22 year old female with nephrotic syndrome and hyperglycaemia

 FINAL PRACTICAL EXAMINATION- SHORT CASE 

HALL TICKET NO- 1701006145

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A 22 year old female resident of miryalguda and daily wage labourer by occupation presented with chief  complaints of no urine output since 5 days and generalised edema since 5 days

Patient was apparently asymptomatic 12 years ago when she developed an episode of fever which was associated with increased appetite and increased frequency of micturition for which she was taken to a nearby hospital and was diagnosed with diabetes. She has been on regular medication ever since. She was initially kept on oral hypoglycaemics for 1 year but later was kept on insulin 2 times per day.

3 years back she had an episode of altered sensorium for which she was taken to the hospital. She was found to be hyperglycaemic and the dose of insulin was increased. 

20 days back she was bought to the opd with generalized edema , decreased urine output and diagnosed with renal failure and nephrotic syndrome. She underwent 5 cycles of dialysis and 1 unit of blood transfusion was done. She got discharged but got admitted again for the same complaints. 

 The edema was initially around the eyes which was more in the morning and decreased towards the end of the day. Later it progressed to involve the entire body.Decreased urine output since 15 days which progressed to no urine output since 5 days.

No hematuria, No loin pain, No history of fever or sore throat recently. 

PAST HISTORY :

Patient is a known case of diabetes since 12 years and hypertension since 1 year. 

No h/o Tb, epilepsy, asthma

No previous surgical history

FAMILY HISTORY :

No history of diabetes or hypertension 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

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the 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

She has generalized edema ( anasarca) 

VITALS :

Pulse - 88 beats per minute, regular rate and rhythm

Respiratory rate - 20 cycles per minute

Blood pressure - 140/80 mm of hg

Temperature - afebrile 

Spo2 - 96% at room air

GRBS - 203 mg/dL

SYSTEMIC EXAMINATION : 

CVS : 

    

S1 S2 heard, no murmurs

CNS : 

No neurological deficit

ABDOMINAL EXAMINATION : 

Inspection - abdomen distended 

                      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- not palpable 

Percussion - fluid thrill present

Auscultation - bowel sounds normal

RESPIRATORY EXAMINATION :

Inspection  - Trachea is central in position. 

                                    Chest is symmetrical. 

                                    Movement of the chest is                                              equal and thoraco-abdominal type of breathing. 

Palpation - Trachea is central in position. 

                     Chest is expanding symmetrically. 

                     Vocal fremitus decreased inframammary, infraaxillary and infrascapular areas on both sides. 

Percussion - Stony dull note in inframammary,                              infraaxillary, infrascapular area on                          both sides. 

                       

Auscultation - Bilateral air entry present. 

                          Normal vesicular breath sounds. 

                          Decreased breath sounds in                                        inframammary, infraaxillary,  infrascapular areas on both sides. 

PROVISIONAL DIAGNOSIS- 

Diabetic nephropathy with secondary nephrotic syndrome and bilateral pleural effusion

INVESTIGATIONS 

on admission -Day1 

Ultrasound report- 

Chest Radiography-

On Day 3 of admission 

DIAGNOSIS : 

Diabetic nephropathy with secondary nephrotic syndrome and bilateral pleural effusions

TREATMENT : 

• Inj. LASIX 60mg/ IV/ BD

• INSULIN INFUSION  6ml / hr

   1ml of insulin in 39ml of normal saline

• Tab. NICARDIA 20mg/ PO / BD

• Tab. TELMA  40mg/ PO / BD 

• Nil by mouth

• Fluid and salt restriction

• Hourly monitoring of GRBS