A 62 YEAR OLD MALE WITH PEDAL EDEMA AND FEVER

 

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 62 year old male came to the OPD with chief complaints of

CHIEF COMPLAINTS:

Pedal edema since 1 month

Decreased urine output since 1 month

Fever since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 years back then developed pedal edema, shortness of breath, fever, cough and was admitted in a private hospital hyd and diagnosed as renal failure.

In February 2022 patient came to kamineni Narketpalli with chief complaints of shortness of breath and decreased appetite and undergone dialysis under 3 sessions and was on conservative management.

In November 2022, patient came with similar complaints and undergone dialysis here

Now he developed pedal edema since 1 month which is pitting type and complained of fever since 3 days which is continuous ,high grade and associated with chills and rigor.

H/o nausea, vomiting, anorexia on 4th jan night.

Vomiting is non projectile, non bilious, non blood tinged contained food particles associated with nausea in 2-3 episodes.

H/o decreased urine output since 1month

No h/o burning micturition, pain abdomen.

H/o abscess over left medial and infra gluteal region 1 year back.

Came for dialysis ( no regular follow up)

Timeline of events:

PAST HISTORY:

K/C/O Diabetes  since 3 years

K/C/O Hypertension since 3 years and on medication for both

Patient had a history of knee injury 3 years back for which he undergone surgery.

N/K/C/O  CAD, epilepsy, asthma, Tuberculosis.

No history of any blood transfusions.

FAMILY HISTORY: No significant family history

PERSONAL HISTORY:

DIET: Mixed

APPETITE: Decreased

SLEEP: Adequate

BOWEL MOVEMENTS: Regular

BLADDER MOVEMENTS: Decreased urine output

ADDICTIONS: Drinks toddy occasionally

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative Well oriented to time, place and person

Moderately built and moderately nourished.

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema-present

VITALS:.                                                          .

Temp:Febrile(102°F)

Blood pressure:130/90mmHg

Pulse rate:82bpm

Respiratory rate:14cpm

SYSTEMIC EXAMINATION.                       

CVS EXAMINATION :-

JVP: Normal

INSPECTION:

Chest wall symmetrical

Pulsations not seen

PALPATION:

Apical impulse – normal

Pulsations – normal

Thrills absent

PERCUSSION:

No abnormal findings

AUSCULTATION:

S1, S2 heard

No murmurs 

No added sounds

 RESPIRATORY EXAMINATION :-

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant on percussion

- Bilateral equal air entry, no added sounds heard.

1. Breath sounds -  Normal Vesicular Breath sounds

2. Added sounds - absent

3.  Vocal Resonance - normal

4. Bronchophony, Egophony, Whispering Pectoriloquy absent

 
CNS EXAMINATION:

No focal neurological deficit.

    

3) ABDOMINAL EXAMINATION :-

INSPECTION:

1. Shape – flat

2. Flanks – free

3. Umbilicus – Position-central, Shape-normal

4. Skin – normal

5. Hernial Orifices - normal

PALPATION:

Abdomen is soft and non tender

No hepatomegaly

No splenomegaly

No other palpable swellings

Hernial orifices normal

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent

AUSCULTATION:

Bowel sounds – normal

No bruits, rub or venous hum

 

PROVISIONAL DIAGNOSIS:

CKD secondary to DIABETIC NEPHROPATHY

With Anemia secondary to CKD

With pyrexia under evaluation ?UTI

INVESTIGATIONS:

◆Hemogram: 

 

Hemoglobin-8.1gm/dl

WBC-7,800 cells/cu mm

Neutrophils- 70%

Lymphocytes- 20%

Eosinophils- 02%

Monocytes- 7%

Basophils- 0

PCV- 25 vol%

MCV- 89.9 fl 

MCH- 30.2 pg

MCHC- 31.2 %

RBC count- 2.68 millions/cumm

Platelet counts- 2.09 lakhs/ cu mm

SMEAR:

RBC - normocytic normochromic

WBC - with in normal limits

Platelets - Adequate

Haemoparasites - no

 

◆Complete urine examination:

Colour - pale yellow

Appearance- clear 

Reaction - acidic

Sp.gravity - 1.010

Albumin - trace

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells - 6-8/HPF

Epithelial cells - 2-3/HPF

RBC s - nil 

Crystals - nil

Casts - nil 

Amorphous deposits - absent

◆Serum creatinine:

5.8 mg/dl

◆Blood sugar: Hypoglycemia:

70 mg/dl

◆Blood urea:

120mg/dl

◆Serum iron:

73 micrograms/dl

◆Serum electrolytes:

Sodium - 139 mEq/L

Potassium - 5.0 mEq/L

Chloride - 105 mEq/L

Calcium ionised - 0.90 mmol/L

◆Liver function test:

Total bilirubin - 0.73 mg/dl

Direct bilirubin- 0.19 mg/dl

AST - 17 IU/L

ALT - 10 IU/L

Alkaline phosphatase - 139 IU/L

Total proteins - 5.4 g/dl

Albumin - 3.2g/dl

A/G ratio - 1.51g/dl

◆ECG:

◆USG:

Impression:

1)Grade lll RPD changes noted in bilateral kidneys with complex renal cortical cysts.

2)Vesicle calculus 32mm is noted.

Doppler studies:

DISCUSSION:

Chronic kidney disease secondary to diabetic nephropathy associated with anemia.