/L

Serum creatinine: 1.9mg/dl

24hrs Urinary creatinine: 0.38g/day

Stool for occult blood: Negative

Pleural fluid cell count:
 Volume: 3ml
 Colour: Pale yellow
 Appearance: Hazy
 Total cells: 110cells/cumm
 Neutrophils: 05%
 Lymphocytes: 95%
 RBCs: 700
 Others: Few mesothelial cells seen
  
Pleural fluid ADA: 25U/L

Pleural fluid cytology for malignancy: Negative

T3: 0.76ng/ml
T4: 10.17 micro g/dl
TSH: 2.73 micro lu/ml








Treatment given:
Salt and fluid restriction
O2 inhalation @4lts/min
Inj. Ceftriaxone 1gm/IV/BD
Tab. Telma 40mg OD
Inj. Lasix 40mg/IV/BD
 Inj. HAI acc to sliding scale
Protein ex powder in half glass of milk TID

Advice at Discharge:

1) Salt (<2.4gm/day) and fluid (<1.5 lt/day) restriction
2) Tab. lasix 40mg BD for 1 week
3) Tab.Telma 40mg OD
4) Tab. Metformin 500mg OD
5) Protein ex powder in half glass of milk TID
6) Egg whites 2-4/day
7) Tab. Ramipril 2.5mg OD








 

Comments

  1. Dr.vaishnavi adepuSeptember 12, 2020 at 9:21 PM

    Hello !
    May I know her serum albumin!
    And also - was proteinuria in nephrotic range ?
    Did we get her 2d echo ?

    ReplyDelete

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