CASE PRESENTATION

Dr Sakina Gul
PGR1
Medicine Unit IV
Patient Tayyaba 13 years old female , unmarried resident of

Quetta with no known comorbidities presented on 2-March-20 with

chief complains of

Generalized body swelling 3 weeks

 According to attendant, patient was in her usual state of health 3 weeks back
then she developed generalized body swelling which was sudden in onset
initially appear around the eyes and face then progresses to the involve the
arms, abdomen and then legs within 2-3 days of the onset. It becomes so
severe that she cannot open her eyes, sit and walk properly. It is painless and
pitting in nature with normal overlying skin and no complain of itching or rashes.
Facial swelling decreases with walking. It is associated with difficulty in
breathing, nausea and vomiting. There is no effect of leg elevation.
 Difficulty in breathing begins with abdominal distention. It is aggravated by
lying down and partially relieved by sitting and walking. There is no
associated PND or chest pain. It settles when abdominal
distention resolves.

 Vomiting also begins with abdominal distention. It is non-projectile, 2-3

episodes per day contained food particles in it and not associated with
blood, abdominal pain or constipation. It also settles when abdominal
distention resolves.
 She also complain of frothy urine but there is no history of burning, hematuria or pain
 There is no complain of constipation, cold intolerance, hair loss, lethargy, dry skin
or dry hair.
 There is no complain of palpitations, chest pain ,sweating, restlessness or cyanosis.
 There is no complain of yellowish discoloration of skin, itching, dark
colored urine or blood in stools.
 No complain fever, abdominal pain, diarrhea or loss appetite.
 No complain of joint pain, rash, photosensitivity, bluish discoloration of finger tips or oral ulcers.
 No complain of muscle weakness, pain, numbness or tingling sensations in hands or feet.
 There is no history of taking any herbal medicine and nephrotoxic drugs.
 No history headache, ALOC, seizures or blurring of vision
 Patient has history of multiple hospital admissions due to same complains for
the last 4 years where she was treated and became symptom free for a
period of 3-4 months and then again develop the same symptoms.( Parents
don’t remember the medicines, dosage and duration of treatment. Also they
don’t have the documents of previous hospital admissions).
 She also have a history of car accident 5 years back due to which her right
leg was fractured . It was fixed with internal fixators which were later
removed. She was also transfused blood during the surgery.
 There is no history of recurrent throat infection, Hep C, Hep B, TB, Asthma, HTN DM, MI,
STROKE
 There is no history of tooth extraction, recent vaccination or tattooing.
 Her appetite is normal with intake of meat 2-3 times in a week.

 Patient achieved her developmental milestones as per age.

 She is unmarried have 3 brothers and 3 sisters. All of her siblings are healthy
and alive.
 She belongs to low socioeconomic class, lives in non cemented house,
drinks unboiled water and raw milk.
 There are no pets or animals in the house.
 EXAMINATION
A young girl with facial puffiness, bilateral pedal edema and markedly
distended abdomen cannulated in her right arm, well oriented to time, place
and person having following vitals

B.P 110/70mmhg( regular, normal volume and character)

Pulse 70/min
Temp 98 F
R/R 22/min
SaO2 93% at room air
GCS 15/15
 Generalized edema present GRADE 4/4
 Non-blanchable erythematous patch of 3x3cm on medial side of left foot.
 Jaundice, pallor, clubbing, koilonychias, lymphadenopathy absent
DATEclear
 Throat WEIGHT ABDOMINAL
GIRTH
 Oral hygiene satisfactory.
5-3-20 52 kg 91.5cm
6-3-20 51kg 63cm
7-3-20 51kg 84cm
8-3-20 53kg 90cm
9-3-20 53kg 90cm
 ABDOMEN

 Abdomen is distented, umbilicus inverted and centrally placed

 All quadrants moving symmetrically with respiration and hernia sites are intact
 No scar marks , visible pulsations, venous prominence or bulge
 No tenderness on superficial and deep palpation
 No visceromegaly
 Shifting dullness and fluid thrill +ve
 Bowel sounds audible.
 RESPIRATORY

 Normal shape of chest, no scar mark and no deformity

 Chest movement is symmetrical
 No tenderness, chest expansion is 3cm and trachea is centrally placed
 Dull percussion note on both lower chest
 Reduced breath sounds on both lower chest
 Decreased vocal resonance on both lower chest
CARDIOVASCULAR SYSTEM

 Normal shape of precordium, no scar marks and no visible pulsations

 Apex beat is normal in character and palpable in left 5 th intercostal space
in midclavicular line
 First and second heart sounds are audible and are normal in character
 No added sounds or murmers present
CENTRAL NERVOUS SYSTEM
RUL LUL RLL LLL
BULK NORMAL NORMAL NORMAL NORMAL

TONE NORMAL NORMAL NORMAL NORMAL

POWER 5/5 5/5 5/5 5/5

REFLEXES NORMAL NORMAL NORMAL NORMAL

PLANTARS DOWNGOING DOWNGOING

 No neck rigidity.
 Pupils B/L symmetrical and reactive to light.
 Sense of crude/fine touch, vibration, proprioception, temperature intact.
 No sensory level present.
 All 12 cranial nerves intact.
 Cerebellar signs-Normal
DIFFERENTIAL DIAGNOSIS

 MINIMAL CHANGE DISEASE

 FOCAL SEGMENTAL GLOMERULONEPHRITIS
 LUPUS NEPHRITIS
 CBC

 WBC 10.5
 HB 12.9g/dl
 HCT 38%
 MCV 81.3 fL
 PLT 492,000 microliter
 COLOUR
URINE D/R
PALE YELLOW
 APPEARANCE CLEAR
 SP GRAVITY 1.015
 ph 5
 PROTEIN 5g/l (4+)
 GLUCOSE NEGATIVE
 KETONE NEGATIVE
 UROBILINOGEN NEGATIVE
 BILIRUBIN NEGATIVE
 HEMOGLOBIN 250/ul (5+)
 NITRITE NEGATIVE
 RBCS 12/HPF
 LEUKOCYTES 02/HPF
 SQ EPITHELIAL CELLS 07/HPF
 GRANULAR CAST 03/LPF
SERUM ALBUMIN 3.0 mg/dl

URINE MICROALBUMIN 2247mg/L

SPOT URINE CREATININE 30mg/dl

ALBUMIN CREATININE RATIO 7490 mg/g

RENAL FUNCTION TEST

BLOOD GLUCOSE RANDOM

 UREA 31 mg/dl
 CREATININE 0.9 mg/dl

 SODIUM 135 mmol/l

 POTASSIUM 4 mmol/l
 CHLORIDE 110 mmol/l

102 mg/dl
 LIVER FUNCTION TEST

 BILIRUBIN TOTAL 0.5 mg/dl

 BILIRUBIN DIRECT 0.2 mg/dl
 BILIRUBIN INDIRECT 0.3 mg/dl
 ALT 23 u/l
 ALK PHOS 351 u/l
 GAMMA GT 12 u/l
 ULTRASOUND ABDOMEN
 MODERATE ASCITES
 BILATERAL PLEURAL EFFUSION
 MILD HEPATOMEGALY WITH INCREASED PARENCHYMA
 BILATERAL ENLARGED KIDNEYS WITH GRADE I PARENCHYMAL DISEASE
VENOUS DOPPLER ULTRASOUND
(BILATERAL LOWER LIMB)

 ECHOGENIC THROMBUS SEEN IN BILATERAL COMMON FEMORAL AND LEFT

POPLITEAL VEIN REPRESENTING DEEP VENOUS THROMBOSIS
 MINIMAL BLOOD FLOW SEEN IN RIGHT POPLITEAL VEIN
 PLAN

 Anti-ds-DNA
 RENAL BIOPSY