General Medicine

 Greetings to one and all who are reading my blog.This is M.Yashwitha, a third semester student.


This is 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. 


CASE DISCUSSION:

 •55 year old man, owns a restaurant at choutuppal presented with the complaints of

Bilateral lower limb swelling since 1 month

Reduced urine out since 20 days

Abdominal distension since 7 days

Scrotal swelling since 4 days


Patient used to previously work as a farmer  and later in 2004 he and his wife started running their own restaurant at Choutuppal. He is a father of 2 children. 


 22 years back:  He got diagnosed with pulmonary kochas for which he used ATT for 6 months 


 1 month back : 


He first developed left lower limb swelling extending upto his ankle and he later gradually developed swelling of his right lower limb and the swelling in both his lower limbs extended upto his thighs


He even had difficulty in passing stools for which he received enema outside 



Since 20 days - he has been experiencing reduced urine output 


10 days back - When he paid a visit to a hospital with these complaints he got diagnosed to be hypertensive and was started on Tab Telma H in a local hospital and was also started on Tab Lasilactone 20/50


At this point his serum creatinine was 1.6 mg/dl

And his usg abdomen showed ascites and his kidney size was normal 


Since 7 days - he even developed abdominal distension 


Since 4 to 5 days he has also developed scrotal swelling


He however has no complaints of fever, cough, burning micturation, loose stools, vomiting


No complaints of dyspnea, hematuria, frothy urine, no complaints of Chest pain, palpitations, orthopnea, PND, bendopnia or trepopnea 


On examination: 

He has pallor with Grade 3 clubbing, that is parrot beak type

Bilateral pedal edema - of pitting type extending upto his thighs

JVP not elevated 


 HR of 75 bpm

Bp of 110/70mmhg

RR 20cpm

Spo2 maintaining at 99% at Room Air


GIT Examination:

Per Abdomen-

Abdomen distended with no scars, sinuses, engorged veins 

No tenderness 


Percussion-

Shifting dullness +


Bowel sounds +


Cvs Examination:

Apex beat + in 6th ICS at MCL

S1, S2+


Lungs:

Inspirstory crepts in bilateral all lung fields


Cns: 

Normal


Provisional diagnosis:

? Nephrotic syndrome



Evaluation:

Hb - 9.4 g/dl

TLC - 5300

Plt - 1.84


CUE:

Albumin +++

Pus cells 4 to 6 cells 


Albumin 2g/dl


Serum creatinine- 3.6mg/dl 

Blood urea - 76 mg/dl


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


Usg abdomen shows normal sized Kidneys with grade 1 RPD changes along with moderate ascites


Diagnosis:

? Nephrotic syndrome 

Known case of Hypertension since 10 days

Anemia under evaluation. 











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:




-Colour Doppler 2D echo:





14/ 08 / 2021: 

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

-ULTRA SOUND REPORT:

16/ 08/ 2021:

-Hemogram:




17/ 08/2021:

-SARS COV 2 Qualitative PCR : Negative. 

-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 :




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 evaluation.
  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 evaluation. 
  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.
















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