A 11 year old child with facial puffiness since 1 month

 This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome

I've 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 a diagnosis and treatment plan.

C/o facial puffiness since 1 month

HOPI- 

Patient was apparently asymptomatic 1 month ago then she developed h/o fever which lasted for3-4days and relieved on medication,associated with h/o cough for       3-4days ,non productice ,non blood stained, relieved on medication .

 After 10 days patient develeped facial puffiness during early mornings which relieved by evening.

Noh/o palpitations,  sob, chest pain ,pedal edema, decreased urine output.

Past history- N/K/C/O HTN, DM, CVA, CAD, EPILEPSY,              THYROID

PERSONAL HISTORY-  

SLEEP- adequate

BOWEL AND BLADDER-regular

No known food and drug allergies

No known addictions

Menstrual history-not attained menarche

O/E-patient was conscious, coherent, cooperative well oriented to time place and person

She is moderately built and nourished

Pallor, Icterus,Cyanosis, clubbing, lymphadenopathy, edema absent.

Vitals-

Temp: Afebrile 

PR- 101bpm    

RR- 20/Min

BP- 110/70 mmHg

SYSTEMIC EXAMINATION

P/A - Shape of abdomen- flat. No scars. No organomegaly. Bowel sounds heard.

CVS- S1 S2 heard, no murmurs

RS- NVBS.

CNS- No focal neurological deficits

Tone- RT. LT

UL. Normal. Normal

LL. Normal normal

POWER

UL. 3/5. 3/5

LL. 3/5. 3/5

Reflexes: right left  

Biceps 2+ 2+

Triceps 2+ 2+

Supinator 1+ 1+

Knee 2+ 2+

Ankle 1+ 1 +

Plantar present. Present







INVESTIGATIONS-

24/11/23-
















PROVISIONAL DIAGNOSIS- NEPHROTIC SYNDROME


TREATMENT-

Protein powder 2 spoons in 1. Glass of water

2-3 egg whites per day

Tab wysolone 20 mg


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