Who is the culprit? An Interesting case of Bilateral Pedal Edema
A 59 year-old Male came to the medicine OPD, with the chief complaints of weakness in both lower limbs, hands, back and neck since 6 days.
He has been working as a sweeper at a local school since the past 6 years, before which he worked as a farmer.
Subjectively
He was apparently asymptomatic 9 days ago, when he presented with
-Fever, 9 days ago, which was sudden in onset, lasted for a day, for which no medication was used as it subsided on its own. It was not associated with any chills and rigors. The patient did not record his temperature because he was unaware and uneducated about the use of a thermometer for measuring his temperature at home. Hence, it is difficult to review the nature of his fever (for example: Whether it was a high-grade fever or a low-grade fever)
-He had a history of Loose stools 6 days ago, only on that day, which lasted for an hour, during which he emptied his bowels 4-5 times. It was watery in consistency, normal colour and was non-blood stained, not associated with foul-smell.
-On the same day, which was 6 days ago, He developed weakness in his lower limbs, which lead to an inability to walk. There was weakness in his upper limbs, back and neck as well.
-After which he consulted his local RMP, who suggested that he should visit our Tertiary Care Hospital for further evaluation and Treatment.
-He complains of swelling in his lower limbs since the past 2 days, which is associated with some shortness of breath.
-He denies any loss of sensation in the limbs, any history of pain (anywhere in the abdomen or the back or neck) , any history of dizziness. He denies any history of nausea and vomiting.
He is a known case of Type 2 Diabetes Mellitus since the past 14 years for which he has been using a 2mg Combination T
tablet of Glimepiride and Metformin, once daily.
He seldom used subcutaneous Insulin injections (about 5 times till now) , the last time being 1 year ago, when his blood sugar was very high.
He admits to be having an increased frequency of micturition, about 8 times a day, ever since he was diagnosed with Diabetes 14 years ago. It was not associated with any burning.
His personal history entails a mixed diet, appetite being normal, and he drinks 90ml of alcohol everyday, since 25 years of age. He smokes 1 pack of Beedis (Local Cigarettes) since 25 years of age.
He has no history of Hypertension, Tuberculosis, Bronchial Asthma, Epilepsy or Coronary Heart Disease.
Family history is insignificant.
Objectively
He appears conscious and coherent, oriented to time, place and person.
He is moderately built and ill nourished.
Bilateral Pedal Edema is present, which is of pitting type.
His vitals are normal, except, his pulse rate was slightly elevated.
On examination of his precordium,
The apex beat could be palpated in the 6th Intercostal space, slightly lateral to the mid-clavicular line.
On auscultation, normal S1 and S2 were heard, with S1 being a little fainter than S2, with no added murmurs or clicks.
Assessment
He was assessed with an electrolyte imbalance and was treated accordingly.
This relieved him of his limb weakness almost immediately.
But, the exact cause of his bilateral, pitting, pedal edema is a mystery yet to be solved.
So, who is the culprit?
Here are some investigations which were done today (On 22/11/2019)
A Chest X-Ray (PA view):
2D- Echocardiography:
He has been working as a sweeper at a local school since the past 6 years, before which he worked as a farmer.
Subjectively
He was apparently asymptomatic 9 days ago, when he presented with
-Fever, 9 days ago, which was sudden in onset, lasted for a day, for which no medication was used as it subsided on its own. It was not associated with any chills and rigors. The patient did not record his temperature because he was unaware and uneducated about the use of a thermometer for measuring his temperature at home. Hence, it is difficult to review the nature of his fever (for example: Whether it was a high-grade fever or a low-grade fever)
-He had a history of Loose stools 6 days ago, only on that day, which lasted for an hour, during which he emptied his bowels 4-5 times. It was watery in consistency, normal colour and was non-blood stained, not associated with foul-smell.
-On the same day, which was 6 days ago, He developed weakness in his lower limbs, which lead to an inability to walk. There was weakness in his upper limbs, back and neck as well.
-After which he consulted his local RMP, who suggested that he should visit our Tertiary Care Hospital for further evaluation and Treatment.
-He complains of swelling in his lower limbs since the past 2 days, which is associated with some shortness of breath.
-He denies any loss of sensation in the limbs, any history of pain (anywhere in the abdomen or the back or neck) , any history of dizziness. He denies any history of nausea and vomiting.
He is a known case of Type 2 Diabetes Mellitus since the past 14 years for which he has been using a 2mg Combination T
tablet of Glimepiride and Metformin, once daily.
He seldom used subcutaneous Insulin injections (about 5 times till now) , the last time being 1 year ago, when his blood sugar was very high.
He admits to be having an increased frequency of micturition, about 8 times a day, ever since he was diagnosed with Diabetes 14 years ago. It was not associated with any burning.
His personal history entails a mixed diet, appetite being normal, and he drinks 90ml of alcohol everyday, since 25 years of age. He smokes 1 pack of Beedis (Local Cigarettes) since 25 years of age.
He has no history of Hypertension, Tuberculosis, Bronchial Asthma, Epilepsy or Coronary Heart Disease.
Family history is insignificant.
Objectively
He appears conscious and coherent, oriented to time, place and person.
He is moderately built and ill nourished.
Bilateral Pedal Edema is present, which is of pitting type.
His vitals are normal, except, his pulse rate was slightly elevated.
On examination of his precordium,
The apex beat could be palpated in the 6th Intercostal space, slightly lateral to the mid-clavicular line.
On auscultation, normal S1 and S2 were heard, with S1 being a little fainter than S2, with no added murmurs or clicks.
Assessment
He was assessed with an electrolyte imbalance and was treated accordingly.
This relieved him of his limb weakness almost immediately.
But, the exact cause of his bilateral, pitting, pedal edema is a mystery yet to be solved.
So, who is the culprit?
Here are some investigations which were done today (On 22/11/2019)
A Chest X-Ray (PA view):
2D- Echocardiography:
-Doctor Sakshi
Could it have been electrolyte imbalance due to diarrhoea leading to edema?
ReplyDeleteAbsolutely. This is the most probable explanation for his edema, since the other causes such as Congestive Heart Failure are likely to be ruled out (as you can see from his Chest X-ray and Echo cardiogram).
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