22yr/Female with c/o facial puffiness, B/L pedal edema and decreased urine output.

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Chief Complaints:

  22 year old female, resident of Naeliculi in Nalgonda, complaints of B/L lower limbs swelling.

C/o facial puffiness, decreased Urine output since 5 months. 

History of Present Illness:

  Patient was apparently asymptomatic 5 months ago then she developed facial puffiness, followed by B/L lower limbs swellings, also decreased urine output and SOB Grade 2. She took Treatment in hospital  located in Nalgonda. She's admitted here on 9/12/22 for the same.

History of Past Illness:

      Not a known case of DM / BP / Asthma / Epilepsy /TB

Personal History:

   Diet: Mixed

   Appetite: Decreased

   Bowel and Bladder Movements: Regular

   Sleep: Adequate 

Family History:

      No known similar complaints in the family members.

 

Menstrual History:

 Age of Menarche: 15 years

 Days of cycle: 29 days

General Examination:

Pallor Present.

B/L pedal edema (pitting edema).

No Cyanosis, Icterus and Clubbing. 

     Vitals:

          Temperature: Afebrile

           Respiratory rate: 18bpm

          Pulse: 82bpm

          Blood pressure: 120/80mm/ Hg

Systemic Examination:

 

 Cardiovascular System:

    Thrills: No

    Cardiac sounds: S1S2 heard

    Cardiac murmurs: No

Respiratory system:

   Position of trachea: Central 

   Breathe sounds: Vesicular 

  

Abdomen:

    Shape of Abdomen: Scaphoid 

     Tenderness:  No tenderness 

     Palpable mass: No Palpable mass

     Hernial orifices: Normal 

     Free fluids:  No

     Bruits:  No

     Liver: Not palpable

     Spleen:  Not palpable

     Bowel sounds: No

Central Nervous system:

    Pt is conscious, coherent, co-operatively well oriented to time and place.

    Speech: Normal 

    Sign of Meningitis: No 

    Cranial Nerves: Intact

    Motor and Sensory system: Intact

Provisional Diagnosis:

     Nephrotic syndrome

Investigation:

    Renal biopsy was taken on 10/12/22 and retake is on 13/12/22.

Treatment:

Inj. Piptaz 4.5mg/ IV

Inj. Tramadol 1mg +100ml IV

Inj. Zofer 4mg IV

Tab. Ramipril 2.5mg BD 

Tab. Lasix 20mg OD

Salt and Fluid restriction.