ANASARCA

June 01, 2024

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

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CHIEF COMPOAINTS:

C/o facial puffiness since 5 months

C/o bilateral swelling of lower limbs since 5months

HOPI :

patient was apparently asymptomatic 5months ago then developed facial puffiness which was insidious,on and off only in morning, gradually decreased by night followed by pedal edema in both legs extends upto mid-thigh, pitting type, gradually progressive.

H/o shortness of breath class 2NYHA abdominal distension swelling of both hands.

No h/o decreased urine output, fever

No h/o chest pain, palpitations

No h/o cough,cold, constipation

No h/o rash , itching

PAST HISTORY

K/C/O nephrotic syndrome secondary to membranous nephropathy ( serological diagnosis) since 1 year 3 cycles of modified ponticelli regimen Was given and on regular medication.

K/C/O HTN since 2 years was on TAB clonidine 0.1mg PO/OD ,TAB CINOD 10mg PO/BD ,TAB.METXL 25 mg PO/BD

K/C/O DM since 2 years was on TAB.LINAGLIPTIN 5mg PO/OD

N/K/C/O epilepsy , thyroid disorders,CVACAD,ASTHMA,TB

GENERAL EXAMINATION

Patient is conscious coherent cooperative

No pallor, icterus,cyanosis, clubbing, pedal edema present on both lower limbs

VITALS

BP 130/80mmhg

PR 88 bpm

RR 18cpm

SPO2 98%

Temp 96F

CVS: S1S2 heard no murmurs

CNS:BAE + ,NO added sounds

RS: 18cpm

P/A soft scaphoid and no distension nephrologist opinion I/v/o nephrotic syndrome

Adv- T .WYSOLONE 50MG PO/OD

TAB TELMA -40MG PO/OD

TAB . MYCOPHENOLATE 500MG PO/OD

OPHTHALMOLOGY REFERRAL I/v/o diabetic retinopathy changes: normal fundus study,no retinopathy changes

COURSE IN THE HOSPITAL

65yr old male came with complaints of generalised swellings of lower limbs,upper limbs, abdominal distension.on further history taking pt was diagnosed to have nephrotic syndrome secondary to membranous nephropathy ( serological diagnosis,serum PLA2R+) modified ponticelli regimen was started in July 2023 and 3 cycles were given,but patient discontinued follow up since march and on irregular medication.on further investigations pt was found to have proteinuria nephrology opinion was taken and advised TAB WYSOLONE 5 mg po/of,TAB .MET XL 50mg po/od,TAB TELMA -40mg po/od ,TAB. MYCOPHENOLATE 500mg po/od . Biopsy couldn't performed due to presence of renal cysts.

Patient vitals are stable at the Time of discharge.

INVESTIGATIONS

Hemogram