GM case
October 11, 2021
Anvitha reddy
Roll no:06
Below is an elog describing patient centered data approach and discussion regarding patient de-identified health data.
Chief complaints
A 15 year female patient, student by occupation from kashvarigudam came to causality with chief complaints
1. Bilateral lower limb swelling since last 15 days
2.abdominal distension since last 10 days
3. Cough associated with epigastric pain since 5 days
4. Fever four days back
History of present illness
Patient was apparently asymptotic 15 days back then she developed facial puffiness and swelling of upper and lower limbs extended up to thigh since 15 days and abdominal distension since last 10 days and abnormal menstrual cycle that is two cycles per month with clots she visited local hospital and went to hospital in Hyderabad we’re she was prescribed with medicine that didn’t reduce generalised edema , so she visited kamineni hospital 5 days back.
History of past Illness
Bilateral pedal Seema since 15 days and no history of diabetes, hypertension, thyroid and bronchial asthma.
Personal history
Diet: mixed
Bowel: normal
Bladder: froath urine
Sleep: adequate
Family history
She was born out of a 3rd degree consanguinous marriage. She has 2 healthy siblings. Her father expired when she was 10 years old, he was a chronic alcoholic, according to her mother who is unsure regarding the cause of his death, she attributes it to ? Respiratory Failure and Liver failure .
According to her mother, her father's elder sister had a kidney disease due to which she expired.
General examination
Moderately bulit and moderately nourished.
Pallor, icterus,
No cyanosis and no clubbing.
Systemic examination
Her weight on 4/10/2021 was 55kg
Her serum creatinine was 1.3g/dl
Urine showed albuminuria 4+
Along with 4-6 rbcs and 10 - 12 pus cells, 2 - 4 epithelial cells
Her spot protein creatinine ratio was more than 7.2
Her spot urine creatinine was 150mg/dl
Spot urine protein was 940mg/dl
Her USG abdomen revealed bilateral pleural effusion
And showed raised echogenecity of Kidneys
Ascites
She was prescribed Tab Lasilactone 20/50 BD
Along with Tab Omnocortil 60mg OD
Tab Metolazone 2.5mg OD which she took for 3 days .
RR - 26cpm
PR -102bpm
BP- 120/80mmhg
Afebrile
Abdominal -
Distended
Bowel sounds +
Lungs -
Inspiratory crepts in bilateral IAA,ISA
Cvs - S1,S2+
Provisional diagnosis
Nephrotic syndrome
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