1

SOAP Note
Problem list : Primary Nephrotic syndrome
S: 51 (
2/10/58)
CC :
HPI: 4 m PTA
primary
nephrotic syndrome kidney biopsy
IgA nephropathy,
2 m PTA 2 , 1 m PTA

PMH: DM type II 2 , hypertension 2
ALL: NKDA
O:
PE; Gen : Thai man, tired-looking, generalized edema, BW 69 kg (BW
63-64 kg), Ht 172 cm
V/S : BP 129/74 mmHg
Abd : Marked distended, ascited (+), not tender, liver and
spleen impalpable
Heart: Normal S1,S2, no murmur Lung: Clear, normal breath
sounds
Gen: Scrotal swelling
Ext : Pitting edema 3+
MH;
Enalapril 5 mg OD pc ,
Prednisolone 5 mg 6
tab BID pc
Omeprazole 20 mg OD ac,
Calcium carbonate 1,250
mg OD pc
Furosemide 40 mg 2 tab BID -,
Atorvastatin 20
mg OD pc
Lab ;
29/5/5 26/6/5 31/7/58 4/9/58
8
8
BUN (mg/dl)
48
62
31
48
Scr (mg/dl)
1.26
1.57
1.57
1.99
FBS (mg/dl)
145
119
175
159
Protein
4+
3+
4+
4+
Urine protein (random
374.7
urine) (mg/dl)
Urine creatinine (random
113.6
urine) (mg/dl)
Total cholesterol (mg/dl)
586
556
572

LDL-C (mg/dl)
Triglyceride (mg/dl)
A:

522
160

480
207

449
281

primary nephrotic syndrome

4
Edema, Nephrotic-range proteinuria >
3+ (3-4 +) spot protein to creatinine ratio > 3-3.5 mg/mg (3.29
mg/mg) , Hyperlipidemia albumin
hypoalbuminemia NS
membranous nephropathy (MN)

1.

< 3g/day
(< 1.5L/day)
2..
Diuretics

0.5-1 kg/day AKI

electrolyte imbalance
3. ACEIs
proteinuria

4. Lipid-lowering agents hypoalbuminemia
albumin lipoprotein
NS artherosclerosis MI
statins
5. Corticostreoid

NS

P:
Therapeutic plan
Enalapril 5 mg OD pc
Prednisolone 5 mg 6 tab
BID pc
Furosemide 40 mg 2 tab BID -
Atorvastatin 20
mg OD pc

Therapeutic goal :

Efficacy monitoring :
UA
Toxicity monitoring
Enalapril : hypotension, dizziness, headache, cough
Prednisolone : GI ulcer, myopathy, Osteoporosis,
hyperglycemia, acne, Adrenal suppression
Furosemide : hypokalemia, hyperuricemia
Atorvastatin : Diarrhea , Arthralgia, Increased transaminases
Patient education :
,



urine dipstick

:
, .


. Royal Thai Army
Medical Journal. 63 2 - 2553.53-64