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
- Chronic renal failure 2nd to hypertension/nephritis
- nephrotic syndrome 2nd to glomerulonephritis
- CCF x
- 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