72 YEAR OLD MALE WITH BILATERAL PEDAL EDEMA

 Kausalya Varma, Intern 

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan. 

AN 72 YEAR OLD MALE BROUGHT TO THE HOSPITAL WITH BILATERAL PEDAL EDEMA AND DECREASED URINE OUTPUT 

CASE:

CHIEF COMPLAINTS: 

A 72 year old male patient came with the complaints of bilateral pedal edema for the past 1 week, decreased urine output and scrotal edema since the past 5 days, and shortness of breath for the past 4 days. 

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 1 week back when he had a hemorrhoidectomy procedure after which he had complaints of pedal edema that was putting type and extending until the level of the knees. He also has presence of scrotal edema for the past 5 days.

- He has complaints of decreased urine output since the past 5 days (reduced flow of urine) 

- H/O increased frequency and urgency of urine

And no history of post void dribbling 

- He has complaints of shortness of breath since the first post operative day of surgery.

- No H/O fever, cold, cough, vomitings, loose stools.

- No H/O chest pain, palpitations, syncopal attacks, orthopnea, PND

PAST HISTORY-

- H/O haemorrhoids for the past 40 years and has complaints of blood in stools (irregularly)

- H/O of bilateral knee pains for the past 3-4 years (on NSAIDs irregularly) No similar episodes in the past. 

- H/O denovo HTN for the past 1 week, and is on irregular medication on Tab Telma 40mg 

- Patient is not a k/c/o DM, Asthma, TB, epilepsy

- H/O head injury 40 years ago, and he complained about weakness of upper limb and lower limb and slurring of sleep and was operated for the same (? EDH ?Intracranial bleed) 

- Patient underwent a procedure for removal of bladder stones outside our hospital 2 years back 

PERSONAL HISTORY- 

Occupation: Farmer 

Diet: Mixed 

Appetite- Normal 

Sleep: Normal 

Bowel and Bladder: Regular

No allergies 

Takes alcohol/toddy occasionally (only on festivals) 

Used to be a smoker, smoked beedi regularly, stopped 4 years ago.

FAMILY HISTORY- 

No similar history in family.

GENERAL EXAMINATION- 

Patient is examined in a well lit room after taking informed consent. 

Patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 

Pallor: Absent 

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Generalized Lymphadenopathy: Absent 

Edema: Absent

Dehydration: Mild 

VITALS

Blood Pressure: 150/100 mmHg

Respiratory Rate: 22 cycles per minute

Pulse: 92 bpm

GRBS- 110mg%

Temperature: Afebrile

 SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM-  

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

No adventitious sounds heard

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM-

CENTRAL NERVOUS SYSTEM EXAMINATION- 

Higher mental functions

- Conscious

- Oriented to  time,place and person

- Memory - Intact

- Speech - no deficit

Cranial nerve examination 

          • 1 - olfactory sense - normal

          • 2- Direct and indirect light reflex present

          • 3,4,6 - no ptosis Or nystagmus

          • 5- corneal reflex present 

           • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

          • 8- Decreased hearing

          • 9,10- position of uvula is central ,Gag reflex- present

          • 11- sternocleidomastoid contraction present

          • 12- no deviation of tongue

Motor system 

Attitude -  left and right lower limb flexed at knee joint

Reflexes 

                          Right        Left            

Biceps                3+            3+      

Triceps                3+            3+       

Supinator            2+            2+

 Knee.                  3+.           2+

Ankle.                   2+.           2+

Power.           Lt.        Rt

Upper limb -5/5.       5/5

Lower limb  -5/5       5/5                                  

               

TONE.                    Lt.        Rt

 Upper limbs           N        N                

 Lower limbs           N        N                 

No Involuntary movementss

SENSORY SYSTEM

I – SPINOTHALAMIC       R     L

1. Crude touch                 N     N 

2. Pain.                              N.    N

3. Temperature.               N.     N

II – POSTERIOR COLUMN

1. Fine touch.                    N.    N

2. Vibration.                      N.     N

3. Position sense.             N.     N

4. Romberg’s sign  -Negitive

III – CORTICAL

1. Two point 

    discrimination.               N.    N

2. Tactile localisation.       N.    N

3. Graphaesthesia.            N.    N

4. Stereognosis.                N.    N

CEREBELLAR Tests

No Nystagmus

Finger Nose test - normal

Heel Knee test - normal

Dysdiadokokinesia - normal

INVESTIGATIONS : 

26/12/22

HEMOGRAM

Hemoglobin: 13.9

TLC: 13200

Platelet: 2.25

ELECTROLYTES

Na: 127

Cl: 89

K: 4.1

RENAL FUNCTION TESTS

Urea: 89

Creatinine: 2.9

Uric acid: 7.7

Serum albumin- 3.2 

Urinary- Na- 155, K-17.5, Cl- 180

Spot urine protein creat ratio- 0.29

LIVER FUNCTION TESTS

Total Bilirubin: 2.29

Direct Bilirubin: 0.59

SGOT:25

ALT:24

ALP:129

Total Protein: 6

Albumin: 3.11

CUE

Albumin, sugars are nil 

Pus cells- 3-4

Epithelial cells- 2-3 

ECG REPORTS 

USG REPORT 

Go

2D ECHO

CHEST X-RAY 

PROVISIONAL DIAGNOSIS-

? Post renal AKI 

? CKD secondary to analgesic abuse 

TREATMENT- 

Tab LASIX 20 mg PO BD 

Tab Ultracet 1/2 tab po QID 

Tab PAN 40mg PO OD 30 min before breakfast 

Tab Nodosis 50omg PO BD for 2 weeks 

Tab Shelcal CT PO OD

Cap Bio D3 PO once weekly