46 year old man with bipedal edema since one year and abdominal distension since one month

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Here is a case i have seen:

 Case history taken by Dr.Aditya

A 46 year old man farmer by occupation residing at miryalguda presented with a 1 year history of progressive bilateral lower extremity swelling. A previously capable agriculturalist with a bachelor's degree in arts, this man was feeling well until 1 year ago when he started noticing bilateral lower extremity swelling which was pitting on pressure. It is gradually progressing.There was no history of facial puffiness in the morning, dyspnea on exertion or distension of abdomen, the patient takes time to recall but denies any of these symptoms.There was an increased latency of responding to questions asked.

A month after his edema began, the patient sought a consultation with a general practitioner in his village who told him that he had a kidney problem. When asked specifically, he denied a history of fever, sore throat, rash, hematuria, cough or expectoration. He also denied a history of night sweats. The patient however reported a profound fatigue.

Later on his sister, who reported to us that his fatigue was grossly apparent for last 6 months to 1 year and that his work in fields reduced to simply providing emotional support to others. There was no history of weight loss or loss of appetite as the patient can't recall much beyond the past 3 months. 

On asking his sister both symptoms were alarmingly apparent to her because she stays away from the patient's home and visits him about once or twice monthly and says that these changes were quite apparent from visit to visit. 

Patient reported that he had difficulty in getting up from bed in the morning for the last 6 months, he had difficulty in turning in bed, difficulty in getting up from a chair without support and the most concerning problem was a difficulty in getting up from a squatting position he takes to pass stools. He associates these problems to have compounded by the distension of abdomen he developed for the last 1 month. He denies a history of jaundice, pain abdomen or chest pain, hemoptysis or hematemesis. He is unsure of his bowel habits. 

A quick review of systems is done - he denies palpitations, chest pain, dizziness, he reports early satiety. He denies having gait imbalance, stiffness of buckinling of his knees, he does not report of any sensory symptoms. 

He lives with his wife and only daughter. He denies alcoholism or smoking or any recreational drug abuse. His sleep is decent. In fact the sister says that he often feels weak a sleeps quite often during the day too.

Past history:

Not a k/c/o DM, HTN, CVA, CAD.

On examination: patient is conscious,coherent,cooperative.

Pallor+

No icterus

No cyanosis 

No clubbing

No lymphadenopathy

Pedal edema+ upto knees, pitting+










Weight 57kgs

Vitals:

BP 140/90mmhg

Spo2 99%

RR 16/min

PR 74/min

Systemic examination:

Per abdomen-

Inspection-

Shape of the abdomen-distended, all quadrants of abdomen are moving equally with respiration,umbilicus everted, no scars,no sinuses,no visible pulsations,no visible peristalsis,hernial orifices are free.




Palpation-

Tenderness absent,liver and spleen not palpable,abdominal girth:100cms.

Percussion-

Shifting dullness present.

Auscultation-

Bowel sounds heard.

Respiratory system: Bilateral air entry present,normal vesicular breath sounds heard.

CVS: S1,S2 heard.

CNS:no abnormality detected.

Investigations

Hb:9.5

TLC 5,600

Plt 3.06

LFT-

TB 0.33

DB 0.12

AST 18

ALT 10

ALP 203

TP 3.7

Alb 1.1

A/G 0.44

Serum LDH 292

RFT-

Urea 21

Creat 1. 0

Na 137,k 4.0,cl  97

CUE-

Albumin +++

Sugar +

Pus cells 6-8

Spot urine protein- 161

Spot urine creat- 49.1

Ratio 3.27


PT 14

INR 1.0

APTT 29


Serology-

HbsAg, Hiv, Hcv negative


Ascitic fluid:

Serum albumin 1.1

Ascitic albumin 0.2

SAAG 0.9

Sugar 95

Protein 1.0

Ascitic fluid LDH 46

Ascitic fluid ADA 15


USG abdomen:

1.right kidney grade 1 rpd changes

2.left kidney increased echotexture

3.gross ascites with thin internal echoes

4.diffuse abdominal wall edema

5.altered echitexture of liver with surface irregularities. 


CXR:



ECG:



Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Tab.lasilactone 10mg/50mg PO BD

Day-2

On examination:pt. is conscious, coherent,cooperative

Temp:98.4F

PR:84bpm

BP:110/90mmhg

RR:17cpm

Cvs:S1,S2 heard

RS:BAE+

P/A:soft,distented,umbilicus everted

Wt.-57 kgs

Abdominal girth-100cms

I/o-400/300 since night

Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Inj. lasix 20mg iv bd

5.tab. aldactone 50mg po bd

6.tab.neurobion forte od

Investigations-

Ascitic fluid cytology



Lipid profile-

Total cholesterol-208

Triglycerides-221

HDL-62

LDL-112

VLDL-44

 Day-3

C/o loose stools 5 times

On examination:pt. is conscious, coherent,cooperative

PR:112bpm

BP:110/80mmhg

RR:16cpm



Cvs:S1,S2 heard

RS:BAE+

P/A:soft,distented,umbilicus everted

Wt.-52 kgs

Abdominal girth-97cms

I/o-1100/900

Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Inj. lasix 20mg iv bd if sbp more than 110 mg

5.tab. aldactone 50mg po bd

6.tab.neurobion forte od

7.tab sporolac ds po tid

8.tab alpha d3 po od

9.inj.pan 40mg iv od

10.tab.metrogyl 400mg po tid

Investigations-

Hb:10

Tlc:2,500

Plt:2.82

Day-4

On examination:pt. is conscious,coherent

Temp:98.4F

PR:110bpm

BP:110/80mmhg

RR:16cpm

Cvs:S1,S2 heard

RS:BAE+

P/A:soft,distented,umbilicus everted

Wt.-52 kgs

Abdominal girth-97cms

I/o-900/600

Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Inj. lasix 20mg iv bd if sbp more than 110 mg

5.tab. aldactone 50mg po bd

6.tab.neurobion forte od

7.inj.kcl 2 amp in 500ml NS iv 

8.tab alpha d3 po od

9.inj.pan 40mg iv od

10.tab.metrogyl 400mg po tid

11.inj.thiamine 100mg in 100ml NS iv bd

12.inj.optineuron 1 amp in 100ml NS iv od

Investigations-

Hb:8.4

Tlc:12,500

Plt:2.01

Serum Na 107

             K-2.8

              Cl-80

24 hr urinary protein-2571mg/day

Pt. is having episodes of memory loss and sometimes unable to do simple calculations although pt.is well educated,so psychiatry referral is done.they examined and told mild cognitive impairment,need to be evaluated again after 2 days

Day-5

O/E pt conscious,coherent

There is evening rise of temperatures(although pt denies c/o fever) 

Temp at 8am 98.6F

No night sweats

Abdominal girth 97cms

Wt 52kgs

PR 88/min

BP 110/80

Cvs s1 s2 +

RS BAE+

P/A soft, distended, non tender, umbilicus everted

I/O 1200/1000

Grbs 165mg/dl

Hb 7.5

Tlc 11,500

Plt 1. 97

MCV 82.4

MCH 28.6

MCHC 34.8

PCV 21.5

Na 137

K 3.1

Cl 105

Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Inj. lasix 20mg iv bd if sbp more than 110 mg

5.tab. aldactone 50mg po bd

6.tab.neurobion forte od

7.inj.kcl 2 amp in 500ml NS iv 

8.tab alpha d3 po od

9.inj.pan 40mg iv od

10.tab.metrogyl 400mg po tid

11.inj.thiamine 100mg in 100ml NS iv bd

12.inj.optineuron 1 amp in 100ml NS iv od

Day-6

On examination-pt.is conscious,coherent

Temp-98.4

PR-82bpm

BP-110/70

RR-17cpm

Abdominal girth-97 cms

Wt.-52kgs

Cvs s1 s2 +

RS BAE+

P/A soft, distended, non tender, umbilicus everted

I/O-1100/800

Grbs 99mg/dl

Serum k-3.2

Treatment:

1.Fluid restriction upto 1.5 lit per day

2.Salt restriction 

3.Protein powder 2 tsp in 100ml milk PO TID

4.Inj. lasix 20mg iv bd if sbp more than 110 mg

5.tab. aldactone 50mg po bd

6.tab.neurobion forte od

7.inj.kcl 2 amp in 500ml NS iv 

8.tab alpha d3 po od

9.inj.pan 40mg iv od

10.tab.metrogyl 400mg po tid

11.inj.thiamine 100mg in 100ml NS iv bd

12.inj.optineuron 1 amp in 100ml NS iv od










Comments

  1. 1. Why does the patient have a difficulty in recalling his history?
    2. Why does he have an unusually increased latency in responding to the questions asked by the PGs?
    3. The denial of the history given by the patient cannot be fully relied upon due to the apparent hampering of his memory, which may be causing a recall bias.
    4. what is the reason for his profound fatigue and how and why did it impair his functional capabilities?
    5. Did he have any history of hematuria? How have his bowel habits apparently changed - any h/o diarrhea or constipation? What about his bladder habits?
    6. what was the frequency and urgency of passage of urine? what is the color of urine? does he have a h/o urine incontinence or urinary retention?
    7. Does he have any h/o skin rashes, arthralgia, arthritis, alopecia? (to rule out collagen vascular diseases eg : SLE)
    8. h/o loss of appetite and involuntary weight loss is suggestive of malignancy
    9. we need to find out the type of primary malignancy, considering his socio demographic and other details revolving around his history and examination findings, if at all it is malignancy. what could be the other differentials for loss of weight and appetite associated with nephrotic symptoms like progressive edema, fatigue and muscle weakness.
    10. what causes bone marrow failure, what is the pathophysiology? could it also have been caused by drugs? what is his drug history?
    11. Considering the patient's socioeconomic status, how can we manage this case, including further investigations, to reach a definitive diagnosis in a cost-effective way, without burning a hole in the patient's pocket?
    12. What are some approaches from integrative medicine (like AYUSH) that can be used to manage his condition?

    ReplyDelete
  2. Maam could steroid treatment be recommended in this case ?
    Does the presence of pus cells indicate some infection as the cause for fever on days three to five?
    Maam what about the results of thyroid function test?

    ReplyDelete
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