You are an FY2 working in a GP practice and your next patient is a 34 year old cleaner who is concerned about her ankles being swollen.
Initial thoughts – Before even seeing the patient, have a think about possible causes of this and systems that may be involved.
Which of the following systems do you think might be important in the investigations of this lady’s breathlessness?
She is young and fit that she can work. While this is unlikely it would be important to rule this out .
This is possible and would certainly need to be investigated to see whether she has underlying undiagnosed chronic kidney disease. Her history may help to identify if this is a possible cause
Given that the swelling is bilateral this is unlikely. If she had a history of trauma this would lend more to this as a cause of her presentation
Given her age, this is a possible cause for this lady’s presentation.
Again this is a possible cause of leg swelling due to hypoalbuminaemia. Family history or alcohol history might help to confirm or rule this out.
You call this lady into your consulting room and begin to take a history.
What questions would you like to ask?
Think about this question. Prior to clicking on reveal write down the questions you would ask.
-How long has she had the swollen ankles? Is it getting worse? What is the extent of the swelling? Are both ankles affected? Are her hands or abdomen swollen?
-Has she ever experienced this before?
-Is there any pain in her feet, skin changes, numbness/pins & needles?
-Does she have any other symptoms – SOB, fatigue, confusion, urine output, abdominal pain, chest pain?
– Has anything helped or made things worse?
– Has she any past medical history or family history of chronic medical conditions
Click below to see her responses to your questioning..
She first noticed this 2 weeks ago after work and attributed it to being on her feet all day. She has not had any trauma to the area.
Both ankles are affected, initially just around her ankle bones but she now thinks that her calves are a bit puffy. She has no swelling elsewhere.
She has never suffered with this problem before.
She feels some tightness of her skin but denies any pain/numbness/redness.
Denies any SOB, abdo pain or chest pain.
She states she has been more tired than usual but she has been doing extra shifts. She hasn’t taken much notice of how much she is weeing but thinks it may be less than before. There isn’t much time to drink at work so just thought she was a bit dehydrated.
She has no past medical history and no family history of renal, cardiovascular or diabetes.
Following this history, which of the above body systems do you think may be involved in her presentation?
Renal and pregnancy are still possible causes for her presentation.
She has had possibly had a reduced urine output and together with leg swelling, a renal cause remains a possibility.
Without a history of trauma, other features of liver disease or cardiovascular events the other bodily systems remain unlikely causes of her leg swelling.
You complete taking a thorough history including social history (alcohol, street drug use, sexual history), Medications (including over-the-counter) and Allergies.
She is otherwise well, had never seen a doctor until about a month ago about back pain.
She has no family history. Her mother and father are both alive and well.
She is an occasional alcohol drinker (once a week), not sexually active at present, no drug use, smokes 10/wk.
The doctor gave her some painkillers for her back pain – taking Naproxen 500mg BD. No other meds.
You move on to examine this lady. What examinations and investigations would you like to do?
Write down what you would like prior to selecting reveal
-Measure her BP
-Examine her abdomen – ballotable kidneys? Flank tenderness?
-Listen to lungs – ?basal crepitations – effusion.
-Listen to heart sounds – ?murmur –> heart failure
-Assess her ankles – extent of oedema and for any neurovascular compromise/cellulitis
–Dip urine – protein/blood in urine, pregnancy test if unclear sexual Hx
-Take bloods there and then – review urgently.
-> FBC, U&E, LFT, CRP
-Send urine for ACR/PCR
-BP 105/57, Temp 36.8, HR 89, RR 12, SpO2 98%
-Abdo SNT, kidneys not ballotable, no flank tenderness
-Chest clear, no basal crepitations.
-Peripheral oedema, pitting to mid calf. No sacral oedema
-Urine Protein +++, blood +;
-Pregnancy test: NEGATIVE
Blood results – returned 24 hours after taking them:
-FBC – NAD
-U&E – Urea 12.5, Cr 202, eGFR 45, K 4.7
-LFT – NAD
-CRP – 10
What do you think is the cause of her renal impairment?
Name possible causes for this diagnosis
Write down as many as you can think of
-Dehydration – Contributing factor, working extra shifts, reduced oral intake.
-Sepsis – Unlikely given normal temp & FBC
-Nephrotoxic drugs – Likely – NSAID use in preceding weeks.
-Intrinsic renal disease – Possible but rare
-Obstruction – Unlikely as still passing urine
What course of action would you recommend?
Yes, some individuals with AKI need admission to monitor strict fluid balance and for intravenous rehydration as for some individuals it may be difficult to replace the fluid lost orally.
Yes, this is likely contributing to her renal impairment and ongoing medication and dehydration is likely to lead to a worsening of this.
It would be wise to monitor her renal function over the next few days to weeks to ensure it is returning to normal. This could be done either as an outpatient or an inpatient. It will be important to make sure that her AKI is improving and does not need any ongoing renal team input.
No, although she does have an AKI she currently has no indication for dialysis and at her current renal function there is no requirement for this.
No, this is not an option for this lady. Without prompt action her renal function is likely to deteriorate further and may become irreversible.
Note there are many types of nephrotoxic medications which may need to be withheld during sickness or dehydration. A reminder of these is:
-Diuretics – loop and thiazide
-Vancomycin & Gentamicin.
Well done you have completed this case.