A 43 year old male patient with nephrotic syndrome
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs
Date of admission :30th October
A 43years old male patient welder by occupation came to the OPD with body pains,body swellings and SOB since 6months.
History of present illness
Patient was apparently asymptomatic one and half year back.In the month of march he experienced seizures associated with leg swellings(nearly 20bouts of seizures in one day)He then was admitted in Mamatha and recovered.He experienced 2 episodes of seizures 6months back.The symptoms of patient during seizures are dizziness,tingling and numbness.
History of shortness of breath (Grade-4)since 3years.
Pedal edema is present-pitting type since 18months
Sacral edema - present
Patient developed anasarca with facial puffiness for which he visited the hospital and was diagnosed with nephrotic syndrome.
Patient complaints of decreased urine output and decrease urine frequency.
Patient complaints of low back pain(pricking type) radiating to the side and to the lower limbs.
Patient complaints of pain at knee and ankle joint.
History of weight loss
Patient complaints of loose stools.(On Sunday -31th October at 3:00-7:00am-4episodes and Monday morning at 3:00-9-00am 3episodes)and also complaints of hard stools on the other day
History of past illness :
Patient was known case of diabetes since 6years and hypertension since 6months.
Personal history
No loss of appetite
Inadequate sleep
Bowel bladder movements-irregular
History of alcohol consumption occasionally since 10years
Patient has habit of chewing pan since 2years.
No habit of smoking.
No drug allergy
Family history
No relevant history found
General Examination
Patient was conscious,cooperate and coherent at the time of joining
No pallor
No icterus
No cyanosis
No clubbing
Pedal edema is present
No generalized lymphadenopathy
VITALS:
Temperature-98.5F
Pulse-82 beats/min
Bp-120/80mm Hg
Respiration rate-20 /min
SYSTEMIC EXAMINATION
CVS
No thrills
S1 S2 heard
No murmurs
RESPIRATORY SYSTEM
No dyspnoea
No wheeze
Position of trachea-central
Breath sounds-vesicular
ABDOMEN
Shape of abdomen-scaphoid
No tenderness
Bowel sounds-present
No bruits
CNS
Patient is conscious
Speech is present
Reflexes are normal
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS
Nephrotic syndrome
TREATMENT
Tab Ecosprin AV/Po/HS
Tab Livogen Po/OD
Tab Nodosis 500mg/Po/BD
Tab PAN 40mg Po/OD
Fluid restrictions <2litres/day
Salt restrictions <2g/day
Tab CELGLIM Po/OD
Comments
Post a Comment