Case presentation 2

September 05,2021

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome 


A 57 yr old male patient  who runs a hotel near choutupal came to opd with a cheif complaint of swelling of body from legs to upper abdomen since 1 month 

HISTORY OF PRESENT ILLNESS : 
 Patient was  asymptomatic 1 month back when he noticed the swelling in right leg 
Swelling gradually increased to upped abdomen region with enlargement of scrotal sac 
Patient was hypertensive since 1 month 

HISTORY OF PAST ILLNESS : 
Patient had difficulty in fecal excretion and fullness of abdomen 1 month back and consulted doctor 
Doctor advised for enema and medication 
Patient hand pleural edema 20 yrs back and consulted a doctor and cured on medication ( medication not specified) . 

PERSONAL HISTORY : 
diet : mixed 
Appetite : low 
Sleep :adequate 
Bowel and bladder: regular 
Addictions : no addictions 

FAMILY HISTORY: 
No history of similar complaint in the family
 
TREATMENT HISTORY : 
patient is on use of pain killers  ( as he walks more he used tablets when there is pain ) 
Patient is on use of calcium tablets along with pain killers 
No history of allergy to known drugs 

GENERAL EXAMINATION : 
Patient was conscious coherent and well built 
Pallor  is present 
No icterus 
No cynosis 
Clubbing is present  parrot beak type 
Bipedal edema of pitting type is seen 
No lymph node enlargement 

Vitals: 
Temp : 

Heart Rate  of 75 bpm

Bp of 110/70mmhg

Respiratory rate  of 20cpm

SYSTEMIC EXAMINATION: 

CVS: s1 and s2 are heard,  no murmures 

CNS : consicious, no abnormalities


Provisional diagnosis :

Nephrotic syndrome 


Evaluation:

Complete blood picture : 

Hb - 9.4 g/dl

TLC - 5300



Complete urine examination: 

Albumin +++

Pus cells 4 to 6 cells 


Albumin 2g/dl

Serum creatine and urea levels: 

Serum creatinine- 3.6mg/dl 

Blood urea - 76 mg/dl


24 hours urinary protein shows a protein loss of 2,622 mg/dl 




INVESTIGATIONS:

12/08/2021:
  • Blood urea: 74 mg/dl.
  • Serum creatinine: 3.6 mg/dl.
  • Serum Albumin : 2.0 gm/dl.
  • Serum proteins: 4.0 gm/ dl.
Serum electrolytes:
  • Sodium: 132 m eq/ l.
  • Potassium: 5.1 m eq/l.
  • Chloride: 105 m eq/l.


Hemogram 
Complete urine picture 
ECG 

14/ 08 / 2021: 

-URINARY PROTEINS ( 24 hours)
 ▪︎24 hr urinary protein : 2,622 mg/ day. 
 ▪︎24 hrs urine volume : 1900ml.
16/ 08/ 2021:

-Hemogram:

17/ 08/2021:


-Peripheral smear:
  • RBC : Normocytic Normochromic.
  • WBC: with in normal limits with relative Eosinophilia.
  • Platelets: Adequate. 
  • IMP: Normocytic Normochromic with relative Eosinophilia.
-Reticulocyte count : 0.5%.

-Complete urine picture :
18 /8/21 
Chest x ray 
19/8/21
Fever chart 
Serum electrolytes: 

20/8/21
Serum electrolytes: 

Pleural protein, sugar and LDH:

Pleural Sugars 105
Proteins 0.4

Pleural LDH is 120
Serum LDH is 271.5

Pleural Serum Protein ratio is 0.10
Pleural Serum LDH ratio is 0.4 

DIAGNOSIS : 
Nephrotic syndrome
Pleural effusion  




TREATMENT:

16/ 08/ 2021:

  1. Fluid Restriction <1.5 L/ day.
  2. Salt restriction <2 g/ day.
  3. Inj.Lasix 40 mg I.V / BD, if SBP is >>110 mmhg.
  4. Tab.Pan 40 mg PO/OD.
  5. Tab.ZOFER 4mg PO/SOS.
  6. Strict I/O charting.
  7. BP/PR/RR/SpO2 charting 4th hourly.

17/08/ 2021:

  1. Head end elevation.
  2. INJ.Pantop 40 mg I.V/ OD.
  3. INJ.Lasix 40 mg I.V/BD.
  4. Adviced.
          - fluid restriction <1 L/ day.
           -salt restriction < 2 g/ day.
      6. Strict I/O charting. 
      7. Monitor vitals.
      8. Tab.RAMIPRIL 2.5 mg/PO/OD.


18/ 08 / 2021:

  1. Head end elevation. 
  2. Inj.Pan 40 mg I. V/ OD.
  3. Inj.Lasix 40 mg I. V/BD.
  4. Fluid Restriction <1L/ day and Salt restriction < 2 g/ day.
  5. Strict I/O charting. 
  6. Monitor vitals. 
  7. Tab.RAMIPRIL 2.5 mg/PO/OD.

19/8/21

  1. Head end elevation. 
  2. Inj.Pan 40 mg I. V/ OD.
  3. Inj.Lasix 40 mg I. V/BD.
  4. Fluid Restriction <1L/ day and Salt restriction < 2 g/ day.
  5. Strict I/O charting. 
  6. Monitor vitals. 
  7. Tab.RAMIPRIL 2.5 mg/PO/OD.
  8. Ointment ANOBLIS

20/8/21

  1. Head end elevation. 
  2. Inj.Pan 40 mg I. V/ OD.
  3. Inj.Lasix 40 mg I. V/BD.
  4. Fluid Restriction <1L/ day and Salt restriction < 2 g/ day.
  5. Strict I/O charting. 
  6. Monitor vitals. 
  7. Tab.RAMIPRIL 2.5 mg/PO/OD.
  8. Ointment ANOBLIS

21/8/21
  1. Head end elevation. 
  2. Inj.Pan 40 mg I. V/ OD.
  3. Inj.Lasix 40 mg I. V/BD.
  4. Fluid Restriction <1L/ day and Salt restriction < 2 g/ day.
  5. Strict I/O charting. 
  6. Monitor vitals. 
  7. Tab.RAMIPRIL 2.5 mg/PO/OD.
  8. Ointment ANOBLIS
  9. TAB.OROFER XT PO/OD

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