THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
EMR summary:
Age/Gender: 32 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 14/08/2025 07:38 PM
Name of Treating Faculty
HOD
PGY1
Diagnosis
ACUTE GASTROENTERITIS
IGA NEPHROPATHY-MESANGIO PROLIFERATIVE GLOMERULONEPHRITIS
K/C/O HYPERTENSION SINCE 8MONTHS
Case History and Clinical Findings
CHIEF COMPLAINTS
C/O VOMITING SINCE 1WEEK
C/O LOOSE STOOLS SINCE 1WEEK
C/O FEVER LOW GRADE SINCE 4DAYS
HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 1WEEK BACK THEN SHE DEVELOPED
VOMITINGS 6-7EPISODES PER DAY CONTAINING FOOD PARTICLES, NON BILIOUS, NON
PROJECTILE AGGRAVATED AFTER CONSUMPTION OF FOOD C/O LOOSE STOOLS 4
EPISODES PER DAY WATERY IN CONSISTENCY, BLACKISH COLOR FEVER LOW GRADE
WITH CHILLS SINCE 1WEEK H/O BURNING MICTURITION +, NO H/O
HEMATURIA, OLIGURIA, POLYURIA.
NO H/O CHEST PAIN, PALPITATIONS, DYSPNOEA, ORTHOPNOEA, PND.
HISTORY OF PAST ILLNESS
K/C/O CKD WITH HTN SINCE 8 MONTHS ON TAB TELMA 40MG OD AND TAB ARKAMIN 0.1MG
BD
K/C/O MESANGIOPROLIFERATIVE GLOMERULONEPHRITIS ON TAB PREDNISOLONE 5MG OD
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KIMS HOSPITALS
PERSONAL HISTORY: MARRIED, MIXED DIET, REGULAR BOWEL AND BLADDER MOVEMENTS
NO KNOWN ALLERGIES ADDICTIONS - OCCASIONAL ALCOHOLIC, NO SMOKING.
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL EXAMINATION: NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION, PEDAL EDEMA
VITALS: - TEMP: 98 F, BP:140/70MMHG, RR: 20 CPM, PR: 68 BPM, SPO2: 96% AT RA, GRBS:263 MG/DL
SYSTEMIC EXAMINATION CVS - S1 S2 HEARD, NO MURMURSRS - NORMAL PER ABDOMEN -NON TENDER, SOFT CNS- HIGHER MENTAL FUNCTION INTACT, NFND.
RT LT
TONE U/L N N
L/L N N
POWERU/L 5/5 5/5
L/L 5/5 5/5
REFLEXES
B +2 +2
T + +
S + +
K +2 +2
A + +
P FLEXOR FLEXOR
Investigation
CBP 14-08-2025
HB9.7
TC12000
PLT2.7
PCV 29.2
RBC 3.4
RFT 14-08-2025
BLOOD UREA 50
S. CREATININE 3.7
S. SODIUM 134
S. POTASSIUM 3.2
S. CHLORINE 98
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KIMS HOSPITALS
LFT 14-08-2025
T. BILIRUBIN 75
D.BILIRUBIN 0.18
SGPT 10
SGOT24
ALK PHOSPHATE 118
T. PROTEINS 5.4
ALBUMIN 3.5
A/G RATIO 1.76
S. CALCIUM 0.93
ABG 14-08-2025
PH 7.45
PCO2 31.9
PO2 43.9
SPO2 80
HCO3 21.9
SMEAR UR CR UA HIV HBSAG HCV
COMPLETE URINE EXAMINATION (CUE) 14-08-2025 10:12:PM COLOUR Pale yellow APPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE
SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 EPITHELIAL CELLS 2-4 RED BLOOD CELLS
Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
Treatment Given (Enter only Generic Name)
INJ MONOCEF 1GM IV/BD
INJ PAN 40MG PO/OD
INJ ZOFER 4MG IV/TID
TAB PREDNISOLONE 5MG PO/OD
TAB HCQ 200MG PO/OD
TAB TELMA 40MG PO/OD
TAB ARKAMINE 0.1MG PO/OD
TAB DYTOR 10MG PO/BD
STRICT I/O CHARTING
PLENTY OF ORAL FLUIDS
MONITOR VITALS AND INFORM SOS
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Advice at Discharge
TAB TAXIM-O 200MG PO/BD FOR 3DAYS
TAB PAN D PO/OD FOR 3 DAYS
TAB PREDNISOLONE 5MG PO/ODTO CONTINUE
TAB HCQ 200MG PO/OD TO CONTINUE
TAB TELMA 40MG PO/OD TO CONTINUE
TAB ARKAMINE 0.1MG PO/BD TO CONTINUE
TAB DYTOR 10MG PO/BD AT 8AM AND 4PM TO CONTINUE
Follow Up
REVIEW TO NEPHRO OPD AFTER 1 WEEK AND SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF
PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date:18/08/2025
Ward: NEPHRO
Reports of the patient from NIMS on 4th April 2025
[20-08-2025 21.20] PPM 1: Wish we could have obtained the biopsy report other than a cursory mention of it's being MPGN with IgA nephropathy
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