55 year old man with pedal edema

55 year old man with c/o decreased urine output, pedal edema,sob since 1year.

Patient was apparently asymptomatic 1year back then he developed bilateral pedal oedema (pitting type). Gradually progressive a/w sob and h/o decreased urine output.no h/o palpitation,burning micturition.

K/c/o HTN ON tablet Nocardia 10mg

N/k/c/o DM,TB,ASTHAMA, EPILEPSY,CAD.

ON EXAMINATION_PATIENT IS CONSCIOUS,COHERENT , COOPERATIVE.

TEMP-AFEBRILE.

PR-83BPM

BP-120/80MMHG

RR-17CPM

SPO2-98

GRBS-121MG/DL

CVS-S1S2+

RS-BAE+,NVBS.

CNS-NAD

INVESTIGATIONS-

ON 22/12/2021

BLOOD UREA-79MG/DL

SERUM CREATININE-7.4MG/DL

SODIUM-148MEQ/L

POTASSIUM-3.9MEq/L

CHLORIDE-98mEq/L

SERUM IRON- 94ug/dl

HBsAg-negative

HIV-NON REACTIVE

HCV-NEGATIVE

BLOOD GROUP-O POSITIVE

Rx-

FLUID AND SALT RESTRICTION

T. LASIX 40MG PO/BD

T. NICARDIA 10MG PO/BD

INJ. ERYTHROPOIETIN 4000IU IV/SC WEEKLY ONCE

Ward D

55/M 

S- c/o decreased appetite since yesterday

O- 

C/c/c

Bp- 130/80mmHh

PR-92bpm

RR- 16cpm

CVS- S1 S2 heard

RS- BAE (+VE)

P/A- SOFT NON TENDER

A- 

Shortness of breath - ? Heart failure 

Decreased urine output - chronic renal failure

P- 

FLUID AND SALT RESTRICTION

T. LASIX 40MG PO/BD

T. NICARDIA 10MG PO/BD

INJ. ERYTHROPOIETIN 4000IU IV/SC WEEKLY ONCE

65/M Farmer/Ration shop owner

65/M 

FARMER BY OCCUPATION

 

Pt WAS APPARENTLY NORMAL 16 YEARS AGO,

WHILE WORKING IN THE FIELDS, A THORN PRICKED HIS LEFT LEG AND FORMED A NON HEALING ULCER, WENT TO A PRIVATE HOSPITAL AND WAS FOUND TO BE DIABETIC, STARTED ON OHA (UNSURE OF THE MEDICATION), AND CONTINUED TO USE MEDICATION

IN LATE 2019, ANOTHER INJURY OCCURRED TO THE LEFT FOOT, FORMED ANOTHER ULCER, RESULTING IN GRADUAL BLACKENING OF THE TOES. DIAGNOSED AS DIABETIC FOOT. AMPUTATION OF THE FIRST TWO GOES OF LEFT FOOT DONE.

PATIENT HAS BEEN USING A CANE FOR SUPPORT TO WALK SINCE THEN.

IN DECEMBER 2020, H/O SOB GRADE 2 SINCE 4 MONTHS WHICH PROGRESSED TO GRADE 3 2 MONTHS AGO AND DIAGNOSED AS ADHF AND CAG WAS DONE. ON REGULAR MEDICATION

(SEPTEMBER, 2021)FIVE MONTHS AGO HE HAD C/O SWELLING OF ARMS AND LEGS (UPTO THIGHS) ,FACIAL PUFFINESS,NAUSEA VOMITING,CONSTIPATION AND ABDOMINAL DISCOMFORT FOR WHICH HE WENT TO A HOSPITAL IN KHAMMAM WHERE INVESTIGATIONS WERE DONE HE WAS ADVICED ADMISSION BUT HE DENIED AND WENT TO NIMS,HYD ON 04-09-2021.

DIAGNOSED AS HYPERTENSIVE, STARTED ON MEDICATION HE PRESENTED WITH FLUID OVERLOAD,UREMIC SYMPTOMS AND HEMODIALYSIS WAS INITIATED THROUGH RIGHT FEMORAL ACCESS. 20 SESSIONS OF HEMODIALYSIS WAS DONE BETWEEN SEPTEMBER-OCTOBER

THEN PT CAME TO KIMS NKP FOR FURTHER TREATMENT AS IT IS CLOSER TO THEIR RESIDENCE

20 SESSIONS OF HEMODIALYSIS WERE DONE SINCE NOVEMBER, 

31/1/22- last session

 PAST HISTORY:

 K/C/O DM 2 SINCE 16 YEARS AND IS ON INSULIN. (On insulin since 2019, two times a day, 8units and 10 units) 

K/C/O CAD SINCE 2019 IN 2020 DECEMBER, ADMISSION IN CARDIOLOGY FOR ADHF,S/P CAG ADVISED CABG,BUT WAS NOT DONE

K/C/O HTN SINCE 5 MONTHS AND IS ON MEDICATION

Patient stopped farming 3 years ago due to difficulty, has been manning his ration shop as a cashier since then. His wife continues to farm.

2/2/22

Hb- 10.0%

Creatinine- 4.4mg/dl

Serum iron- 72 mcg/dl

RBS- 238mg/dl

Pt is c/c/c

Temp- afebrile

Bp- 140/90 mmhg

PR- 68bpm

RR- 13cpm

CVS- S1 S2 heard

Rs- BAE+

CNS NFND

P/a- soft non tender

FLUID AND SALT RESTRICTION

T. LASIX 40MG PO/BD

T. NICARDIA 10MG PO/BD

T. OROFER XT PO/BD

T. NODOSIS 500MG PO/OD

T. SHELCAL CT PO/OD

T. CAP BIO D3 PO/OD

INJ. ERYTHROPOIETIN 4000IU IV/SC WEEKLY ONCE

INJ. HAI SC/BD (10U--X--8U)

Diagnosis CHRONIC RENAL FAILURE WITH GLOBAL HYPOKINESIA WITH HTN,DM-2.CAD WITH HERPES ZOSTER S/P LEFT CRITICAL LOWER LIMB ISCHEMIA 

45/F cook by occupation

 45 year old with pedal edema

 A 45 year old female, cook by occupation, mother of two, came to the OPD on 21/1/22 with chief complaints of loss of appetite and  vomiting since 2 months 

Pedal edema since 1 year

No c/o Shortness of breath, decreased urine output, burning micturition.

The patient was apparently asymptomatic 1 year ago then she developed pedal edema, on and off,  upto mid calf level ,which relieved on walking. 

C/o facial puffiness on and off since 1 year 

The pt went to a hospital in Nalgonda for the same where her Sr.creat was 11.0

The pt was advised for dialysis I/v/o high serum creatinine but they were not willing to get it done and so was started on medication after which her serum creatinine came down to 7. 

The pt has been using the same medication since the past one year with which she was comfortable  as her complaints subsided and was leading a normal life.

Since 2 months  ago she developed loss of appetite and vomiting for which she went to a private hospital. 

She was referred to KIMS, NKP for dialysis I/v/o high serum creatinine.

Patient is a k/c/o Hypertension since 1 year, on medication.

Not a k/c/o DM, TB, Asthma, Epilepsy 

Vitals:

Temp- 98.6F

BP- 140/80 mmhg

PR- 86 bpm

RR- 17 cpm

Spo2- 99% at RA

GRBS- 94 mg/dl

General Examination:

Patient is conscious/coherent/cooperative 

Moderately built and well nourished

Pallor +

Icterus -

Cyanosis -

Koilonychia -

Lymphadenopathy-

Pedal edema + upto ankle 

CVS- S1 S2 + No murmurs 

RS- BAE+ No added sounds 

P/A- Soft, Non tender 

CNS- NAD

Dx-ANASARCA DUE TO GLOMERULAR INJURY,

ANOREXIA DUE TO AZOTEMIA

Treatment-

FLUID AND SALT RESTRICTION

T. LASIX 40MG PO/BD

T. NICARDIA 10MG PO/BD

T. OROFER XT PO/OD

T. NODOSIS 500MG PO/OD

T. SHELCAL CT PO/OD

2/2/22 24hr URINARY PROTEIN CREAT RATIO-

25/1/22

Hb- 7.5

RBS- 94

Blood urea- 194mg/dl

Creat- 14.6

30/1/22

Blood urea- 123

Creat- 9.7

2/2/22

Urea- 70

Cret- 7.3

Lipid profile- TOTAL CHOLESTEROL- 207

TRIGLYCERIDES- 81

HDL CHOLESTEROL- 42

LDL CHOLESTEROL- 98

VLDL- 16.2

Hb- 6.6

24 hr Urinary protein- 1938 mg/day, 

24hr urine volume- 1700ml

4/2/22

T3- 0.80

T4- 12.93

Tsh- 7.81

Urea-

25/1-194

30/1-123

2/2/22-70

Hb- 

25/1/22- 7.5

2/2/22- 6.6

4/2/22- 8.2

Creat- 

25/1/22-14.6

30/1/22 -9.7

2/2/22- 7.3

29/1/22- 1st dialysis session

1/2/22- 2nd dialysis session

3/2/22- 3rd dialysis session

70/M paddy farmer with pedal edema upto thighs

A 70 year old Paddy farmer, came to OPD with c/o B/L pedal edema and shortness of breath since 6 months

Pt was apparently asymptomatic 6 months back, then developed B/L pitting type of pedal edema upto thighs, facial puffiness, anasarca. Then he went to a private hospital in Hyderabad, during routine investigations was told to have elevated creatine levels and was told to undergo dialysis

Pt then came to KIMS, NKP for further management. 

Pt has lost his livelihood since the last 6 months because he's been unable to work. He's survived by his wife and his son who lives elsewhere. He also has two daughters but they don't live with him.

C/o B/L hip pain since 6 months 

No c/o decreased output of urine

No h/o Fever, cough, cold

In KIMS, KNO, pt underwent 10 sessions of dialysis

1st-8/12

2nd-11/12

3rd-15/12

4th-22/12

5th-27/12

6th-31/12

7th-8/1

8th-17/1

9th-22/1

10th-26/1

Patient is a k/c/o Hypertension and DM since 20 years, on regular medication.

Started on insulin 4months back, twice a day, 10-20 units of insulin

Not a k/c/o TB, Asthma, Epilepsy 

Operated for inguinal hernia 4 years back

H/o Burn 6 years back

Vitals:

Temp- 98.6F

BP- 140/80 mmhg

PR- 86 bpm

RR- 17 cpm

Spo2- 99% at RA

General Examination:

Patient is conscious/coherent/cooperative 

Moderately built and well nourished

Pallor +

Icterus -

Cyanosis -

Koilonychia -

Lymphadenopathy-

Pedal edema + upto ankle 

CVS- S1 S2 + No murmurs 

RS- BAE+ No added sounds 

P/A- Soft, Non tender 

CNS- NAD

FLUID AND SALT RESTRICTION

T. LASIX 40MG PO/BD

T. NICARDIA 10MG PO/BD

T. OROFER XT PO/OD

T. NODOSIS 500MG PO/OD

T. SHELCAL CT PO/OD

57/M with HTN since 4 months

 This is an 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 patient's 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 the comment box

A 57 year old male patient with bilateral pedal edema

57 year old male farmer by occupation

Came with complaints of fever since 3 days

Patient was apparently asymptomatic 4 months back then he developed: 

Bilateral pedal edema, pitting type, insidious in onset, gradually progressive from ankle to below knee

H/o dcreased urine output

No h/o palpitations or burning micturition or chest pain.

C/o B/L knee pain since 4 months

Patient went to the outside hospital were renal function tests were done and he was found to have raised urea and creatinine levels

Patient was taken for dialysis (total of 4 dialysis were done), last session 10/12/21

He was diagnosed with hypertension at the same time and is on regular medication(Tab. NICARDIA 10MG)

Patient came to our hospital for dialysis and central line placement was tried but failed and hence patient was put on conservative management. 

H/o HTN since 4 months

N/K/C/O DM, TB, BA, Epilepsy

Appetite- normal

Bladder and bowel movements- regular

Patient takes alcohol (180ml 2-3 times/week)

Smokes beedi (2-3/day)

History of NSAID's abuse (takes tablets when he has knee joint pains)

O/E- pt is c/c/c

Bp- 130/80mmhg

Pr- 78 BPM

RR- 17cpm

CVS- S1 S2 heard

RS- BAE (+)

P/A soft, non tender

CNS- NFND

Reports as of 24/1/22 (outside reports)

1/2/22

S- c/o B/L knee pain no c/o fever

O- 

O/E- pt is c/c/c

Bp- 130/70mmhg

Pr- 80BPM

RR- 14cpm

CVS- S1 S2 heard

RS- BAE (+)

P/A soft, non tender

CNS- NFND

A-

NSAID Induced Nephropathy with hypertension

P- 

T. LASIX 20mg PO/BD

T. ULTRACET ½TABLET QID

29/M with fever and lower backache since 2 days

29 year old male came to casualty with complaints of fever and lower backache since 2 days.

Fever low grade, a/w chills and rigors, subsided on medication. Pain was dragging type, in lower back radiating to front.

Pt was apparently asymptomatic 1 year back, then presented to casualty with similar complaints along with decreased urine output hicupps and vomiting from 2 days, then developed involuntary movements of right lower limb for which he visited local hospital and on routine investigations was found to be hypokalemic, took some medication and the situation resolved. 6 months later he developed lower backache and investigations revealed renal calculi for which conservative management was done and complaints got resolved. then pt developed right sided involuntary movements again, went to local RMP, had 2 episodes of GTCS and referred to KIMS, NKP for further evaluation. Was diagnosed as ACUTE KIDNEY INJURY/NCC/TUBERCULOMA (2° seizures) and (in March of 2021) pt underwear 4 sessions of dialysis

NO H/O HTN,DM, TB,ASTHMA.CVA,CVD

OIE-PT CONCIOUS.COHERENT COOPRATIVE, GCS-15/15 

-NO SIGNS OF ICTERUS CYNOSIS.CLUBBING, LYMPEDEEMOATHY,GENERALISED EDEMA,

-VITALS-

BP. 140/BMMG PR.8ZBPM PR 18CPM.SPO2 98%AT ROOM AIR 

SYSTEMIC EXAMINATION -CVS-s1,82+ RS-BAE+ P/A-SOFT NON TENDER

55/F with sweating and low sugars

55 year old house wife came to casualty with complaints of:

Sweating and seizure like activity since 1½ hr, after insulin injection

Pt was apparently asymptomatic 10 years back then on routine checkup was told to have Diabetes Mellitus type 2 and advised to use Inj. Human Mixtard 15 units, twice a day. Dosage increased to 20 units one month back.

Pt had C/O polyuria, polydypsia and loose stools 1 month back. stools were watery consistency, non blood stained, 10 episodes per day for 3 days. Watery stools subsided on medication.

Last night pt consumed her meal, followed by s/c insulin injection. ½ hr later pt developed profuse sweating, cold to touch, clenching of fists, uprolling of eyes, frothing at mouth and loss of consciousness. 

Seizure like activity lasted ½ hr

Post ictal confusion (+)

Non responsive to verbal commands or touch stimulus

No H/O fever, burning micturition, cold

Pt was administered 2 IVF- 25 D, after that pt regained consciousness and no seizure episodes after that. 

K/C/O DM-Type2 since 10 years, on insulin

K/c/o HTN since 3 months, on regular medication

N/K/C/O TB, BA, CAD, CVA, thyroid disorders

Similar complaints, 4 episodes in the last 1 year, most recent being yesterday. 

H/o 4 hospital admissions for similar complaints in the past 10 years, duration of 4-10days, latest being 1 year back. 

Grbs on presentation- 11mg/dl in both hands

After stabilization- 168mg/dl

Pt is conscious

Bp- 180/90mmhg

PR-91 BPM

Rr-20cpm

Temp- afebrile

GRBS- 11mg/dl in both hands (168mg/dl after stabilization)

CVS- S1 S2 heard

Rs- BAE+ve

CNS- NFND

P/a- soft non tender

Rx-

IVF NS @75ml/hr IV/STAT

IVF 25-D bolus IV/STAT

GRBS, BP chatting hrly