65 YEARS OLD MALE CAME WITH PEDAL EDEMA, FACIAL PUFFINESS, SOB AND HOARSENESS OF VOICE

2017 batch

ICU bed 4 & DIALYSIS UNIT

DR.PAVAN
DR. NAVYA
DR.SNEHA

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Patient came with chief complaints of pedal edema since 2 days, associated with facial puffiness since 2 days, shortness of breath (Grade II of MMRC) since 2 days and hoarseness of voice since 2 days.

TIMELINE OF EVENTS & DAILY ROUTINE-

- Patient’s usual daily routine is that he typically wakes up at around 6-7AM, gets ready for the day and usually just goes to the milk shop to collect milk, comes home, eats breakfast and works occasionally as a farmer in paddy fields.

- Patient works occasionally on and off to keep his mind occupied, usually has lunch at around 1-2 pm, takes a small nap and then starts his social activities with neighbors and family members.

- Usually has dinner on time with his family and goes to bed by 10.

- Patient was fine, living his normal routine life up until 2017 where he was diagnosed to have hypertension and was given medication for the same during a routine general check up.

- Patient noticed both his ankles and feet swelling associated with SOB of grade II of MMRC back in 2018, was diagnosed with Chronic Renal Failure and as per the advice of his physician at the time, he was asked to stop anti-hypertensive drugs altogether, and given conservative treatment for the CKD (which was Prolomet XL along with an antacid and vitamin supplements)

HISTORY OF PRESENT ILLNESS-

- Patient was apparently asymptomatic until 2 days ago where he developed Pedal edema which was sudden in onset, gradually progressing, since 2 days of pitting type below the knees

- Associated with facial puffiness, which was insidious in onset, gradually progressing, no aggravating of relieving factors.

- and Shortness of breath (grade II of MMRC) along with hoarseness of voice, that was insidious in onset, gradual in progression, no aggravating or relieving factors.

- not associated with cough, cold, fever, chills, palpitations, sweating, decreased urine output, blood in urine.

PAST HISTORY-

- H/O HTN since 2017, was on regular medication till 2018 then stopped as per the advice of his physician but has been prescribed Prolomet XL (metoprolol combination drug)

- No H/O DM, Thyroid disorders, Asthma, Epilepsy, TB, CVA, CAD

PERSONAL HISTORY-

DIET- Currently consuming more of a non vegetarian diet

APPETITE- Normal

BOWEL AND BLADDER MOVEMENT- regular

SLEEP- adequate

HABITS- only used to consume half to one litre of toddy occasionally during functions 20 years back. No present day addictions as such.

FAMILY HISTORY- insignificant

GENERAL PHYSICAL EXAMINATION:

- Patient is conscious, coherent and cooperative.

- Well built and moderately nourished

- height- 178cm

- weight- 78kgs

- pallor- present

- no signs of icterus, clubbing, lymphadenopathy

- at time of doing this blog, patient has received treatment and dialysis for which most of his symptoms including pedal edema have subsided to a major extent so no signs of edema presently.

PR- 82bpm

BP- 130/70 mmHg

RR- 22cpm

SpO2- 98% on RA

Temp- 98.4 F

SYSTEMIC EXAMINATION-

Cardiovascular examination :

- inspection- No previous surgical scars, sinuses, no apical

Impulse seen

- palpation- Apex beat is medial to mid clavicular line between 4-5th intercostal space.

- auscultation- S1S2 heard, no murmurs present.

Respiratory examination-

- inspection- no previous scars, sinuses or engorged veins; expansion of chest appears equal, no appearance of broken ribs, position of trachea appears central.

- palpation- expansions of chest equal on both sides, no rise in temperature, Inspectory findings confirmed

- percussion- Resonant on all areas

Anterior- Clavicular (direct); Mammary and infra mammary (indirect)

Lateral- mid axillary line (6th ICS)

Posterior- Supra and infra scapular; mid scapular (superior, middle and inferior)

Per Abdomen-

- at the time of presentation, it was distended on appearance but after treatment was given, it is scaphoid in shape,

- soft, non tender

- no organomegaly.

Central Nervous Examination- Higher motor functions intact. No abnormal findings

PROVISIONAL DIAGNOSIS- Chronic Renal Failure

INVESTIGATIONS-