CASE PRESENTATION

BY

DR. GHULAM SADDIQUE

PATIENT BIO DATA

Name :- ANITA

Sex :- FEMALE

Occupation:- STUDENT

Age:- 14yrs.

Resident:- Resident Of SHAHDARA LAHORE

MoA :- OPD

DoA :- 7TH

NOVEMBER, 2014

Presenting Complaints

• Progressively increasing Abdominal distention for

2 months

• Progressively increasing feet and legs swelling for

2 months

HISTORY OF PRESENT ILLNESS

• My patient who is a student of 6th class and not a smoker and not addict was in her usual state of health and studying in school regularly and punctually.

• when two years back she remained admitted in mayo hospital north surgical ward for gangrene of left foot lateral 4 toes which were later on amputated and patient was discharged. There was no diagnosis made at that time. Since then patient was in her usual state of health..

HISTORY OF PRESENT ILLNESS

• She initially noticed swelling on her feet which progressively increased gradually and started involving lower legs and it was not associated with any pain, it was involving both lower limbs and it was not associated with any change of colour or temperature.

• There was no history of any nodule formation or insect bite in this area. Along with this, she noticed distension of abdomen which was gradual in onset and distension increased over 2 months period to become tense at presentation.

• It was not associated with jaundice, upper gi bleed, epigastric pain, right hypochondrial pain etc. it was associated with periorbital puffiness.

• She noticed decrease in urine output and froth during micturation. But there is no associated blood or pus in urine.

• She has been noticing froth for last 3 months but she has not shared this due to shyness to her parents

HISTORY OF PRESENT ILLNESS

• 1 month back, she started having difficulty in performing daily household works due to her increasing abdominal distension.

• According to her family, she visited some saint baba as well for its treatment but her symptoms kept on getting worse. Then they decided to take her to mayo hospital OPD.

HISTORY OF PRESENT ILLNESS• She has frequent history of

headaches and bodyaches.There is history of pain in both fingers of the hands and involvement of both knees. There is history of mild swelling which relieves by taking pain killers but no history of joint deformity or any restriction of movement.

• There is history of photosensitivity and facial flushing and redness involving cheeks on even slight exposure to sunlight.

• There is also history of irregular menses and for last three months she had amenorrhea.

• There is no shortness of breath on walking or on lying flat. She has no history of any chest pain or retrosternal burning. There is no history of any congenital malformation involving heart.

• There is no history of upper respiratory tract infection in last one month, epistaxsis, frequent coughing or any previous disease affecting her bridge of nose. There is no history of pain during deep breathing. There is no history of diarrhea, black tarry stools etc.

• Patient has been using pain killers due to joint pain and pain in amputation adjacent parts

Systemic review• No History of weight loss• History of decrease sleep due to pruritis over

abdomen • No history of seasonal variation in symptoms• No history of nasal discharge or postnasal drip or

epistaxis• No history TB or contact with TB, hepatitis B or

hepatitis C• No history of HTN , DM , IHD , CLD or any

congenital malformation• No history of any fits , weakness or any

neurological deficit• history of raynaud's and history of skin ulceration

and photosensitivity

Past history

• History of visits to hospital OPD and remained admitted in North surgical ward for left foot toes amputation

• No history of any other surgery in the past

Family history

• No family history of HTN , DM, TB , IHD , CLD or connective tissue disorder

Personal history

• not a smoker not an addict• student

Socio-economic history

• Lower middle class

Examination Young adolescent female anxious looking lying in bed propped up with

brannula on both arms and distended abdomen and swollen feet• Pulse : 96/min• BP: 90/60mm of Hg• Temp : 100 F• Respiratory rate : 18/min• Pallor :-ve• Clubbing :-ve• Cyanosis :-ve• Pedal edema: +ve• Jaundice, kilonychia are not present• JVP :not raised• Lymph nodes :not palpable• Thyroid :not enlarged• mild swelling of proximal interphalengeal joints• Abdominal distension: +ve

Examination

• Cardiovascular system:• no Visible pulsations in suprasternal notch and

apical areas• No visible scar mark• Apex beat in 5th intercostal space lateral to mid

clavicular line normal in character and rhythm

Examination

• Respiratory system :a) Rate : 20 /min

b) No visible scar mark

c) Thoraco-abdominal type of respiration

d) Chest movements B/L equal but decreased

e) Chest expansion 4cm

f) NVB and decreased breath sounds at the bases

Examination

• Gastro-intestinal system

a) Distended abdomen with everted umbilicus and fullness in the flanks

b) No visible scar mark but a visible dressing on the right iliac fossa region

c) No visible pulsations but visible veins

d) Thoraco-abdominal type of respiration

e) It is slightly tender on palpation

f) Liver span 12cm and it is not palpable

g) Spleen not palpable

h) Shifting dullness is present but fluid thrill is absent

i) Bowel sounds are heard

Examination

• CNS: NAD• URINARY: intact hernial orifices• genital is normal for her sex with scarce pubic

hairs and there is no ulceration• slight tenderness in both flanks but kidneys are

not palpable

On opthalmoscopy

• grade 1 hypertensive changes were seen

Differential diagnosis

• sle with lupus nephritis complicating this presentation with nephrotic syndrome

• rheumatoid arthritis with renal involvement• minimal change disease • Nsaids induced renal damage d/t long term use

• TO REACH A DIAGNOSIS

FOLLOWING INVESTIGATIONS WERE PLANNED:• CBC • ESR• serum Albumin level and lipid profile• Rfts• Lfts• Ascitic tap• Urine complete• 24hrs urinary proteins• RA and ANA• double stranded DNA• complement levels• VIRAL MARKERS• Renal biopsy

Investigation results

• HB : 12.6g/dl• WBC : 7000/UL• RBC: 4150,000• HCT: 30.7%• PLT: 90,000• ESR: 34• ascitic tap shows 0.8g/dl proteins and less than 4

WBCs• urine complete shows 4+ve proteins and no pus

cells and no blood and glucose• cholesterol 300, LDL 250

Investigation results

• UREA: 40 mg/dl• Serum Creatinine: 0.9mg/dl• Bilirubin: 1.4• ALT: 32• AST: 30• low complement levels• 4g/24hrs urinary proteins• ALK PHOS : 315• double stranded DNA +ve, ANA +ve, RF -ve• SERUM PROTEIN: 6.7• SERUM ALBUMIN: 2.1• Na+: 135meq/l• K+: 4.0meq/l• ANTI HCV -ve• HBsAg –VE• ANTI HIV -VE

Investigation results

• ABGS:-

pH 7.42

pO2 81.6 mmHg

pCO2 25.5mmHg

HCO3- 20.7 mmol/L

Base excess - 1.7

O2 96 %

Respiratory alkalosis

Ultrasound report

• Enlarged liver 12cm• Enlarged spleen 9cm• Kidneys: normal size with early echogenecity• Modeeate abdomino-pelvic ascites

Urine complete

• Yellow colour• PH 6• Specific gravity 1.030• Protein: ++++ve• Sugar: nil• Blood: -ve• Pus cell : 3-5 cells

• PT: 13sec control 15• aPPT: 35minute control 35

Final diagnosis

• SLE with kidney involvement causing nephrotic syndrome and hypoabluminemia leading to pedal edema and ascites due to decrease oncotic pressure