A 14year old male patient with acute glomerulonephritis

A 14year old male patient came to the casuality  with the chief complaints of-

1) Involuntary movement   of the both limbs since 3AM yesterday.

2) vomtings since yesterday and were subsided with medication.

3) h/o Fever 5 days back which was subsided with medication.

4)H/o reddish discolouration of urine

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 10 days back then he developed Pedal edema associated with facial puffiness, then patient was taken to the local hospital where tab.Dytor was given and was discharged.

Then patient started having fever which was high grade and was taken to another hospital , where patient was treated and samples for ANA, complement were sent and patient was discharged and taken to home.

The next day patient started developing vomtings along with involuntary movements and  he was taken to local hospital and got treated and discharged with sodium valproate.

PAST HISTORY:

Not a known case of diabetes, HTN, asthma, TB, epilepsy. 

No similar complaints in the past. 

FAMILY HISTORY 

Parents 2nd degree consanguinous marriage.

Patient is the 2nd child ,normal vaginal delivery

-developmental history normal

PERSONAL HISTORY:

DIET: mixed

APPETITE: normal

SLEEP: adequate

BOWEL AND BLADDER MOVEMENTS: regular

ADDICTIONS: none

GENERAL EXAMINATIONS:

Patient is conscious, coherent, cooperative with moderate nourishment and moderate built. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 130/90mmHg. 

PR: 78/min. 

RR: 18 CPM 

TEMP: afebrile

SPO2: 99% RA

GRBS: 122 mg%

 SYSTEMIC EXAMNATION:

CVS: S1 and S2 heard

RS:BLAE present,NVBS heard 

P/A: soft, non tender, no palpable masses, hernia orifices clear, no free fluid, no organomegaly. 

CNS: no focal deformities

Provisional diagnosis -

?Acute glomerulonephritis with seizure under evaluation

Investigations -

HEMOGRAM

Chest x-ray PA VIEW

CUE 

CT BRAIN 

RBC IN URINE MICROSCOPY 

INVESTIGATIONS 

24HOUR URINARY ELECTROLYTES

SOAP NOTES DAY 1

A 14 year old male with acute glomerulonephritis secondary to psgn??pign??Ig A nephropathy with hypertensive encephalopathy  with hypertension

Subjective-No complaints

Objective-pr-72 BPM

Bp-120/90 mm hg

Cvs-s1,s2 heard

Resp-BAE +

Per abdomen-soft,non tender

A-acute glomerulonephritis with hypertensive encephalopathy with hypertension.

Plan of care-

Fluid restriction less than 2 l/day

Salt restriction less than 4 gm/day

Tab.arkamine 0.1 mg/po/tid

Tab.cinod 10 mg/po/od

Tab.sodium valproate 500 mg/po/od

Tab.lasix 20 mg/po/od

Tab.zincovit po/od

Investigations-

 

SOAP NOTES DAY-2

A 14 year old male with acute glomerulonephritis secondary to psgn,with hypertensive encephalopathy  with hypertension.

Subjective-fever spike (100.5 F) at 8:00 am,no other complaints.

Objective-pr-76 BPM

Bp-110/70 mm hg

Cvs-s1,s2 heard

Resp-BAE +

Per abdomen-soft,non tender

A-acute glomerulonephritis secondary to PSGN  with hypertensive encephalopathy with hypertension.

Plan of care-

Fluid restriction less than 2 l/day

Salt restriction less than 4 gm/day

Tab.sodium valproate 500 mg/po/od

Tab.lasix 20 mg/po/od

Tab.zincovit po/od

Tab.pcm 650 mg/po/sos