56 Year Old Male with NEPHROTIC SYNDROME WITH HYPERTENSION
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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.
A 56 year old male came with complaints of abdominal distension from 2 days
Pt was apparently asymptomatic 2 and half months back ,then he developed pedal edema -pitting type grade 1 then gradually progressed to grade 2 over 10 days to grade 3 over 15 days
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
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
H/o pulmonary koch's 22 yrs back ,used ATT for 6 months
HTN since 2 months
PERSONAL HISTORY
Married
Appetite-decreased
Regular bowel and bladder movements
Occasionally alcoholic
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished
Pallor present ,grade 3 clubbing
No Icterus, cyanosis Lymphadenopathy
B/L pitting type upto thighs
VITALS :
Temp: afebrile
PR: 120 bpm
BP: 160/80 mm hg
RR: 24 cpm
Spo2 - 96% at RA
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Bilateral decreased air entry +
Expiratory wheeze + in all areas
PER ABDOMEN:
Abdomen distended with no scars, sinuses, engorged veins
No tenderness
Percussion-
Shifting dullness +
Bowel sounds +
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
PROVISIONAL DIAGNOSIS-
NEPHROTIC SYNDROME WITH HTN
Treatment given on 30/9/21
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 40MG PO/TID
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
Treatment given on 1/10/21
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 40MG PO/TID
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
SOAP NOTES DAY-1
SUBJECTIVE :
- abdominal tightness
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 130/80 mmHg
Pulse rate - 84 bpm
Central Nervous System- NAD
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , NON TENDER, Bowel sounds- heard
Abdominal girth-90.5 cms
Weight-64 kgs
Respiratory System- BAE +
Expiratory wheeze + in IAA
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/TID
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
SOAP NOTES DAY-2
SUBJECTIVE :
- abdominal tightness
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/90 mmHg
Pulse rate - 88 bpm
Central Nervous System- NAD
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , NON TENDER, Bowel sounds- heard
Abdominal girth-92.5 cms
Weight-64.5kgs
Respiratory System- BAE +
Expiratory wheeze + in IAA
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/TID
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
56Y/M ; ward patient
SOAP NOTES DAY-3
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/80 mmHg
Pulse rate - 92 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , NON TENDER, Bowel sounds- heard
Abdominal girth-92 cms
Weight-62.9kgs
Respiratory System- BAE +
Expiratory wheeze + in IAA
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/TID
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
56Y/M ; ward patient
SOAP NOTES DAY-4
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/80 mmHg
Pulse rate - 96 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , TENDERNESS + in HYPOCHONDRIUM , Bowel sounds- heard
Abdominal girth-97cms
Weight-63.1kgs
Respiratory System- BAE +
NVBS , crepitations +
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/BD
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
56Y/M ; ward patient
SOAP NOTES DAY-5
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
- pedal edema
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/90 mmHg
Pulse rate - 80 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , TENDERNESS + in HYPOCHONDRIUM , Bowel sounds- heard
Abdominal girth- 98cms
Weight-63.4kgs
Respiratory System- BAE +
NVBS , crepitations +
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/BD
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
56Y/M ; ward patient
SOAP NOTES DAY-6
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
- pedal edema
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 130/80 mmHg
Pulse rate - 82 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , TENDERNESS + in HYPOCHONDRIUM , Bowel sounds- heard
Abdominal girth- 95cms
Weight-63.14kgs
Respiratory System- BAE +
NVBS , crepitations +
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 60MG PO/BD
4.TAB RAMIPRIL 5 MG/PO/BD
5.TAB PAN-D PO/OD
6.MONITOR WT & ABDOMINAL GIRTH DAILY
7. I/O CHARTING
56Y/M ; ward patient
SOAP NOTES DAY-7
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
- pedal edema
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/80 mmHg
Pulse rate - 86 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , TENDERNESS + in HYPOCHONDRIUM , Bowel sounds- heard
Abdominal girth- 93cms
Weight-62.6kgs
Respiratory System- BAE +
NVBS , crepitations +
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 80MG PO/BD
4.TAB PAN-D PO/OD
5.MONITOR WT & ABDOMINAL GIRTH DAILY
6. I/O CHARTING
Reports of 6/10/21
56Y/M ; ward patient
SOAP NOTES DAY-8
WARD PATIENT
SUBJECTIVE :
- abdominal tightness
- pedal edema
OBJECTIVE :
- patient is conscious, coherent and cooperative
Temperature: Afebrile
Blood Pressure- 140/80 mmHg
Pulse rate - 92 bpm
Central Nervous System- NFND
Cardiovascular system- S1,S2 HEARD
P/A - DISTENDED ,SOFT , TENDERNESS + in HYPOCHONDRIUM , Bowel sounds- heard
Abdominal girth- 9 5cms
Weight-62.7kgs
Respiratory System- BAE +
NVBS , crepitations +
ASSESSMENT :
- Nephrotic syndrome with hypertension
PLAN OF CARE :
1.FLUID RESTRICTION < 1 LIT/DAY
2.SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 80MG PO/BD
4.TAB PAN-D PO/OD
5.MONITOR WT & ABDOMINAL GIRTH DAILY
6. I/O CHARTING
