56year male with nephrotic syndrome
History taken in August 18 2021
56 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 local bandi for breakfast at Choutuppal. He even serves breakfast on cycle. 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
He is an occasional alcoholic and occasional consumes NSAIDs after long working hours.
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:
Chest Xray PA view showing left sided CP angle obliteration- suggesting left pleural effusion
Hb - 9.4 g/dl
TLC - 5300
Plt - 1.84
Normocytic normochormic picture
CUE:
Albumin +++
Pus cells 4 to 6 cells
Albumin 2g/dl
Serum creatinine- 3.6mg/dl
Blood urea - 76 mg/dl
Serum Sodium - 135 meq/L
Serum Potassium- 5.1 meq/L
Serum Chloride - 101 meq/L
Total Bilirubin- 0.56 mg/dl
Direct Biliribin - 0.10 mg/dl
AST - 17 IU/L
ALT - 11 IU/L
Serum Protein - 3.9 g/dl
Serum Albumin- 2.6
24 hours urinary protein shows a protein loss of 3,622 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
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Patient presented again on November 2021 with grade 4shortness of breath
https://06akhil.blogspot.com/2021/11/general-medicine-case-4.html?m=1
Provisional diagnosis:CRF ,HFpEF,with hypertension.
Nephrotic syndrome
Investigations:
Ferritin-415 ng/ml
Blood urea-164 mg/dl
Serum creatinine-8.7 mg/dl
HIv 1/2 rapid test- non-reactive
Anti HCV antibodies- non-reactive
FBS- 105 mg/dl
Serum iron- 80ng/dl
Serum electrolytes:
Na+ - 143mEq/L
K+ - 4.7mEq/L
Cl- - 98 mEq/L
P - 7.8 mg/dl
Ca - 8.7 mg/dl
HBsAg-rapid - negative
Complete blood picture:
Hemoglobin - 7.7 gm/dl
Total count - 5,900 cell/cumm
Neutrophils - 60%
Lymphocytes - 28%
Eosinophils - 2%
Monocytes - 10%
Basophils - 0%
Platelet count - 4.02 lakh/cumm
Smear - Normocytic normochromic anemia
Liver function test:
Total bilirubin - 0.62 mg/dl
Direct bilirubin - 0.20 mg/dl
SGOT(AST) - 10 IU/L
SGPT(ALT) - 10 IU/L
Alkaline phosphatase - 162 IU/L
Total protein - 4.3 gm/dl
Albumin - 2.0 gm/dl
Hemogram
Hemoglobin - 7.8 gm/dl
Total count - 9,700 cell/cumm
Neutrophils - 88%
Lymphocytes - 09%
Eosinophils - 01%
Monocytes - 02%
PCV - 23.8vol%
MCV - 88.1fl
MCH - 28.9 pg
MCHC - 32.8%
RDW-CV - 13.8%
RDW-SD - 45.6%
RBC count - 2.70 millions/cumm
Platelet count - 3.18 lakh/cumm
Smear:
RBC - Normocytic normochromic
WBC - within in normal limits with relative neutrophilia
Platelet - adequate
Hemoparasites - no hemoparasites detected
Impression - Normocytic normochromic anemia with relative neutrophilia blood picture.
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