70 yr old male with bilateral pedal edema and shortness of breath

 A 70 year old male patient, resident of Nalgonda came. To hospital with chief complaints of 

  Bilateral pedal edema since 1 week

  Shortness of breath since 1 week

History of  presenting illness

Patient was apparently asymptomatic 1 week back, then he developed bilateral pedal edema which was on and off. Pedal edema was pitting type and was initially up to ankle but gradually progressed up to the knee when he presented to  hospital.

He developed shortness of breath which was initially present on doing some work or climbing up stairs. But since last 1 week he has shortness of breath on doing daily activities .

No H/O fever, cough, loss of weight.

Past history

No similar complaints in past

No H/O diabetics, asthma, tuberculosis, coronary artery disease, epilepsy

He is  known case of hypertension since 10 years

Personal history

Diet: mixed

Appetite: decreased

Sleep: adequate

Bowel and bladder: decreased urine output

Addictions: alcohol since 30 years

                      Smoking tobacco since 30 years

Family history

No similar complaints in family

Treatment history

Uses telmesartan 40mg every morning since 10 years

Uses NSAIDS for joint pains, for 3 to 4 times a week

General examination

Patient is conscious coherent and cooperative, moderately built and nourished.

Pallor - absent

Icterus - absent

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - absent 

Edema - bilateral pedal edema up to knee which is of pitting type

Vitals

Temperature: 97*f

Respiratory rate: 18 cpm

Pulse rate: 97 bpm

Blood pressure: 110/80

Systemic examination

Respiratory system

Inspection:

Trachea appears central

No visible scars, sinuses, engorged veins

Chest is bilaterally symmetrical and moves symmetrically which inspiration 

Palpation: 

Inspectory findings are confirmed on palpation

No local  rise in temperature and no tenderness

Percussion:

Dull note is heard on percussion in infra auxiliary and infrascapular area

All other areas are resonant on percussion

Auscultation: 

Decreased breath sounds in infra auxiliary and infrascapular regions

Bilateral air entry is present

Normal vesicular breath sounds are heard

CNS

No focal neurological deficits are present

CVS

S1 S2 heard, no murmurs

Abdomen

Abdomen is soft and non tender 

No organomegaly  is felt on palpation

Provisional diagnosis

Bilateral pleural effusion 

Investigations

LFT

Total Bilirubin:      1.3 mg/dl

Direct bilirubin:     0.3 mg/dl

AST:                         43 IU/dl

ALT:                         27IU/dl

ALP:                         358 IU/dl

Total protein:         4.8 Gm/dl

Albumin:                 2.7 Gm/dl

A/G ratio:               1.33

RFT

urea:                 73 mg/dl

Creatinine:      4.2 mg/dl

Uric acid:        4.0 mg/dl

Calcium:         7.5 mg/dl

Phosphorus:  3.4 mg/dl

Potassium:     3.7 mEq/dl

Sodium:          131 mEq/dl

Chloride:        99 mEq/dl

Hemogram

Hemoglobin:      9.3 Gm/dl

Total count:        12800 cells/cumm

Neutrophils:       95 %

Lymphocytes:     02 %

Eosinophils:       00 %

Monocytes:        03 %

Basophils:          00 %

PCV:                    28.7 vol%

MCV:                  92.3 FL

MCH:                  29.9 pg

MCHC:               32.4 %

Diagnosis

Bilateral pleural effusion with chronic renal failure

Treatment

 Inj, lasix 40 mg/IV/bd 

 Tab, nodosis 50 mg/po/BD

 Tab, nicardia 10 mg/po/BD

 Tab, dytor 20 mg/po/BD

 Monitor vitals every 6th hrly