A 42 YEAR OLD MALE WITH PEDAL EDEMA & SOB


CHIEF COMPLAINT:

A 42 year old male patient was brought to casuality with chief complaints of bilateral lower limb swelling (pitting type) (l>r) since 15 days, Fever since 7 days and SOB since 2 days.

HISTORY OF PRESENT ILLNESS:

•Patient was apparently  asymptomatic 15 days back  & then he noticed  bilateral lower limb swelling which was insidious in onset gradually progressing pitting type ( left more than right ) extending  up to the knees.
•Patient had history of trauma over the left malleoli 10 days back followed by an ulcer & increased swelling  of the left lower limb
•History of Fever which is low Grade intermittent associated  with generalized weakness since 7 days
•Patient also complaining of breathlessness since 2 days which is Grade 2 initially progressed to Grade 3-4 associated with orthopnea & PND

No h/o cough, chest pain

No h/o pain abdomen, vomiting, loose stools

No h/o decreased urine output/ burning micturition and no other complaints 

HISTORY OF PAST ILLNESS:

•In 2018

He accidentally got injured by an iron rod on left foot big toe which formed into an ulcer for which he took some symptomatic Rx but it didn’t  subside and the very next day the foot got swollen (?cellulitis) and he came to our hospital for which he was treated  with antibiotics and other supportive  care f/b SSG to left foot ulcer.

•In 2020

He had history of fever, decreased appetite, cough for which he went to a local hospital where he was diagnosed with Tuberculosis and is on irregular medication

He was not k/c/o DM , HTN , Bronchial Asthma , Epilepsy CVA CAD

PERSONAL HISTORY:

Diet – Mixed

Appetite – Decreased

Sleep – Decreased

Bladder & Bowel movements – Regular

He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and  khaini 2-3 per day for the past 20 years.

GENERAL EXAMINATION

Patient is conscious,coherent,cooperative

Thin built & moderately nourished

Icterus is present

Pedal edema is  present 

No pallor, cyanosis, clubbing, lymphadenopathy 

VITALS:

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min , regular

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg

 

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM

Inspection: 

•Chest is barrel shaped, bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•JVP:Raised 
•Visible epigastric pulsations 
•No scars or sinuses
•Apical impulse seen in left 6th intercostal space lateral
to midclavicular line 
 
 
  VISIBLE APEX BEAT


VISIBLE EPIGASRTIC PULSATIONS


JVP 

Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Antero-posterior diameter of chest >Transverse 
diameter of chest
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line
•Parasternal heave present (Grade-3)
•Palpable P2 + 
 
Auscultation: 
•S1 S2 heard
•No murmurs


RESPIRATORY SYSTEM:

Inspection: 

•Chest is barrel shaped, bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•Visible epigastric pulsations 
•No scars or sinuses
•Apical impulse seen in left 6th ICS lateral to MCL

   BARREL SHAPED CHEST 


Palpation:

•All inspectory findings are confirmed: 
Trachea is central, movements equal 
bilaterally. 
•Antero-posterior diameter of chest 
>Transverse diameter of chest
•Apex beat felt in 6th intercostal space
 lateral to midclavicular line
•Vocal fremitus decreased in right IAA 
& ISA

 
AP diameter-23cms, Transverse diameter- 23cms


Percussion: 

•Dull note heard in right IAA & ISA
•Resonant note heard in all other areas
 bilaterally
 

Auscultation: 

•Bilateral air entry present – Normal 
vesicular breath sounds heard
•Breath sounds decreased in right IAA & 
ISA
•Vocal resonance decreased in right IAA & 
ISA
•Expiratory wheeze heard bilaterally

                                    

PER ABDOMEN:

•Scaphoid
•Visible epigastric pulsations
•No  engorged veins/scars/sinuses
•Soft , non tender
•No organomegaly
•Tympanic node heard all over the abdomen
•Bowel sounds present
 

CENTRAL NERVOUS SYSTEM:

•HMF - Intact
•Speech – Normal
•No Signs of Meningeal irritation
•Motor and sensory system – Normal
•Reflexes – Normal
•Cranial Nerves – Intact
•Gait – Normal
•Cerebellum – Normal 
•GCS Score – 15/15
 

PROVISIONAL DIAGNOSIS : 

HEART FAILURE

RIGHT SIDED PLEURAL EFFUSION

COPD

LEFT LOWER LIMB CELLULITIS

         

INVESTIGATIONS:

Investigations on 1/7/21:

CHEST X-RAY
                                               

LIVER FUNCTION TEST 

SERUM CREATININE 

BLOOD UREA

                                                   
SERUM ELECTROLYTE 

HEMOGRAM

COMPLETE URINE EXAMINATION

                              

2D ECHO 


                                                    

                                                                       ECG
 
FINAL DIAGNOSIS:

HFrEF ? 2° to CAD   

B/l PLEURAL EFFUSION (R > L)

AKI ( ? prerenal )    CRS -1 

ALCOHOLIC LIVER DISEASE

COPD 

LEFT LOWER LIMB CELLULITIS
 

Investigation on 3/7/21:
                                                     
ECG: ATRIAL FIBRILLATION, Irregular RR interval, No P wave


Investigations on 5/7/21:
                                            
ECG 

HEMOGRAM

BLOOD UREA 

SERUM CREATININE 

SERUM ELECTROLYTES 

Investigation on 7/7/21:
                                            
ECG 



TREATMENT : 

Treatment on 2/7/21 : 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) BP PR temp and spO2 monitoring

Treatment on 3/7/21 :
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) BP PR temp and spO2 monitoring

Treatment on 4/7/21: 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) Inj. CLINDAMYCIN 600mg IV/TID 
8) BP PR temp and spO2 monitoring

Treatment on 5/7/21 : 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) Tab DIGOXIN 0.25 mg stat 
8) Inj. CLINDAMYCIN 600mg IV/TID 
9) BP PR temp and spO2 monitoring

Treatment on 6/7/21 : 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) Tab DIGOXIN 0.25 mg OD
8) Inj. CLINDAMYCIN 600mg IV/TID 
9) BP PR temp and spO2 monitoring

Treatment on 7/7/21 : 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
3) Inj. Ceftriaxone 1gm IV/BD 
4) Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab ECOSPIRIN-AV 75/20 mg OD
7) Tab DIGOXIN 0.25 mg OD
8) Inj. CLINDAMYCIN 600mg IV/TID 
9) BP PR temp and spO2 monitoring
 
 
Patient improved symptomatically and was discharged in a hemodynamically stable condition.


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