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