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23 YEAR-OLD PRESENTED

WITH ABNORMAL RFT

NUR AYUNI BINTI MOHD SALLEH


History Taking
Presenting Patient was admitted 4 days ago following a referral from Sunway Medical
Symptom Centre for abnormal renal function test.
HOPI 1 week and a ½ ago, patient experienced a constellation of symptoms such as
+abdominal pain
+nausea
+vomiting
+lethargy
+fever
+bilateral painless leg swelling

Went to a GP and was kept on observation, advised to go to A&E if condition


worsened. 2 days after, patient went to Ampang Hospital and was admitted for
2 days for Dengue Fever with warning signs. Given saline and paracetamol,
however, patient has issues with his insurance, discharged himself at his own
risk (AOR). Renal function test results at Ampang noted to be abnormal and
patient was reffered to Sunway Medical Centre.

On the same day of admission, Kawser went to Sunway Medical Centre to do a


full medical checkup and noted to have renal failure, and reffered to UMMC.

For the past 6 months, patient experiences


+lethargy
+undocumented unintentional weight loss
+Loss of appetite
+multiple leg cramps
+frothy urine

(Systemic Review)
NO hx of
Anaemia: Giddiness, fainting
Urinary sx: Increase in frequency, nocturia, polydipsia, hematuria, painful
urination, flank pain, no hx of multiple UTI
Cardio: No chest pain, orthopnea, PND, palpitations
Liver: No hx of jaundice, tea-coloured urine, pale stool
Vascular: Hypertension?? Headache, blurring of vision

Others,
No history of jungle trekking, swimming, strenuous exercise (marathon etc)
Denied rat exposure
Denies taking traditional medication/herbs/supplements
Water source- vending machine
No URTI symptoms recently
No

Currently, patient claimed to be nauseas and having generalized itchiness for 4


days.
Ankle swelling reduced

Assess Volume overload


Complication Anemia
of Disease Metabolic Bone pain, joint pain, deformity
acidosis
Bone disorder
such as
osteoporosis
Hyperkalemia Fast Irregular pulse , palpitations, weakness, light-
headedness chest pain

Skin infection Pruritus, dry skin, rash


Cardiovascular
disorder such as
cardiac failure
Metabolic Gout – Urate retention
abnormalities Hypoglycaemia – in DM

Erectile
Dysfunction
Differential
Diagnosis 1) Diabetes

2) Glomerulonephritis (
commonly IgA
nephropathy , rarer
disorder eg.
Mesangiocapillary GN,
systemic disorder,eg. SLE,
vasculitis)

3) Unknown

4) Hypertension or
renovascular disease
5) Pyelonephritis and reflux
nephropathy

6) Renal malignancy

Past Medical NKMI


History Last medical checkup was 4 years ago, normal

Past Surgical Nil


Hx
Drugs and Nil
Allergy Denies ever taking painkiller regularly
Family Family in Bangladesh
Parents healthy in their forties.
Dad owns a grocery shop
Mother housewife
Sister 18, well.

Social Hx Came to Malaysia last 4 years to work.


Works as an errand boy at an office.
Nature of job is mostly randm errands, not sedentary.
Lives in an apartment with 10-15 others.
Salary 1900/month.
Personal health insurance
Diet & Lifestyle Irregular meals
Sleeps 3-4 hours daily out of habit
Not active since 4 years ago
Issues & 1) Finding cause of renal injury
Concerns 2) Managing current symptom
3) Dialysis vs Medication
4) Insurance and nationality, support
Physical Examination
General Blood pressure !!!!!

Alert, cncious, pink

Crt<2sec
Good pulse volume
Warm peripheries
Not tachypnaeic
Able to lie flat

Left IJC in place, bandaged


Abdomen Flat, no scar
Soft, non-tender
Liver 12cm, edge not palpable
No splenomegaly
Kidneys not-ballotable
No ascites/shifting dullness
No renal bruits
Bilateral mild ankle oedema up to shin
Respiratory System Not tachypnaeic
No O2
Bilaterally equal chest rise
*chest expansion not done
Stony dullness on percussion bibasally
Significantly reduced breath sound from midzone to lower zones
bilaterally
Fine crepitations heard on right middle zone

Cardio S1S2NM
Apex not palpated

Funduscopic Examination for


Hypertensive Changes

vs
Summary Kawser, a 23 year old Bangladeshi presented to the hospital upon
referral due to advanced renal disease under investigation. Experienced
lethargy, loss of appetite, frothy urine for the past one month and 1
week ago complaining of pruritus and bilateral leg swelling. Previous
admission was 2 weeks ago for dengue fever with warning signs.
Otherwise, no family history of chronic kidney disease, hx of taking
medications.

Physical examination reveals patient is adequately hydrated


With signs of fluid retention evident by bilateral ankle swelling up to
ankle,
Respiratory findings suggestive of bilateral pleural effusion and
pulmonary oedema.

Differential Diagnosis
Investigations
Blood Ix
FBC Hb- Anaemia of CKD Normocytic anemia

Urine UFEME Urine albumin nephrotic Microscopic Erythrocyte 8


Rbc – Nephritic
Others Hb 2+
Gucose 2+
Protein 4+
RFT Urea;creatinine ration
eGFR
Electrolytes for imbalance
to determine the extend of organ injury
LFT Baseline for starting tx ALT 85 H
ALP 134 H
AST 71 H
Hypo Ca
HyperK
GGT 231 H
Complement 3
&4
RBS To rule of diabetes
Lipid Profile Nephrotic Syndrome criteria Normal
Imaging
Chest Xray To confirm physical findings of pleural effusion Clear on 22nd
and pulmonary oedema
Cardiomegaly
Pleural effusion (blunted costophrenic angle,
meniscus sign, homogenous haziness, loss of
lung markings, rib spaces widened)
u/s Abdomen To look at kidney size (small kidney=CKD), Increased in echogenicity
echogenicity Impression: renal parenchymal
disease
KUB Xray TRO Obstructive Uropathy/ Anatomical
abnormalities(?)
Renal biopsy To confirm diagnosis of nephropathy
ECG ECG signs of HyperK, LVH indicates long
standing hypertension, pulmonary vessels
congestion
ASOT TRO cause of nephritic >200IU/ml
ESR
CRP
Lepto Serology TRO Leptospirosis because
ABG TRO metabolic acidosis
MANAGEMENT
Fluid overload Fluid restrictions
Uraemia Indication for RRT in AKI

HyperK despite medical Tx


Fluid overload despite medical Tx
Uraemia
Severe/prolonged acidosis
Metabolic imbalance
Notify for Lepto, Dengue

IVD maintainence
Figures

NEPHROTIC SYNDROME

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