Gross haematuria with ansarca

 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. red coloured urine since 36 days 

2) pedal edema since 33 days


HOPI:

Patient was apparently asymptomatic 39 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 .it relieved on medication after 3days

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
No addiction 
Occupation: Student

She wakes up at 6am and help her mother in house hold work and ready for school by 9am after 4pm she comes to home and again she help her mother in her household work ,play games and have dinner by 7 and sleep.







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
  S1,s2 heard 
No murmur




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
No focal neurological deficit

PROVISIONAL DIAGNOSIS:

POST INFECTIOUS GLOMERULONEPHRITIS ?SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI
Investigation
Fever chart


Urine sample 





Treatment


17/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly


18/12/22


13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o generalised swelling of body







O



Pt is C/C/C



BP:120/90mmHg



PR:74bpm



RR:18cpm



SpO2:98% on RA



Temp :afebrile



CVS:S1S2 +



RS :BAE +



PA-soft no organomegaly



A



POST INFECTIOUS GLOMERULONEPHRITIS SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI

P
Salt and fluid restriction
Vital monitoring 4hrly

20/12/22


13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o b/l lower limbs

No shortness of breath






O



Pt is C/C/C



BP:110/80mmHg



PR:72bpm



SpO2:98% on RA



Temp :afebrile



CVS:S1S2 +



RS :BAE +



PA-soft no organomegaly



A



POST INFECTIOUS GLOMERULONEPHRITIS



ANEMIA OF CHRONIC INFLAMMATION 




P


SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Vitals monitoring 4th Hrly



Plan for renal biopsy today








P




SALT AND FLUID RESTRICTION 




TAB LASIX 40mg PO/BD








21/12/22




13 year old girl, high school student came to the OPD with history of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .


No presented with the complains of hematuria since 33 days, gross hematuria whole stream of urine.Both lower limb pedal edema since 30 days, pitting type.


No history of sore throat, decreased urine output .



S

C/o b/l lower limbs

No shortness of breath



O


Pt is C/C/C


BP:110/80mmHg


PR:72bpm


SpO2:98% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


POST INFECTIOUS GLOMERULONEPHRITIS


ANEMIA OF CHRONIC INFLAMMATION 


P


SALT AND FLUID RESTRICTION 


TAB LASIX 40mg PO/BD


Vitals monitoring 4th Hrly


Plan for renal biopsy today



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