Case history 6
CASE HISTORY 6
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A fifteen year old girl presented to OPD with chief complaint of :
Bilateral pedal edema since 15 days
Reduced urine output since 15 days
Abdominal distension since 5 days
Facial puffiness since 3 days
Non productive cough since 3 days
HISTORY OF PRESENT ILLNESS :
Patient is apparently asymptomatic 15 days back
And then developed bilateral pedal edema with decreased urine output since 15 days
And also facial puffiness and cough since 3 days
Patient developed dypsnea on rest from 3 days .
PAST HISTORY :
There are no similar complaints in the past
No history of diabetes, hypertension, asthma ,epilepsy .
History of pneumonia when she is 5 years old
History of swelling in the vaginal area 10 days back which got burst on it's own.
FAMILY HISTORY :
there are no similar complaints in the family members .
TREATMENT HISTORY:
No treatment taken by the patient before joining the hospital
GENERAL EXAMINATION :
patient consent is taken and she is conscious, coherent and well oriented to time and place .
Pallor is seen
Cyanosis not seen
Lymphadenopathy not seen
Icterus not seen
Bilateral pedal edema not seen
Patient is moderately nourished and well built
Edema seen is of pitting type .
VITALS :
Temperature : 98.6 °F
Blood pressure : 120 / 80
Pulse rate : 80 per min
Respiratory rate : 20 per min
SPO2 : 98% in room air
SYSTEMIC EXAMINATION :
RS : bae positive basal respiratory chepta are seen
CVS : S1 and S2 are heard
P/ A : slightly distended and non tender
CNS : HMF intact
INVESTIGATIONS :
ULTRASOUND :
Colour doppler :
Blood urea :
Serum creatinine :
PROVISIONAL DIAGNOSIS :
Nephrotic syndrome.
TREATMENT :
1. Fluid restriction upto 1.5 l / day
2. Salt restricted diet upto 24 g / day
3. Tab pantop 40mg po / od
4. Inj lasix 40 mg iv / bd
5. Tab wyslane 60 mg po / of
6. Suryp ambroxyl 10 ml / po / tid
7. Tab . Pcm 650 mg / po / sos
8 . Inj augmentin 1.2 g iv/ bd
9 . Temperature charting every 4th hourly and tepid sponging if necessary .
10 . Strict I / O charting
11 . BP/ pr / spo2 charting every 4th hourly
12 . GRBS charting every 12th hourly
13 . Daily body weight monitoring .
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