Pregnant woman with proteinuria** DDx: Preeclampsia, Nephrotic syndrome Day and night just to finish it !!! Just take it !! It's worth copying XDDD!!

1. Case report
Intern吳易儒

2. Basic data
Chart number:45660472
Age:22
Sex:Female
Education:Junior high
Occupation:Business（菜市場）
Marital status:Married

3. Present illness
● CC:Shortness of breath for weeks
● G2P1, pregnancy GA 32wk
● History:
○ polycystic ovary syndrome
○ Termination due to generalized edema
and lower legs twitching(2012/7/17)
○ Prednislolone treatment(2013/2/7-6/30)

4. Present illness
● OPD(8/15,1 week before admission):
○ Lower abdominal tightness
○ General edema+ weight gain 5 kg in 2
months
○ Orthopnea+PND+DOE since 4wk
gestation
○ foamy urine
○ Improved by Ritodrine

5. Present illness
● This time(2 days ago):
● Progressive DOE with proteinuria and
decrease urine output
● severe hypertension(-), headache(-)
visual abnormalities(-), upper abdominal or
epigastric pain(-), N/V(-),mental status
change(-).

6. Social history
Allergy: Kind of painkiller
Alcohol drinking: Denied
Betelnut chewing: Denied
Cigarette smoking: Denied

7. Family history
● Grandmother-hypertension
● Mother-DM
● Aunts-polycystic ovary syndrome

8. Review of systems
General：
Recent weight change：+
Fever/Chills：-
Change in appetite：-
Fatigue：-
Generalized weakness：-
Skin：
Rashes: -
Itching: -
Bruising: -
Petechiae: -
Spider angioma: -
Hair loss: -
Nail change: -

9. Review of systems
Respiratory：
Lung disease：-
Cough：+
Sputum：-
Hemoptysis：-
Shortness of breath：+
(especially on exertion)
Wheezing：-
HEENT：
Head trauma: -
Blurred vision: -
Photophobia: -
Hearing impairment: -
Tinnitus: -
Rhinorrhea: -
Gum bleeding: -

10. Review of systems
Cardiovascular：
Heart trouble：+
Chest pain：-
Dyspnea on exertion：+
Orthopnea：+
Palpitation：-
Intermittent claudication：-
Varicose veins：-
Edema：+
Gastrointestinal：
Dysphargia: -
Bloating: -
Tarry stool: -
Constipation: -
Diarrhea: -
Palpating tenderness: -
Jaundice: -

11. Review of systems
Endocrine：
Polyuria or polydipsia：-
Thyroid disease：-
Heat or cold intolerance：-
Genitourinary：
Decrease in urine output:+
Nocturnal micturation: -
Urinary urgency: -
Post-micturation dripping: -
Urinary incontinence: -

12. Musculoskeletal：
arthralgia：-
Myalgia：-
Back pain：-
Neurological：
Syncope：-
Seizures：-
Focal weakness/paralysis：-
Numbness/paresthesias：-
Tremor：-
Psychiatric：
Irritability：-
Difficulty concentrating：-
Memory loss：-
Depression：-
Anxiety：-
Psychiatric treatment：-

13. Physical examination
Height：149 cm; Weight：76.4 kg;
Vital signs:
T/P/R: 36.3/94/20
BP:142/83
General Appearance：
Consciousness: clear, alert, fair looking
GCS: E4M6V5

14. Physical examination
HEENT:
Head: normocephalic, no atraumatic lesions
Eye: no cornea without lesion, no pale conjunctiva, no
icteric sclera, equal pupil,2mm,round,reactive to light

15. Physical examination
Ears:normal appearance, no obvious hearing loss
Nose:no nasal discharge, no deformity, no sinus tenderness
Mouth & throat: no lips cyanosis, no pallor lips

16. Physical examination
Neck: Supple
no evidence of tracheal deviation, no jugular venous
engorgement,no lymphadenopathy, normal thyroid size,
no palpable thyroid nodules
Heart：Regular heart beats withouth murmur

17. Physical examination
Chest：Symmetric expansion
No focal tenderness
No chest wall lesion
BS: crackles over bilateral lower lung
Abdomen：Soft, no focal tenderness
Liver and spleen: not palpable
Bowel sound: normally active
CV angle: no knocking pain

18. Physical examination
Skin：
No cyanosis
No focal erythema
Extremities：bilateral leg edema,2+
Free movement with full ROM
No clubbing finger
Neurological：
No flapping tremor, Muscle power: full

19. Initial lab data

20. Initial lab data

25. Renal echo 2014/8/22
1. Kidney Size ( cm )
Right : Normal 10.35 x 1.55 cm
Left : Normal 10.81 x 1.56 cm
2. Kidney Outline
Right : Smooth
Left : Smooth
3. Cortical echogenecity
Right Cortical echogenecity : Normal
Left Cortical echogenecity : Normal

26. Renal echo 2014/8/22
4.Central sinus area
Right Central sinus
area : Dilatation
Left Central sinus
area : Normal
Ultrasound Diagnosis
Right mild pelviectasis

27. Heart echo 2014/8/22
Ventricles
.Normal sizes of ventricular chambers.
.LVEF by M-mode is 61.7 %.
.Mitral inflow: E/A ratio 1-2.
.Deceleration time of mitral inflow 0.22 sec.
.Isovolemic relaxation time is 0.05 sec.
.Lateral E' : 10 cm/s.

28. Heart echo 2014/8/22
Valves
.MR jet area is <20% of LA area.
.TR jet area is <20% of RA area.
.Estimated systolic pulmonary artery pressure is 22 mmHg.

29. Chest echo 2014/8/22
Clinical Diagnosis :
dsypnea
Ultrasound Findings :
Effusion :
Bilateral free of pleural effusion
Ultrasound Diagnosis :
Bilateral free of pleural effusion

32. Termination

33. Diagnosis
Proteinuria
Nephrotic syndrome during pregnancy
Pulmonary edema improved

34. Treatment
Lasix supplement
Albumin supplement

35. Review
Nephrotic syndrome in pregnancy

50. Thanks for your attention