1) A 2 year 6 month old male child presented with abdominal distension, swelling of the face and feet for 1 week along with anuria for 12 hours. 2) He was diagnosed with nephrotic syndrome based on massive proteinuria, hypoalbuminemia, generalized edema and hypercholestermia. 3) He was treated with prednisolone for nephrotic syndrome and antibiotics for a resolving lower respiratory tract infection.

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 Levosalbuta
mol
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
album
in
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.