THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS GUARDIAN'S 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.
[05-09-2025 16.59] PPM 1: Admitted in 2021 EMR summary:
Age/Gender: 14 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 17/05/2021 04:16 PM
Name of Treating Faculty
Diagnosis
NEPHROTIC SYNDROME
WITH B/L MILD HYDROCELE
Case History and Clinical Findings
A 10 year old male child was brought by parents with c/o periorbital and facial puffiness since 3 days,
c/o abdominal distension since 3 days and c/o swelling of scrotum since 3 days.
HOPI: Child was apparently asymptomatic 3 days back and then developed c/o periorbital puffiness
and facial puffiness since 3 days, increasing gradually.
C/O abdominl distention since 3 days, not associated with any pain, vomitings or diarrhoea.
C/O scrotal swelling since 3 days, insiduous in onset, increasing on walking, decreasing on lying
down.
No h/o decreased urine output or cola coloured urine, no h/o burning micturition or hematuria, no h/o
pedal edema, no h/o fever/cough/cold/ear discharge, no h/o any skin infections, no h/o abdominal
pain, vomitings or loose stools.
PAST HISTORY: Child had similar complaints1 month back and was admitted in a children's hospital
in Nalgonda and was diagnosed with Nephrotic syndrome and was started on prednisolone 50mg/day
on 20/4/21. After 3 das the child was discharged against medical advice with lasix, ofloxacin and
prednisolone on 23/4/21. Child was taken to a local pediatrician on 27/4/21, lasix was stopped and
prednisolone was continued. Child was not compliant with medication, h/o 3 days of missed doses
present. Outside reports on 27/4/21: CUE- albumin ++++, pus cells-6-7, Serum cholesterol 330 mg/dl,
Serum albumin-2.3g, CRP-negative.
ANTENATAL HISTORY: Unremarkable
NATAL HISTORY: Term, NVD, cried immediately after birth, birth weight-3 kgs
POST NATAL HISTORY: No h/o NICU admissions.
Page-2
KIMS HOSPITALS
DVELOPMENTAL MILESTONES: Attained as per age, no delay.
IMMUNISATION HISTORY: BCG scar present, last vaccinated at 5 years of age.
FAMILY HISTORY: Non consanguineous marriage. No similar complaints in other siblings.
GENERAL EXAMINATION: Child was active
No pallor/icterus/lymphadenopathy
All peripheral pulses felt normal.
VITALS AT ADMISSION: Temp-97.8F, HR-81bpm, RR-27cpm, SpO2-99% at RA, BP-110/90 mmHg,
GRBS-130mg/dl
HEAD TO TOE EXAMINATION: Periorbital puffiness present,
Abdomen distended,
Scrotal swelling present 10x10cms
ANTHROPOMETRY:
Ht= 125cms (3rd to 50th centile)
Wt= 25kgs (10th to 50th centile)
BMI= 16kg/m2 (<50th centile)
AG= 63cm
CC= 63.5cm
Wt for age= 80.1%
Ht for age= 90.7%
SYSTEMIC EXAMINATION:
P/A: Distended, soft, non tender, no organomegaly
RS: Decreased air entry on mammary and infra-axillary area.
CVS: S1S2 heard, no murmurs
CNS: HMF normal.
Investigation
HEMOGRAM: Hb-13.1%, TLC-7100, N/L/E/M-80/15/2/3, PCV-38.1, PLT-2.32lakhs
BGT: B+ve
CRP: Negative
HAV: Negative
HCV: Negative
HBsAg: Negative
LIPID PROFILE: TGS-133, Total cholesterol-248, HDL-50, LDL-71
SPOT URINE PROTEIN CREAT RATIO: 4.06
24 HOUR URINE PROTEIN: 183
Page-3
KIMS HOSPITALS
Investigations
BLOOD C/S: No growth after 24 hours of aerobic incubation
URINE C/S: No growth
USG B/L INGUINOSCROTAL REGION: B/L minimal hydrocele, diffuse scrotal wall edema
USG CHEST: Right chronic moderate pleural effusion, left mild pleural effusion
USG ABDOMEN: Increased echogenicity of b/l kidneys, moderate ascites
2D ECHO:
Page-4
KIMS HOSPITALS
Name Value Range Name Value Range
COMPLETE URINE EXAMINATION (CUE) 17-05-2021 12:51:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
COMPLETE URINE EXAMINATION (CUE) 17-05-2021 05:17:PM
COLOUR Pale yellow
COLOUR Pale yellow
APPEARANCE Clear
APPEARANCE Clear
REACTION Acidic
REACTION Acidic
SP.GRAVITY 1.010
SP.GRAVITY 1.010
ALBUMIN ++++
ALBUMIN +++
SUGAR Nil
SUGAR Nil
BILE SALTS Nil
BILE SALTS Nil
BILE PIGMENTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-4
PUS CELLS 3-6
EPITHELIAL CELLS 2-4
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
RED BLOOD CELLS Nil
CRYSTALS Nil
CRYSTALS Nil
CASTS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
OTHERS Nil
RFT 17-05-2021 05:17:PM
UREA 23 mg/dl 42-12 mg/dl
CREATININE 0.4 mg/dl 1-0.5 mg/dl
URIC ACID 5.1 mmol/L 7.2-3.5 mmol/L
CALCIUM 8.5 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 4.8 mg/dl 4.5-2.5 mg/dl
SODIUM 131 mmol/L 145-136 mmol/L
POTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.
CHLORIDE 97 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 17-05-2021 05:17:PM
Total Bilurubin 0.82 mg/dl 1-0 mg/dl
Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 24 IU/L 35-0 IU/L
SGPT(ALT) 23 IU/L 45-0 IU/L
ALKALINE
PHOSPHATASE
191 IU/L 483-54 IU/L
TOTAL PROTEINS 4.2 gm/dl 8-6 gm/dl
ALBUMIN 1.56 gm/dl 4.5-3.2 gm/dl
A/G RATIO 0.59
Page-5
KIMS HOSPITALS
HEPATITIS- B
SURFACE ANTIGEN
(HBSAg) RAPID
TEST 17-05-2021
05:23:PM
Negative Kit Name:
Abon
SARS-COV-2
Qualitative PCR 18-
05-2021 10:23:AM
Negative
COMPLETE URINE EXAMINATION (CUE) 18-05-2021 05:30:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +++
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-5
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
COMPLETE URINE EXAMINATION (CUE) 19-05-2021 08:08:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +++
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-6
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
COMPLETE URINE EXAMINATION (CUE) 21-05-2021 04:54:AM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 3-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
COMPLETE URINE EXAMINATION (CUE) 21-05-2021 05:58:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 1-2
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
Page-6
KIMS HOSPITALS
COMPLETE URINE EXAMINATION (CUE) 23-05-2021 04:57:AM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
COMPLETE URINE EXAMINATION (CUE) 23-05-2021 08:14:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Trace
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
Treatment Given (Enter only Generic Name)
Child as admitted to PICU with complaints and necessary investigations were done.
Child was started on INJ CEFTRIAXONE and given for 5 days. TAB PREDNISOLONE (60mg/m2)
was continued.
Child had right ear pain and ENT opinion was taken and was diagnosed with Furuncle in right ear.
Child was started on TAB AMOXICLAV and given for 2 days.
Supportive therapy with INJ PANTPOP, TAB SHELCAL, TAB ZINCOVIT and TAB SPOROLAC was
given.
CONDITION AT DISCHARGE: Child is active, periorbital puffiness, facial puffiness, abdominal
distension and scrotal edema subsided.
No pallor/icterus/Lymphadenopathy
All peripheral pulses felt normal
WEIGHT AT DISCHARGE:
AG AT DISCHARGE:
VITALS AT DISCHARGE: Temp-98.1F, HR-63bpm, RR-24cpm, SpO2-99% at RA, BP-100/60 mmHg
Advice at Discharge
1. PROTEIN RICH DIET, 3 EGG WHITES PER DAY, SALT RESTRICTED DIET
2. TAB AMOXICLAV (50mg/kg/day) (1tab=625mg)
1 tab/PO/BD FOR 3 DAYS
3. TAB PREDNISOLONE (60mg/m2) (1tab=20mg)
1 1/2 tab/PO AT 8AM
1 tab/PO AT 8PM EVERYDAY TILL 31/5/21
Page-7
KIMS HOSPITALS
ALTERNATE DAY THERAPY FROM 1/6/21 TO 12/7/21
4. TAB. PANTOP (1mg/kg/day) (1tab=40mg)
1/2 tab/PO/OD
5. TAB SHELCAL
1TAB/PO/OD FOR 2 MONTHS
6. TAB ZINCOVIT
1TAB/PO/OD FOR 2 MONTHS
7. TAB SPOROLAC
1TAB/PO/BD FOR 3 DAYS
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:
08682279999 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: 24/5/21
Ward: PICU
Unit:1
Follow Up
REVIEW TO PEDIATRIC OPD AFTER ONE WEEK (31/5/21) WITH CUE REPORT.
REVIEW SOS.
[05-09-2025 17.00] PPM 1: Current findings
[07-09-2025 10:16] PPM 3: Of course. Here is a clear and structured summary of the provided Electronic Medical Record (EMR).
### *Patient Summary: Nephrotic Syndrome (Relapse)*
*Patient:* 14-Year-Old Male
*Admission Date:* May 17, 2021
*Discharge Date:* May 24, 2021
*Treating Physicians:* Dr. Prasad / Dr. Shreya
*Final Diagnosis:* Nephrotic Syndrome with Bilateral Mild Hydrocele, Moderate Ascites, and Bilateral Pleural Effusion.
---
### *1. Chief Complaint & History*
The patient was admitted with a 3-day history of:
* Periorbital and facial puffiness
* Abdominal distension
* Scrotal swelling
*Past Medical History:* Diagnosed with Nephrotic Syndrome one month prior (April 2021) and was started on Prednisolone. He was discharged against medical advice (AMA) after 3 days. He was non-compliant with his medication, having missed 3 days of doses prior to this admission, leading to the relapse.
---
### *2. Key Examination Findings on Admission*
* *General:* Active child, no pallor/icterus.
* *Edema:* Significant periorbital puffiness, abdominal distension, and a large (10x10 cm) scrotal swelling.
* *Vitals:* Stable (BP: 110/90 mmHg).
* *Systemic:* Distended but soft, non-tender abdomen. Decreased air entry in lungs on examination.
---
### *3. Critical Investigation Results*
* *Urine Analysis:* Confirmed heavy proteinuria (Albumin ++++ on admission).
* *Blood Tests:*
* *Hypoalbuminemia:* Very low serum albumin (1.56 g/dL).
* *Hyperlipidemia:* Elevated cholesterol (248 mg/dL).
* *Hyponatremia:* Low sodium (131 mmol/L).
* Normal renal function.
* *Imaging:*
* *USG Abdomen:* Moderate ascites, increased kidney echogenicity.
* *USG Chest:* Bilateral pleural effusion (right moderate, left mild).
* *USG Scrotum:* Bilateral minimal hydrocele with scrotal wall edema.
---
### *4. Hospital Course & Treatment*
1. *Admitted to PICU* for monitoring and management.
2. *Steroid Therapy:* High-dose Tab. Prednisolone (60mg/m²) was restarted and continued.
3. *Antibiotics:* Inj. Ceftriaxone was given for 5 days prophylactically. Later, Tab. Amoxiclav was added for 2 days to treat a right ear furuncle.
4. *Supportive Care:* Included Inj. Pantop (PPI), Tab. Shelcal (Calcium), Tab. Zincovit (Zinc & Multivitamins), and Tab. Sporolac (Probiotics).
5. *Progress:* The patient responded well to treatment. All edema (facial, abdominal, scrotal) subsided, and urine protein reduced from ++++ to Nil by the time of discharge.
---
### *5. Condition at Discharge*
The child was active, alert, and all symptoms had resolved. Vitals were stable.
---
### *6. Discharge Advice & Medications*
* *Diet:* Protein-rich, salt-restricted diet. 3 egg whites per day.
* *Medications:*
* *Tab. Prednisolone:* 1.5 tabs (30mg) at 8 AM and 1 tab (20mg) at 8 PM daily until May 31st, 2021. Then switch to an *alternate-day therapy* from June 1st to July 12th.
* *Tab. Amoxiclav (625mg):* 1 tab twice daily for 3 days.
* *Tab. Pantop (40mg):* 1/2 tab once daily.
* *Tab. Shelcal, Zincovit:* 1 tab once daily for 2 months.
* *Tab. Sporolac:* 1 tab twice daily for 3 days.
* *Follow-up:* Review in Pediatric OPD after one week (on May 31, 2021) with a *Complete Urine Examination (CUE) report.*
### *Key Takeaway:*
This case describes a steroid-sensitive Nephrotic Syndrome relapse in a pediatric patient, directly linked to medication non-compliance. The hospital management involved high-dose steroid re-initiation, treatment of a concurrent infection, and supportive care, which successfully induced remission. Strict adherence to the tapering steroid regimen and follow-up is crucial to prevent future relapses.
[07-09-2025 10:28] PPM 1: The LLM has gathered the narration of the past discharge in 2021 and couldn't gather the hand written current narrative due to hand written data capture limitations
[07-09-2025 10:33] PPM 3: Of course. Here is a cleaned-up, structured, and interpreted summary of the provided medical assessment.
---
### *Medical Case Summary*
*Section:* IX
*Age:* 60 Years
*IP No.:* [Not provided in the text]
---
#### *1. Chief Complaints & Duration*
The patient presents with the following primary issues:
* *Bilateral Pedal Edema:* Present for 5 days.
* *Facial Puffiness:* Present for 4 days.
* *Constipation:* Present for 2 days.
#### *2. History of Present Illness*
The patient was apparently well until 5 days ago when they developed:
* *Bilateral Pedal Edema:* The swelling was of *sudden onset, **gradually progressive, and associated with **decreased urine output*.
* This was followed by the development of *facial puffiness (edema)*.
* The patient also reports a recent history of *constipation* (2 days), which was also sudden and progressive.
*Review of Systems (Negative Findings):*
The patient specifically *denies* history of:
* Cold, cough, or fever.
* Nausea, headache, or vomiting.
* Loose stools.
* Chest pain, palpitations, or shortness of breath (SOB).
* Excessive sweating.
#### *3. Past Medical History*
* *Nephrotic Syndrome:* Diagnosed 4 years ago (since ~2021).
* *Current Medication:* Tab. Prednisolone 5 mg (likely a maintenance dose for Nephrotic Syndrome).
* *No known history* of:
* Diabetes Mellitus (DM)
* Hypertension (HTN)
* Coronary Artery Disease (CAD) or Cerebrovascular Accident (CVA/Stroke)
* Asthma
* *Past Surgery:* History of Pulmonary Tuberculosis (PTB), treated.
---
### *Key Interpretation & Notes:*
* The current symptoms (new onset pedal and facial edema with low urine output) are highly suggestive of a *relapse or exacerbation of the patient's known Nephrotic Syndrome*.
* "Tab: PREPINSOLON E. Bomysporus" is interpreted as *Tab. Prednisolone 5 mg*.
* "Niklilo T.DM, HTN..." is interpreted as *"No known history of DM, HTN..."*
* "ASHuman Hyposider Pulum T8" is interpreted as a *history of pulmonary Tuberculosis (PTB)*, which is a past illness, not a current complaint.
[07-09-2025 10:35] PPM 3: It’s my bad, I did not share the handwritten data on the 1st instance
[07-09-2025 10:40] PPM 3: Based on the new clinical note provided, here is a summary of the patient's current presentation and how it relates to their previous history.
### *Patient Update: Nephrotic Syndrome (Suspected Relapse)*
*Date of Note:* September 4, 2025
*IP No.* ( presumable from 2007 admission)
*Age:* Not explicitly stated in new note, but would now be approximately *18 years old*.
---
### *1. Current Complaints & Duration*
The patient presents with symptoms highly suggestive of a *relapse of Nephrotic Syndrome*:
* *Bilateral Pedal Edema:* Present for 5 days. Insidious onset, gradually progressive, and associated with decreased urine output.
* *Facial Puffiness:* Present for 4 days.
* *Constipation:* Present for 2 days.
---
### *2. History of Present Illness*
The development of edema and facial puffiness is consistent with a classic nephrotic syndrome flare. The note specifically mentions *decreased urine output*, a significant finding. The patient does not report common associated symptoms like fever, cough, nausea, vomiting, or chest pain.
---
### *3. Relevant Past Medical History*
This presentation is directly linked to the patient's known, long-standing medical condition:
* *Nephrotic Syndrome:* Diagnosed 4 years ago (which aligns with the initial 2021 admission summarized previously).
* *Medication History:* Was previously on *Tab. Prednisolone* (the standard first-line treatment for this condition).
* *No other significant illnesses:* The note denies a history of Diabetes Mellitus (DM), Hypertension (HTN), heart disease (CAD), stroke (CVA), asthma, or tuberculosis (TB).
---
### *Assessment & Implication*
This clinical note describes a new acute episode (relapse) of Nephrotic Syndrome in a patient with a known history of the condition. The symptoms of edema, facial puffiness, and decreased urine output are hallmark signs of proteinuria and fluid retention, indicating the disease has become active again.
The planned course of action would likely involve:
1. Confirming the relapse with investigations (Urine test for protein, serum albumin levels).
2. Re-initiating treatment with *corticosteroids (Prednisolone)*.
3. Managing symptoms (e.g., edema, constipation).
4. Patient education on the relapsing-remitting nature of the disease and the importance of medication adherence and follow-up.
[07-09-2025 11:04] PPM 1: Age 14
10 years in 2021
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