68 Y/M complaints of Pedal edema and Shortness of breath

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 a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section.

68 year old man, previously a farmer, came to the casualty with complaints of
- swelling of legs since 15 days
- Shortness of breath since 15 days. 

Patient was apparently asymptomatic 10 years back then he had a fall from tractor while working and hence had to stop farming since then. 
He injured his right hip from this fall for which traction was given but no surgery was performed. Patient used NSAIDs for his hip pain for 3 months then, thrice a day. 
He was diagnosed with Hypertension 10 years back. He is on Tab NICARDIA 20 and Clonidine. 

In Dec 2019, patient had similar complaints of pedal edema and shortness of breath. He was advised and started on hemodialysis. Patient underwent 10 sessions of HD in the months December 2019 and January 2020 after which his investigations showed Urea of 26 mg/dl, Creatinine- 26 mg/dl and Hb- 7.3 mg/dl.
Then after patient was advised to stop his dialysis sessions as he was doing symptomatically better with also his investigations reflecting the same. 

From Jan 2020 to Feb 2022 patient was doing better with no complaints of pedal edema or shortness of breath, which he developed again in the last 15 days. 
B/L swelling of legs upto the level of ankles+
Patient experiences shortness of breath on walking for a short distance (SOB grade 3)
Urine output is normal. Patient also complains of Burning micturition since 10 days not associated with any urgency, frequency, narrow stream of urine, fever or suprapubic pain. Nocturia+ (2-3 times) 

No h/o DM, asthma, epilepsy, CAD. 

PERSONAL HISTORY

Appetite- Normal
Sleep- Adequate
Bowel and Bladder movements- Regular
Addictions- Patient used to consume alcohol twice or thrice weekly 6 years back (90 ml each time). 
Occasional smoker. 

VITALS

Temp- 98.8 F
PR- 84 bpm
BP- 140/80 mmHg 
RR- 18 cpm
Spo2- 98% at RA

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative. 
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.






Shortening of right leg seen

SYSTEMIC EXAMINATION

CVS: S1 S2 heard, no murmurs/thrills
RS: BAE+, NVBS heard
PA: Soft, non tender. 
CNS: NFND

PROVISIONAL DIAGNOSIS

Renal failure (?Hypertensive Nephropathy) 

Investigations on 21/2/22:

Hb: 8.3 mg/dl
Blood Urea: 113 mg/dl
Serum Creatinine: 7.1 mg/dl
USG Abdomen:
- b/l grade 3 RPD with simple renal cortical cysts
- Urinary bladder wall thickened with diverticulae suggestive of chronic cystitis
- evidence of hyperechoic foci in urinary bladder wall likely emphysematous cystitis

Investigations on 22/2/22:

Chest X-ray


X-ray Right Hip




Treatment

1. Fluid and Salt restriction
2. Tab Lasix 40 mg PO/BD
3. Tab Nicardia 20 mg PO/BD
4. Inj. ERYTHROPOIETIN 4000IU SC weekly once

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