26/F nephrotic syndrome MN Hypothyroidism

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 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 inputs on the 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 



A 26 YEAR OLD FEMALE CAME TO THE OPD WITH THE COMPLAINTS OF GENERALISED
SWELLING OF THE BODY SINCE 8  MONTHS, SHORTNESS OF BREATH SINCE 6 MONTHS .
PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS WAS
PROVISIONALLY DIAGNOSED AS ANASARCA SECONDARY TO NEPHROTIC
SYNDROME.INVESTIGATIONS:-T3- 1.18 NG/ML, T4- 17.6 MICROGRAM/DL, TSH- 9.17 MICRO
IU/ML, LIPID PROFILE- TOTAL CHOLESTEROL- 229 MG/DL, TRIGLYCERIDES- 323 MG/DL, HDL
CHOLESTEROL-44 MG/DL, LDL CHOLESTROL- 120 MG /DL, VLDL-64.6 MG/DL.
THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT (3 EGG WHITES PER DAY, TAB.
PAN 40 MG PO OD , TAB. MVT PO OD , INJ. CEFTRIAXONE 1 GM IV BD,POWDER ALBURICH 2
SCOOPS WITH GLASS OF MILK TWICE DAILY.)
GENERAL EXAMINATIONTHE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
MODERATELY BUILT AND NOURISHED
SIGNS OF PALLOR PRESENT
NO ICTERUS,CYANOSIS, CLUBBING, EDEMA
 VITALS:
TEMP: 96.8 F
PR: 88 BPM
RR: 18 CPM
BP: 110/70 MM HG
SPO2: 98% @ RA
CVS: S1, S2 HEARS, NO MURMURS
RS: BAE+, NVBS
TRACHEA: CENTRAL
NO DYSPNOEA AND WHEEZE
NO RHONCHI
ABDOMEN:SOFT,NON-TENDER , NO ORGANOMEGALY.
LIVER AND SPLEEN NOT PALPABLE
BOWEL SOUNDS HEARD
CNS:
LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT
SPEECH: NORMAL
NECK STIFFNESS ABSENT
KERNINGS SIGN ABSENT
CRANIAL NERVES: NORMAL
MOTOR SYSTEM: NORMAL
SENSORY SYSTEM: NORMAL
GCS: 15/15 E4V5M6
TONE:
UL: NORMAL IN BOTH
LL:NORMAL IN BOTH
POWER:
UL: BOTH 5/5
LL: BOTH 5/5
REFLEXES: RT LT
B: +2 +2
T: +2 +2
S: +1 +1
K: +2 +2
A: +1 +1
NEPHROLOGY OPINION WAS TAKEN AND ADVISED FOR COLLAGEN PROFILE AND RENAL
BIOPSY.
PLANNED FOR RENAL BIOPSY ON 27/12/2023
REVIEW WITH COLLAGEN PROFGILE REPORT TO GENERAL MEDICINE OPD.
Investigation
COMPLETE BLOOD PICTURE (CBP) 20-12-2023 
HAEMOGLOBIN10.9 gm/dl
TOTAL COUNT8000 cells/cumm
NEUTROPHILS60 %
LYMPHOCYTES30 %
EOSINOPHILS05 %
MONOCYTES05 %
BASOPHILS00 %
PLATELET COUNT2.60
SMEAR Microcytic
Hypochromic Anemia
COMPLETE URINE EXAMINATION (CUE) 20-12-2023 
COLOURPale yellow
APPEARANCEClear
REACTIONAcidic
SP.GRAVITY1.010
ALBUMIN++
SUGARNil
BILE SALTSNil
BILE PIGMENTSNil
PUS CELLS3-6
EPITHELIAL CELLS2-4
RED BLOODCELLSNil
CRYSTALSNil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERS Nil
RFT 20-12-2023
UREA21 mg/dl
CREATININE0.6 mg/dl
URIC ACID5.1 mg/dl
CALCIUM10.0 mg/dl
PHOSPHOROUS4.7 mg/dl
SODIUM130mEq/L
POTASSIUM3.9 mEq/L
CHLORIDE99 mEq/L
LIVER FUNCTION TEST (LFT) 20-12-2023 
Total Bilurubin0.80 mg/dl
Direct Bilurubin0.17 mg/dl
SGOT(AST)22 IU/L
SGPT(ALT)20 IU/L
ALKALINE PHOSPHATE115 IU/L
TOTAL PROTEINS5.0 gm/dl
ALBUMIN1.31 gm/dl
A/G RATIO0.36
HBsAg-RAPID - Negative 
Anti HCV Antibodies -RAPID Non Reactive 
T3, T4, TSH 20-12-2023 
T31.18 ng/ml
T417.60 micro g/dl
TSH9.17 micro Iu/ml
ULTRASOUND ABDOMEN :- NO SONOLOGICAL ABNORMALITY DETECTED.
USG - NECK:- NO SONOLOGICAL ABNORMALITY DETECTED.
2D-ECHO:-
NO MR/AR/TR
NO RWMA, NO AS/MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION, NO PAH/PE.
PLANNED FOR RENAL BIOPSY ON 27/12/2023
TREATMENT AT DISCHARGE 
3 EGG WHITES PER DAY
TAB. THYRONORM 50 MCG PO OD TO CONTINUE.
TAB. TAXIM 200 MG PO BD X 5 DAYS
TAB. NEUROBION FORTE PO OD X 10 DAYS
POWDER ALBURICH 2 SCOOPS WITH GLASS OF MILK TWICE DAILY

ON 27/12 /2023
RENAL BIOPSY WAS DONE 

IT SHOWED FOCAL SEGMENTAL GLOMERULOSCLEROSIS 

AND STEROIDS WERE STARTED WITH 
TAB PREDNISOLONE 50 MG 

AFTER 1 1/2 MONTH OF STARTING WITH STEROID THERAPY 
PATIENT DEVELOPED STRIAE OVER ABDOMEN AND ARMS 


THERE REPEAT RENAL BIOPSY WAS DONE .
IT SHOWED MEMBRANOUS NEPHROPATHY 

THEN STEROID DOSAGE WAS GRADUALLY TAPERED I/V/O STEROID INDUCED CUSHING SYNDROME 

GRADUALLY THE STRIAE OVER THE ABDOMEN HAVE DECREASED



AND TAB TACROLIMUS 1MG BD WAS STARTED 
CURRENTLY PATIENT IS ON TAB TACROLIMUS 1MG BD

Patient developed diabetes due to steroids vs tacrolimus is a diagnostic uncertainty 

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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 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 inputs on the 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  CHIEF COMPLAINS  60 year old female daily wage labourer by occupation, resident of Tirumalagiri, mothkur  presented to the casualty on dec 25 th 2023 with the complains of pedal
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