13 YEAR OLD WITH GROSS HAEMATURIA AND ANASARCA

 

Sunday, December 25, 2022

13 YEAR OLD WITH GROSS HAEMATURIA AND ANASARCA

This is an 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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan.
13Y/F presented to the opd with chief complaints of 
1) fever since 36 days
2) red coloured urine since 33 days 
3) pedal edema since 30 days
HOPI:
Patient was apparently asymptomatic 36 days ago , then developed fever which was low grade, intermittent type, relieved with medication not associated with chills & rigors . Vomitings 4 episodes /day for 3 days , content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery , not associated with abdominal pain, blood in stools .
Patient presented to the opd with complaints of hematuria since 33 days whole stream of urine red in colour. No burning micturition and frothiness of urine 
Then patient developed generalised swelling of body ,initially both lower limbs pedal edema then abdominal distension and facial puffiness.No h/o sore throat , decreased urinary output.
PAST HISTORY:
No history of similar complaints in the past

Not a k/c/o of DM, HTN, epilepsy, TB, CAD,CVD

PERSONAL HISTORY :

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel and bladder: regular

Occupation: Student

MENSTRUAL HISTORY :

Attained menarche at 11 years

Regular cycles, flow is for 4 days , not associated with any pain and clots

LMP:27/11/22

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent ,cooperative and well oriented to time, place and person.

Pallor- present

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema - present (B/L)

VITALS: 

B.P:110/80 mmhg

P.R:86bpm

R.R: 16cpm

Temp:98.5F

SPO2: 99%@ RA

PER ABDOMEN:

Inspection- umbilicus inverted, all quadrants moving equally with respiration , no scars sinuses and engorged veins with visible pulsations

Palpation: soft , non tender

Auscultation: BS heard

CARDIOVASCULAR SYSTEM:

 on inspection : chest is elliptical bilaterally symmetrical 

Palpation: apex beat felt 

All inspectory findings confirmed

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes - 

Triceps  +2  +2

Biceps.  + 2  +2

Supinator +2  +2

Knee +2  +2

Ankle +2  +2

PROVISIONAL DIAGNOSIS:

POST INFECTIOUS GLOMERULONEPHRITIS ?SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI

INVESTIGATIONS :

Fever chart :

URINE SAMPLE 

TREATMENT:

17/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly

18/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly

19/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Plan for renal biopsy

20/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Vitals monitoring 4th Hrly

Plan for renal biopsy today

21/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Vitals monitoring 4th Hrly

Plan for renal biopsy today