40 yrs old male witth Nephrotic syndrome

 Greetings to one and all who are currently reading my blog. This is Jasmisri,eighth semester medical student


This is an online E - log book to discuss our patients 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 patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

A 48 year old male dailywage labourer from Suryapet came to opd with

CHIEF COMPLAINTS:-

Decreased urine output since 15 months

Facial puffiness Since 1 month

Pedal edema since 1 month 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently a symptomatic Since 15 months back then he had decreased urine output 

Pedal edema since 1 month Initially it was up to ankel gradually progressive to  knee then gradually progressive to face

 It was more in the morning after waking from the bed

There is no history of fever,burning micturition,pain in abdomen


PAST HISTORY:-

N/k/c 

Diabetes

Hypertension

Tuberculosis

Asthma

CAD

PERSONAL HISTORY:-

Married

Diet- mixed 

Appetite-Normal

Micturition-Normal 

Bowel movements-Normal

Sleep-Adequate 

Addictions-No


Daily routine:-





FAMILY HISTORY:-

No significant history


GENERAL EXAMINATION:-

Patient was conscious coherent well oriented to time ,place and person

Height-162cm

Weight-68kgs

Moderately nourished and built

No PALLOR 

No ICTERUS

No CYANOSIS

No CLUBBING

No KOILONYCHIA 

No LYMPHADEONAPTHY

PEDAL ODEMA grade 4

Vitals:-

Temperature:-afebrile

Pulse:-80 beats/min

Bp:-110/80 mmHg

Respiratory rate-16 cycles/min

SpO2:-99



SYSTEMIC EXAMINATION:-


A. Cardiovascular system 


S1 S2 HEARD

NO MURMURS.


B. Respiratory system 

NVBS heard

BAE +

TRACHEA CENTRAL.


C. Per abdominal examination 

Scaphoid,No palpable mass,No tenderness 


D. Central nervous system:-


Conscious 

Speech normal

Cranial nerve-NAD

Motor system-

Sensory system-NAD

Cerebellar system-NAD

No signs of meningial irritation/ meningitis

PROVISIONAL DIAGNOSIS:-

Nephrotic syndrome 


Investigations:-














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