GRAND ROUND PRESENTATION (1)by Dr D.pptx

Approach to polyuria

1. GRAND ROUND PRESENTATION Moderator: Dr. Dawit Z( MD,Internist,Ass’t Prof of IM) Presenters: Dr. Gadise A(R2) Dr. Denebo J(R1)

2. Outline Identification History Physical examination Investigation DDx and discussion of selected DDx Discussion of most likely case Reference

3. Identification Name : D.A Age:26 Sex : F Adress : Bokeji Date of visit: A year back and subsequently on followup

4. History C/c: Polyuria and Polydipsia /02 months duration HPI:A 26-year -old G3P3(2 still birth,alive twin,3C/S scar) presents with worsening of polydipsia and polyuria of 2 months duration one year back. She has a fluid intake of 8 to 10 litres and a frequency of micturition of multiple times in a 24-hour period . Her problems date back to 8 months and begun gradually

5. C ont’d… She was also claimed her LMP 6 weeks ago at time of presentation . I n association she has hx of : S ignificant but unquantified wt loss N ausea, vomiting of ingested mater, fatiguablity and epigastric burning type pain She had also hx of intermittent headache for long time She had a hx of TB lymph adenitis t/t

6. C ont’d… Gave birth(alive twin) 4 months back by CD She denies any psychiatric history and the head trauma No drug hx and allergies

7. Cont’d… No family hx of the same illness No hx of known chronic medical illness For above compliants she visited health care facility were she prescribed desmopressin 0.1 mg po daily,but she hasn’t found the medication and obliged to visit another private care setting where she finally gotten the already prescribed medication.

8. P/E G/A: Well looking V/S: BP 120/90 PR: 120 T:35.2 HEENT : pink conjunctiva, NIS, no anterior neck mass RS : clear chest with good air entry CVS : S1 and S2 are well heard , no murmur no gallop

9. C ont’d… Abdomen: flat move with respiration, no organomegaly or sign of fluid collection MSS: no edema CNS: COPPT

10. Investigations CBC S/2E RFT LFT OTHERS WBC: 5.3K RBC: 3.66K HGB: 11.4 g/dl HCT: 32.3% MCV: 88.3 FL MCH: 31.1 PG MCHC: 35.3 g/dl PLT: 258k LYM: 26.4% MXD: 0.7k NEUT: 60.4% RDW-CV: 14.6% RDW-SD: 48.8 FL K: 3.3 Na+: 137.3 Ica: 1.14 Cr 0.75 mg/dl AST:110 u/l ALT:121 u/l TB:0.48 mg/dl IB:0.14 mg/dl RBS:77 mg/dl Brain MRI:NORMAL ANA: Negative PIHCT:NR

11. DDx Diabetes mellitus Diabetes insipidus Pregnancy Psychogenic polydipisia Drugs

12. Drugs SGLT2I can produce polyuria; glucosuria Onset after initiation of the drug are clues that the medication is responsible for the polyuria Mannitol to patients with increased ICP can produce an osmotic diuresis and polyuria . Exogenous urea or glucocorticoids can produce a diuresis and polyuria . Large volumes of saline may produce an appropriate sodium diuresis . S ince she hasn’t taken any of the above medication which makes drug related polyuria less likely

13. Primary polydipisia D iagnosis PPD is one of exclusion & characterized by Excessive volitional water intake May be no physical effects, but hyponatraemia can occur. Occurs in 6% to 20% of psychiatric patients, and is most commonly seen in people with schizophrenia. It may also present in people with other psychiatric and neurodevelopmental disorders

14. Cont’d… Unlike other people with polydipsia , They are unlikely to complain of excessive thirst and instead provide other nonsensical explanations for their excessive drinking . Absence of psychiatric illness, reasonable explanation for her excessive thirst makes the diagnosis less likely

15. Pregnancy The osmotic thresholds for thirst and AVP release are altered in pregnancy . There is also a fourfold increase in metabolic clearance of AVP due to placental production vasopressinase/ oxytocinase . This can un-mask previously unrecognised central DI. In addition, pregnancy may aggravate the severity of any existing nephrogenic or central DI Even though her illness get worsen following conception but the onset was ahead of her pregnancy w/c makes less likely

16. Diabetes mellitus DM is a group of common metabolic disorders that share the phenotype of hyperglycemia . Caused by a complex interaction of genetics and environmental factors . Glycosuria causes osmotic diuresis ( ie , polyuria) and hypovolemia, which in turn can lead to polydipsia. Normal RBS makes less likely

17. Diabetes insipidus A metabolic disorder characterised by an absolute or relative inability to concentrate urine , resulting in the production of large quantities of dilute urine . It may result from an absolute or relative deficiency AVP or by resistance to its action. Both mechanisms reduce the permeability of the ducts within the nephron to water , reducing water resorption and thus increasing renal water loss.

18. Cont’d… Uncommon ,with a global prevalence of around 1:25,000. Although the exact prevalence data is difficult to estimate, central DI is most common. Clinically it manifests as polydipsia, polyuria, and hypotonic urine.

19. Cont’d… Hx of ETB treatment and gestational worsening of illness make the dx of DI high likely Particularly, response to desmopressin makes the possibility of CDI high likely Normal Ca++,low normal K+,no hx of lithium therapy ,& absence of evidence for CKD makes nephrogenic DI less likely