NEPHROTIC SYNDROME WITH TYPE -I DM, HYPERTENSION,RIGHT PLEURAL EFFUSION
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USG Abdomen and pelvis:
A 20 yrs old female who is a house wife was brought to the casualty with the C/O
• B/L pedal edema since 1 months
•Shortness of breath (grade 2-3 ) since 1 months,which is insidious on onset gradually progressive not associated with orthopnea /PND
•Decreased urine output since 10 days
•Swelling of lips since 3 days
HOPI:-
Patient was apparently asymptomatic 11years ago,then her parents observed her eating more food, increased urine output on a regular check up she was diagnosed with diabetes type -1(On insulin since then)
2018- Patient became drowsy and brought to the hospital , diagnosed with?DKA
From then she is on MIXTARD 18UNITS MORNING,12UNITS NIGHT
•1 year ago ,she got married
• 6 months ago- She was brought to the hospital as she has C/O Fever , Not eating food for 5 days.Then she was diagnosed Hypertensive ,since then she is on Telma 40 mg
•3 Months Ago , patient was diagnosed with UPT positive and had abortion 2 months ago as fetal cardiac activity is absent
• On 9/4/22- Patient was brought to hospital as she has
C/O B/L pedal edema since 3 months, Pitting type
•Shortness of breath (grade 2-3 ) since 3 months,not associated with orthopnea /PND
•Decreased urine output since 10 days
•Swelling of lips since 3 days
FAMILY HISTORY:
Maternal uncle's have DM-2
GENERAL EXAMINATION:
Pt is conscious, coherent, cooperative
Bp-150/90 mmHg
Pr-91bpm
Temp -98.5°F
SpO2- 91%@RA
GRBS -254mg% @admission
CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular ,infrascapular regions,No crepts
CNS : NAD
P/A : Soft, no tenderness . Bowel sounds +
Pallor ++,Edema present in both limbs ,face ,abdomen
No icterus, cyanosis, clubbing or lymphadenopathy
PROVISIONAL DIAGNOSIS:
? NEPHROTIC SYNDROME WITH K/C/O TYPE -I DM(since 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
INVESTIGATIONS:
ABG :
RBS - 260mg/dl
SERUM IRON-95 ug/dl
Reticulocyte count -0.7%
BLOOD GROUPING AND TYPE:- O POSITIVE
PERIPHERAL SMEAR:
RBC : Mild Anisocytosis with Microcytic Hypochromic Cells few Normocytes seen
WBC : With in normal limits
PLATELET : Adequate
CHEST xray:
2dECHO :
Plan of treatment:
1.Head end elevation upto 30°
2.O2 supplementation if spO2<90%
3.Inj.HAI s/c pre meal
4.Tab.Telma 40 mg PO/OD
5.Inj.LASIX 40mg /IV /TID(If SBP <110 mmhg )
6.Salt restriction <2.4 gm/day
7.Fluid restriction <1lit /day
SOAP NOTES Day 2
S- No fresh complaints
O- Patient is consious, drowsy coherent, co-operative.
Pallor ++,Odema present over face , B/L pedal odema ,upper limbs
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 80 BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 94% AT RA
GRBS - 292 mg/dl
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions
CNS : NAD
GRBS : on 9/4/22
4PM : 261mg/dl
8PM :294mg/dl
on 10/4/22
2 AM : 518 mg/dl
6AM :478 mg/dl
Urine for ketone bodies : Positive
FBS:484mg/dl
ESR :45
A -? NEPHROTIC SYNDROME WITH K/C/O TYPE -I DM(since 11yrs) ,K/C/O HTN (6 months) ,RIGHT
PLEURAL EFFUSION WITH DIABETIC NEPHROPATHY WITH CHRONIC KIDNEY DISEASE
P -
•GRBS 7 point profile monitoring
•Insulin drip
SOAP NOTES Day 3
S- Nausea ,Loss of appetite
O- Patient is consious, lethargic, coherent, co-operative.
Pallor ++, Decreased facial puffiness
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 86BPM, REGULAR, NORMAL VOLUME
BP - 170/110MM OF HG
SPo2 - 98%@ 5 lit of O2
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -? NEPHROTIC SYNDROME WITH K/C/O TYPE -I DM(since 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS every 1hr monitoring
SOAP NOTES Day 4
S- Nausea ,Loss of appetite
O- Patient is consious, coherent, co-operative.
Pallor ++, Decreased facial puffiness
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 96BPM, REGULAR, NORMAL VOLUME
BP - 150/70MM OF HG
SPo2 - 98%@ 5 lit of O2
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS every 1hr monitoring
SOAP NOTES Day 5
S- Nausea ,Loss of appetite
O- Patient is consious, coherent, co-operative.
Pallor ++, Decreased facial puffiness
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 180/110MM OF HG
SPo2 - 95%@RA
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS 7 point profile monitoring
OPHTHALMOLOGY OPINION:
S- Decreased Nausea ,Loss of appetite
O- Patient is consious, coherent, co-operative.
Pallor ++, Decreased facial puffiness
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 140/90MM OF HG
SPo2 - 98%@RA
GRBS:
On 13/4/22
@8AM:225mg/dl—8 units of insulin
10AM:223mg/dl
1PM:199mg/dl —8units of insulin
8PM:181mg/dl —6units of insulin
On 14/4/22
@8AM :169mg/dl
I/O:1400/1600ml
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since I'm 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS 7 point profile monitoring
Chest xray:
SOAP NOTES Day 7
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
Pallor ++, Decreased facial puffiness
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 130/90MM OF HG
SPo2 - 97%@RA
GRBS:
On 14/4/22
@8AM:169mg/dl—6units of insulin
2PM:240mg/dl — 8units of insulin
7PM —508 mg/dl 6 units of insulin given (Direct IV)
8PM:287mg/dl —8⁰units of insulin
10PM:273mg/dl
On 15/4/22
@8AM :214mg/dl —8units of insulin given
I/O:1100/1250ml
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since I'm 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS 7 point profile monitoring
SOAP NOTES Day 9
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
Pallor ++, facial puffiness+
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 97%@RA
GRBS:
On 16/4/22
@8AM:389mg/dl—8units of insulin
10AM:464mg/dl
3PM:305mg/dl —
7:30 PM-203mg/dl
On 17/4/22
2AM:109mg/dl
@8AM :69mg/dl
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since I'm 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - GRBS 7 point profile monitoring
SOAP NOTES Day 10
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
Pallor ++, decreased facial puffiness,
No icterus, cyanosis, clubbing, lymphadenopathy.
Resolving pleural effusion
VITALS :
Temperature - 98.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 97%@RA
GRBS:
On 17/4/22
@8AM:69mg/dl
12:30AM:191mg/dl
3PM:192mg/dl —
7:30 PM-160mg/dl
10:00PM-115mg/dl
On 18/4/22
4AM:56mg/dl
5:30AM:84mg/dl
@8AM :102mg/dl
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard , no murmurs
RS : BAE +, Decreased breath sounds in Right infra axillary,midscapular, infrascapular regions, inspiratary crepts present in right inframammary region
CNS : NAD
A -DIABETIC NEPHROPATHY WITH CKD , UNCONTROLLED SUGARS WITH K/C/O TYPE -I DM(since I'm 11yrs) ,K/C/O HTN (6 months) ,RIGHT PLEURAL EFFUSION
P - plan for discharge today
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