Lai is a 42 year old Chinese lady who works as a factory worker (quality check) in Singapore. She was referred to HSA a week ago from Johor Specialist on a 2 month history of swelling in her legs, face and abdomen.

Presenting complaint

Lai presented to the clinic with a sudden onset of swelling in her legs and mild fever on 1st February while she was on a road trip to Penang.

HOPC

Progression: migratory swelling from legs to trunk and face over a period of 2 weeks. In addition, her weight increased from 62kg to 71kg.

Aggravating or alleviating factors: none mentioned by the patient

Associated symptoms:

  • Loss of appetite not associated weight loss but weight gain, started with the onset of oedema. She only takes one meal a day instead of 3 meals per day.
  • No change in urinary habits( no oliguria, anuria or change in frequency).
  • Frothy urine one week after onset of oedema.
  • Disturbed sleep at night, unable to sleep throughout the night, she wakes up around early morning and goes back to sleep near morning. She is not woken up by SOB or need to go to the toilet.
  • General fatigue

Time line

1) went to GP for oedema of legs (1 feb)

2) blood test showing SLE positive results

3) admitted to JS by her GP

4) JS performed a kidney biopsy on her 12/2/08

5) After the biopsy, she complained of haematuria, dysuria, feeling of swelling and mild sharp pain in her kidneys that went away after 2 days.

6) Admitted to H SA on 28/ 3

Rheumatology??

Neurology??

SLE

No other symptoms of SLE (hair loss, photosensitivity, rash, oral ulcers, pain, arthritis, bleeding tendency)

Blurring vision?

Numbess? + weakness?


* important –ve findings should be include in HOPC

Cardiovascular systems review:

Exertional dyspnoea on walking 100m( from one end of the PP1 ward to the other) since hospitalization in HSA.

Leg swelling on both legs (bilateral oedema until mid tibia)

No orthopnoea or PND.

No claudication

No angina, or sweating

No syncope

Respiratory Review

Mild non productive cough ( started 2 weeks ago), through out the day

No hemoptosis

No wheeze

No facial pain

No pleuritic pain

Mild intermittent 1 day fever concurrent with onset of leg oedema

GI

Loss of appetite

No other GI symptoms

Past medical Hx

  • No history of atopy (allergy rhinitis, conjunctiva, asthma, migraine)
    high BP (5 years ago)

– on regular checkup every 3month on antihypertensive medication

– ask about investigation of HTN (maybe 2nd cause)

§ possibility of involvement of renal during onset

  • Stop recently, not staying in Singapore
  • Borderline cholesterol
  • Borderline uric acid
  • No past hospitalization, or trauma.

Drugs/allergy/CAM

· Traditional Chinese meds – 2 pills at Penang, stopped taking the pill because it had no effect on her oedema

· Herbal remedies for general well-being

o last dose was ½ year ago

· On OCP since her visit to the obstetrics and gynecology regarding her menstruation. Been taking the Pill for more than 5 years. She cannot remember when she started on it.

· -antihypertensive

· -prednisolone

Allergies:

  • No drug allergy
  • Allergic to mangoes, rambutan and durian. Feels hot and suffers from a sore throat after consuming the fruits.

Last Menstrual period

Lastmonth

Regular since on OCP

Irregular since menarche (age 14)

Once per 3 month or every few months

Went to OnG – prescribe OCP to regulate her menses.


Family Hx

Mother (70) – hypertension, on antihypertensive

Father (age 75 ) – skin cancer on face 2 years ago, got removed surgically,

Siblings: 2 /12 – no known illness, no history of atopy

Social/occupation

Does not smoke

Passive smoking at workplace (during lunch break)

Doesn’t drink

12hour shift – 7am – 7pm

QC – not exposed to chemicals

Nature of work: involves her standing at the production line and checking the microchips for correct assembly

dDx

  1. Chronic renal failure 2nd to hypertension/nephritis
  2. nephrotic syndrome 2nd to glomerulonephritis
  3. CCF x
  4. chronic liver failure x

Examination

General Inspection:

Alert, comfortable, hydrated, not in respiratory distressed


Vital signs

Pulse: 112 bpm, regular rhythm, strong in volume

RR: 12 breaths/min

T: 370C

BP: 160/110


No elevated JVP

Hands

- Capillary refill normal

- Wasting of Thenar and hypothenar eminence of both hands

- proximal muscle wasting, no weakness

- no flapping tremor

Neurological Examination?

* peripheral neuropathy

Face

- No signs of anemic, central cyanosis, jaundice

- signs of hirsutism

-puffy face

-no malar or discoid rash

-no oral ulcers

-no paraorbital oedema


Chest

- Heart

o Apex beat not displaced

o Audible S1 and S2

- Lungs

o Symmetrical chest expansion

o Dullness on percussion, reduce vocal resonance, reduce breathing sounds at lower L lung

- Abdomen

o Distended

o No signs of tenderness or guarding

o No palpable mass

o +ve shifting dullness test

o Normal bowel sound

- Leg

o Pitting edema up until mid tibial

radial-radial delay?

Radial-femoral delay?

Signs of systemic vasculitis?

*Fundoscopy (microcirculation)

Examine 2nd cause of HTN