Case on nephrotic syndrome

CASE PRESENTATION

1. CASE ON NEPHROTIC SYNDROME R.Anusha Pharm D VI Year Roll No:170514882007.

2. Patient Name:Master MR Gender:Male Age:2 years 6 months IP No:332020 DOA:14/2/20 DOD:19/2/20

3. SUBJECTIVE Chief Complaints: Abdominal distension ,swelling of face, eyes, both feet since 1 week. H/o Anuria since 12 pm. Present Illness History: H/o body swelling for 4 days, more in morning hours associated with reduced urine volume for 3 days. Mother also reports cough and cold for 4 days. There is no fever or hematuria or diarrhoea . Past medical/medication history: His past history is significant for recurrent wheeze that responded to Neb.Levolin . Family history: There is no family h/o kidney disease. Sleeping and eating habits: Normal Vaccinations so far: Immunised as per schedule.

4. OBJECTIVE Physical appearance: Height: 98 cms Weight: 13.7 kgs B.P: 90/60 mmHg. HR:90/min RR:22/min Spo2: 100% Temperature:Normal General examination: Conscious , alert , afebrile , periorbital puffiness+, B/L pedal edema + CVS:WNL RS:B/L Crepts +, Occasional rhonci + Abdomen: Soft,distended+,Bowel sounds+ CNS:NAD MS:WNL B/L pitting pedal edema +, extending upto knees Genitourinary system: B/L Scrotal swelling+

5. FINAL DIAGNOSIS: C/o New onset of Nephrotic syndrome Lower respiratory tract infection (Resolving)

6. DRUG CHART Brand Generic Dose ROA Freq. Start date Indication Inj.Ceftriaxone Ceftriaxone 1g IV OD 15/2/20 Respiratory infection Neb.Levolin Levosalbutamol 0.63mg P/N Q6H 15/2/20 Cough Neb.Budecort Budesonide 0.5mg P/N BD 17/2/20 Bronchodilation Physiomer nasal spray Saline spray 2 puffs P/N TID 17/2/20 Nasal congestion Mometasone Nasonex spray Steriod /saline spray 2 puffs P/N BD 17/2/20 Nasal congestion T.Lasilactone Aldactone PO BD 17/2/20 Edema Inj.Pantodac Pantoprazole 15mg IV OD 18/2/20 Acid prophylaxis Inj.Solumedrol Methyl prednisolone 125mg IV OD 18/2/20 Nephrotic syndrome

7. SOS/STAT Medications Inj.20% Albumin Human albumin 50ml IV Over 2 hours On 15&16 Edema Inj.20% Albumin Human albumin 50ml IV Over 2 hours STAT On 15&16 Edema Inj.Lasix Furosemide 20mg in 15 ml NS IV Post albumin over last 15 mins STAT On 15&16 Edema

8. To prevent further complications To improve quality of life. Goals of the Treatment

9. ASSESSMENT DAY 1(14/2/20) P/A: Gross distension+ Sr.cholesterol : 390 Sr.creatinine:0.6 mg PLAN: Follow up with reports(CBS,RP-II, CUE, Urine for protein, Spot urine creatinine ratio, CRP, Sr.Albumin ) Low salt diet . Plan to start Prednisolone for 6 weeks 2mg/kg/day 60 mg/m2/day after the reports. Strict I/O monitoring.

10. DAY 2(15/2/20) Sr.Albumin : 0.9 gm/dl; Total spot protein : creatinine :13.3 Urine for proteins: 3+ Fitting into nephrotic syndrome: Massive proteinuria, Hypoalbuminemia, Generalised edema , Hypercholestermia BP:110/60 mm Hg; PR:13/min; CVS:S1S2+; P/ A:Soft ; I/O:130ml/80ml; Chest: B/L AE+; Occasional rhonci bases; Spo2:97% on RA

11. PLAN: Start prednisolone 60 mg/m2/day once daily for 6 weeks Strict I/O chart Low salt diet, low fat and high protein diet Fluid 250ml/day Monitor vitals and weight DRUGS GIVEN Inj.Ceftriaxone 1 g IV OD for respiratory infection. Neb.Levolin 0.63 mg Q6H for cough relief. Syp.Calcimax plus 7.5 ml PO OD.

12. DAY 3(16/2/20) Wt:13.8 kgs Wet cough+ swelling of face decreased; pedal edema + PLAN: Give 1 more dose of Inj.ALBUMIN and Inj.LASIX Monitor I/O chart Rx as per chart

13. DAY 4(17/2/20) Occassional cough improving LRTI Newly diagnosis of nephrotic syndrome O/ E:Mild to moderate anascara ; Abdomen non tender Total intake : 250ml/day; Periorbital puffiness+ B/L Pedal edema + PR:94/min BP:110/60 mm Hg SpO2: 98% RA Wt:13.6 kgs

14. DRUGS GIVEN: Continued same treatment and ADD: Neb.Budecort (Bronchodilation) 0.5 mg Neb. BD Physiomer normal spray(Saline spray) 2 puffs P/N TID Mometasone Nasonex spray(Steroid/saline spray) 2 puffs P/N BD T.Lasilactone 50 mg PO BD (9am,5 pm) Family counselling: Course of children with nephrotic syndrome may/will take up to 2 weeks for edema to resolve. Dietary modifications was said to family.

15. DAY 5(18/2/20) C/o Nephrotic syndrome ( 1st episode) LRTI over all slightly better Occasional cough + U/O:260 ml PR:102/min BP:104/70 mm Hg SpO2:94% RA RS:BAE+ Clear P/A: Soft distended , Non tender Total intake: 250 ml/day Wt:13.8 kgs

16. Respiratory infection better – clinically & chest X ray Nephrotic syndrome- stable. PLAN: Continue same meds Start Inj.Solumedrol 125 mg IV OD for 2 days If OK, will plan for discharge tomorrow DRUGS GIVEN: Inj.PANTODAC 15 mg IV OD Inj.SOLUMEDROL 125 mg IV OD in 50 ml NS 1 hour for 2 days(18&19)

17. DAY 6(19/2/20) Nephrotic syndrome Child active, playful Edema + Occasional cough+ Chest: clear Oral intake- good Stools normal No fever/pain abdomen BP:100/64 mm Hg PR: 108/min SpO2:100% RA Total intake: 250-300 ml/day PLAN: Diet as advised Continue Rx as per chart Monitor vitals , weight P/F discharge today

18. PLAN MONITORING PARAMETERS: Monitor BP hourly. Monitor body weight. Strict I/O chart

19. DISCHARGE MEDICATIONS: T.PREDNISOLONE 30 mg by mouth once daily after food @ 9 AM for 1 month(Nephrotic syndrome). T.LANZOL JUNIOR 15 mg by mouth before food @ 7 AM for 1 month(Steroid associated gastritis). Syp.TAXIM O 50mg/5ml 6.5ml by mouth 2 times a day 9AM-8PM for 4 days(Respiratory infections). Neb.LEVOLIN 0.63 mg in 2 ml NS 4 times a day for 3 days. 0.63 mg in 2 ml NS 3 times a day for 3 days. 0.63 mg in 2 ml NS 2 times a day for 3 days. Then stop Neb.BUDECORT 0.5 mg in 2 ml NS 2 times a day for 10 days for 10 days.(Bronchodilator).

20. T.LASILACTONE 50 mg by mouth after food 2 times a day @ 9AM-5PM for 2 days(legs and eye swelling). T.MONTAIR LC KID 4 mg per oral once daily after food@6PM for 4 weeks(Anti-allergy). PHYSIOMER NORMAL SPRAY 2 puffs in each nostril 3 times a day for 2 weeks. MOMETASONE NASONEX SPRAY 1 puff in each nostril @ Bed time for 1 week(Congestion). Low salt , low fat , veg diet Fluids of 250 ml/day until eye and leg swelling resolves Post discharge investigation:- CUE Review on 26/2/20.