\n
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.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
You call this lady into your consulting room and begin to take a history.<\/p>\n\n\n\n
What questions would you like to ask?<\/strong><\/span><\/p>\n\n\n\nThink about this question. Prior to clicking on reveal write down the questions you would ask.<\/em><\/p>\n\n\n\nReveal<\/strong><\/button>\n
\n
-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?<\/p>\n\n\n\n
-Has she ever experienced this before?<\/p>\n\n\n\n
-Is there any pain in her feet, skin changes, numbness\/pins & needles?<\/p>\n\n\n\n
-Does she have any other symptoms \u2013 SOB, fatigue, confusion, urine output, abdominal pain, chest pain?<\/p>\n\n\n\n
– Has anything helped or made things worse?<\/p>\n\n\n\n
– Has she any past medical history or family history of chronic medical conditions<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
Click below to see her responses to your questioning..<\/p>\n\n\n\n
<\/p>\n\n\n\n
Responses<\/strong><\/button>\n
\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
She has never suffered with this problem before.<\/p>\n\n\n\n
She feels some tightness of her skin but denies any pain\/numbness\/redness.<\/p>\n\n\n\n
Denies any SOB, abdo pain or chest pain.<\/p>\n\n\n\n
She states she has been more tired than usual but she has been doing extra shifts. She hasn\u2019t 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.<\/p>\n\n\n\n
She has no past medical history and no family history of renal, cardiovascular or diabetes.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Following this history, which of the above body systems do you think may be involv<\/span>ed in her presentation?<\/span><\/strong><\/p>\n\n\n\nPresentations<\/strong><\/button>\n
\n
Renal and pregnancy are still possible causes for her presentation.<\/p>\n\n\n\n
She has had possibly had a reduced urine output and together with leg swelling, a renal cause remains a possibility. <\/p>\n\n\n\n
Without a history of trauma, other features of liver disease or cardiovascular events the other bodily systems remain unlikely causes of her leg swelling.<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
You complete taking a thorough history including social history<\/strong> (alcohol, street drug use, sexual history), Medications<\/strong> (including over-the-counter) and Allergies<\/strong>.<\/p>\n\n\n\nShe is otherwise well, had never seen a doctor until about a month ago about back pain.<\/p>\n\n\n\n
She has no family history. Her mother and father are both alive and well.<\/p>\n\n\n\n
She is an occasional alcohol drinker (once a week), not sexually active at present, no drug use, smokes 10\/wk.<\/p>\n\n\n\n
The doctor gave her some painkillers for her back pain \u2013 taking Naproxen 500mg BD. No other meds.<\/p>\n\n\n\n
NKDA<\/p>\n\n\n\n
You move on to examine this lady. What examinations and investigations would you like to do?<\/span><\/strong><\/p>\n\n\n\nWrite down what you would like prior to selecting reveal<\/em><\/p>\n\n\n\nReveal<\/strong><\/button>\n
\n
-Measure her BP<\/p>\n\n\n\n
-Examine her abdomen \u2013 ballotable kidneys? Flank tenderness?<\/p>\n\n\n\n
-Listen to lungs – ?basal crepitations \u2013 effusion.<\/p>\n\n\n\n
-Listen to heart sounds \u2013 ?murmur \u2013> heart failure<\/p>\n\n\n\n
-Assess her ankles – extent of oedema and for any neurovascular compromise\/cellulitis<\/p>\n\n\n\n
–Dip urine<\/strong> \u2013 protein\/blood in urine, pregnancy test if unclear sexual Hx<\/p>\n\n\n\n-Take bloods there and then \u2013 review urgently.<\/p>\n\n\n\n
-> FBC, U&E<\/strong>, LFT, CRP<\/p>\n\n\n\n-Send urine for ACR\/PCR<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
Findings<\/strong><\/button>\n
\n
-BP 105\/57, Temp 36.8, HR 89, RR 12, SpO2 98%<\/p>\n\n\n\n
-Abdo SNT, kidneys not ballotable, no flank tenderness<\/p>\n\n\n\n
-Chest clear, no basal crepitations.<\/p>\n\n\n\n
-HS I+II+0<\/p>\n\n\n\n
-Peripheral oedema, pitting to mid calf. No sacral oedema<\/p>\n\n\n\n
-Urine Protein +++, blood +;<\/p>\n\n\n\n
-Pregnancy test: NEGATIVE<\/p>\n\n\n\n
Blood results \u2013 returned 24 hours after taking them:<\/p>\n\n\n\n
-FBC \u2013 NAD<\/p>\n\n\n\n
-U&E \u2013 Urea 12.5, Cr 202, eGFR 45, K 4.7<\/p>\n\n\n\n
-LFT \u2013 NAD<\/p>\n\n\n\n
-CRP \u2013 10<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
What do you think is the cause of her renal impairment?<\/strong><\/span><\/p>\n\n\n\nReveal<\/strong><\/button>\n
AKI<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Name possible causes for this diagnosis<\/strong><\/span><\/p>\n\n\n\nWrite down as many as you can think of<\/p>\n\n\n\n
Causes for presentation<\/strong><\/button>\n
\n
-Dehydration \u2013 Contributing factor, working extra shifts, reduced oral intake.<\/p>\n\n\n\n
-Sepsis \u2013 Unlikely given normal temp & FBC<\/p>\n\n\n\n
-Nephrotoxic drugs \u2013 Likely \u2013 NSAID use in preceding weeks.<\/p>\n\n\n\n
-Intrinsic renal disease \u2013 Possible but rare<\/p>\n\n\n\n
-Obstruction \u2013 Unlikely as still passing urine<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
What course of action would you recommend?<\/span><\/strong><\/p>\n\n\n\nKeep well hydrated<\/strong><\/button>\n
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.<\/p>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
Stop taking naproxen<\/strong><\/button>\n
Yes, this is likely contributing to her renal impairment and ongoing medication and dehydration is likely to lead to a worsening of this.<\/p>\n\n\n\n
<\/p>\n<\/div><\/div>\n\n\n\n
Repeat blood tests<\/strong><\/button>\n
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.<\/p>\n<\/div><\/div>\n\n\n\n
Dialysis<\/strong><\/button>\n
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.<\/p>\n<\/div><\/div>\n\n\n\n
Do Nothing<\/strong><\/button>\n
No, this is not an option for this lady. Without prompt action her renal function is likely to deteriorate further and may become irreversible.<\/p>\n<\/div><\/div>\n\n\n\n
Note there are many types of nephrotoxic medications which may need to be withheld during sickness or dehydration. A reminder of these is:<\/p>\n\n\n\n
<\/p>\n\n\n\n
-Diuretics \u2013 loop and thiazide<\/p>\n\n\n\n
-ACE-I, ARB<\/p>\n\n\n\n
-Metformin<\/p>\n\n\n\n
-NSAIDs<\/p>\n\n\n\n
-Vancomycin & Gentamicin.<\/p>\n\n\n\n
<\/p>\n\n\n\n
Well done you have completed this case.<\/p>\n","protected":false},"excerpt":{"rendered":"
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\u2026<\/p>\n
Continue reading<\/span><\/i><\/a> <\/p>\n","protected":false},"author":7,"featured_media":0,"parent":4106,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-4844","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4844","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=4844"}],"version-history":[{"count":12,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4844\/revisions"}],"predecessor-version":[{"id":5063,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4844\/revisions\/5063"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4106"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=4844"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}