30 year old female with fever and diabetic ketoacidosis

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Here is a case i have seen:

 30  year old female came with cheif complaints pedal edema and back ache since 1 year

Pt was apparently asymptomatic 1 year back then she pedal edema which was pitting type and she also developed back ache  

She also had episodes of shortness of breath ( non progressive )and facial puffiness 

No h/o abdominal pain , abdominal distension , fever , decreased urine output , vomittings , chest pain , burning micturition , generalised weakness.

Menstrual history : 3 - 4/30 ,no clots , no dysmenorrhoea 

One year ago she was diagnosed with nephrotic syndrome then she used T.lasilactone , T.nephrosafe , T.wysolone for 2 months and stopped it . Not follow up since one year. 

Past medical records ( one year back ) :

24 hr urinary protein : 4120 , sr.creatinine : 1.0 , sr.albumin : 3.0 , USG : mild hepatomegaly with fatty infiltration and mild splenomegaly , Cue : alb +++ , Hb : 10.4 , TLC : 12,000

K/c/o HTN , DM , since one year used medication for 2 months and stopped

Not a k/c/o asthma , epilepsy , CAD , TB

O/e : pt is c/c/c

Pallor - absent , icterus - absent , cyanosis - absent , lymphadenopathy - absent , 

Temp - 98.4f , pulse rate - 76bpm , BP - 150/90mmhg , RR - 22cpm , grbs - 114 

S/E : CVS : S1 S2 + , RS : Bae + NVBS , 

CNS : no FND , P/A : soft ,non tender .

Investigations at admission :

APTT : 33 secs

PT : 16 secs , INR : 1.17 

Reticulocyte count : 1.5 

CUE : colour - pale yellow , appearance - clear , reaction - acidic , RBC - 6 - 8/hpf, pus cells - 5 to 6/hpf , epithelial cells - 3 to 4/hpf

Hemogram - Hb - 9.4 

Total count - 12,700 ,. PCV - 30.8

Mcv - 62.1 , MCH - 19.6 , RDW CV - 16.7 , RBC - 4.96 million/cumm

Treatment : 

T.lasix 20mg Po/BD

T.pantop 40mg PO/OD

T.neurobion forte PO/BD

Inj optineuron 1 amp in 100ml NS IV / OD

BP / PR charting 4th hourly

Grbs charting 12th hourly 

Strict I/O charting .

Day 2 : No fresh complaints , no fever spikes 

Grbs -123

O/e : pt is c/c/c 

Pr : 100bpm , BP - 150/90 mmHg , cvs : S1 S2 + , RS : bae + NVBS , P/A : obese , soft , non tender . 

Investigations : 

Fbs - 150 mg/DL , 

Lipid profile - total cholesterol - 309 mg/DL , triglycerides - 728 mg/DL 

Hb1ac - 7.5% 

Plbs - 310 mg/DL 

24 hr urinary protein - 3,120

24 hr urinary volume - 1,300 ml

Urinary creatinine - 0.97

Treatment : 

Same treatment plus T. Atorvastatin f ( 20/160 ) OD and T.telmisartan 20mg PO/OD

 

Day 3 : no fresh compliants

PT is c/c/c

Grbs - 125mg/DL , pulse rate - 92bpm , BP - 140/90mmhg 

CVS - S1 S2 + , RS - bae + NVBS , CNS - no FND , P/A - obese , soft , non tender 

Treatment : same treatment plus T.glimi M1 OD 

Day 4 

No fresh complaints 

PT is c/c/c

PR-72 bpm , BP- 130/90 mmHg

O/e : CVS S1 S2+ , RS : bae + NVBS , CNS - no FND , P/A  - soft ,non tender 

Treatment : same treatment plus T. Metformin 500mg PO/OD 

Diagnosis : nephrotic syndrome under evaluation .