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