A 35 year old male with bilateral pedal edema

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A 35 year old male patient who is a daily wage labourer by occupation came to the opd with complaints of bilateral pedal edema since 2 months with was aggrevated from 20 days,abdominal distension from 20 days,and dry cough from 20 days ,facial puffiness from 3 days

Patient was apparently asymptomatic 2 months back then he developed edema of feet which was on and off .From 20 days the edema gradually progressed till knee,which relieves on elevation of limb.From 20 days he was having abdominal distension and dry cough.He got admitted for these complaints in a private hospital. After 3 days he was reffered to highter centres.Then he came to kims for futhur evaluation.

Patient had similar complaints of pedal edema 6 years back.

No h/o HTN/DM/thyroid disorders/fevere/sore throat/asthma

Alcoholic since 12 years 90 ml/day

GENERAL EXAMINATION:

patient is concious ,coherent, cooperative, oriented to time,place,person,moderately built and moderately nourished

Vitals:

Bp:120/70mm hg

PR:95/min

RR:30/min

GRBS:119mg%

No pallor,icterus,cyanosis, clubbing,lympadenopathy,edema of feet.

 SYSTEMIC EXAMINATION:

Respiratory system:bilateral air entry present,trachea central,normal vesicular breath sounds heard,no adventious sounds heard

Per abdomen:

shape of the abdomen:distented                                  no tenderness,no local rise of temperature           no palpable mass                                                          hernial orifices free                                                      no free fluid  and bruit                                                 liver and spleen:not palpable                                      bowel sounds:normally heard     

  CNS EXAMINATION:

Highter mental functions:

Patient is concoius,coherent,coperative,oriented to time,place,person

Speech is normal in pitch and tone                            memory :recent and remote memory intact        

Cranial nerves:all cranial nerves intact

Motor system:

TONE:     UL                       LL                                        

      Rt       N                          N

      Lt       N                           N

BULK :    UL                      LL

     Rt        N                        N

     Lt         N                        N

POWER:   UL                   LL

    Rt          4-               3+

   Lt           4-                 3+

Sensory system:

Fine touch         N

Crude touch     N

Pain/temp          N

Vibration          decreased 

Joint position     N

Propriception     

Deep tendon reflexes

Biceps            absent          absent

Triceps            absent        absent

Supinator        absent         absent

Knee                 absent          absent

Ankle              absent         absent

Cerebellum :no finger nose incordination

Knee heel test:normal

CVS examination:jvp raised,no visible pulsations,palpable heart sounds in plumonary,tricuspid,mitral areas,s1 and s2 heard,p2 is split

Raised jvp video:

https://drive.google.com/folderview?id=1U2stuJTGF7WZe4xzb9A6uG14xzFZ0VgX

Investigations:

Day 1:

21/8/2020

Day 2:

22/8/2020

Day 3:

23/08/2020

2D ECHO VIDEO:

https://drive.google.com/folderview?id=1TSsy_eX1ZCqxjfRAycAJxrgndefbkkRx

Jvp video:

https://drive.google.com/folderview?id=1U64jiDEZPXsKlyD1rMZmucAqKGBIjZcU

PROVISIONAL DIAGNOSIS:

Type 1 pulmonary arterial hypertension 

Treatment:

1)inj.lasix 40 mg iv×bd

2)fluid restriction less than 1 lit/day

3)salt restriction less than 4 gm/day

4)daily weight measurement 

5)daily abdominal girth measurements 

6)strict i/o charting

7)bp,pr monitoring 1 hrly

8)inj.ceftriaxone 1gm /iv/bd

9)tab.pregabaline 75mg od

Patient came to follow up and he presented with pain in both calf muscles dragging type,continuous,without radiating since 2 months Aggravated on walking .Mild pain during day time increased during first half of night and relieved in second half of night

Patient was apparently a symptomatic 3 months back ,he developed Ed’s a of feet (on and off).From 20 days Edelman gradually progressed till knee,which releives on elevation of limb.From 20 days he was having abdominal distension and dry cough

MOTOR SYSTEM EXAMINATION

POWER                                                                                    Rt                                             Lt

Upper limbs          Shoulder.   flexion-extension                      5/5                                             5/5

                                             Lateral -medial rotation              5/5                                            5/5

                                             Abduction-adduction                   5/5                                          5/5

                            Elbow       Flexion-extension                        5/5                                         5/5

                           Wrist          Dorsiflexion-palmar flexion      5/5                                          5/5

                                                Adduction-abduction              5/5                                          5/5

Lower limbs               Hips   Flexion-extension                5/5,5/5                                        4/5

                                        Lat rotation-medial rotation         5/5                                          5/5

                                        Abduction-addiction                    4/5                                           4/5

                                 Knee     Flexion -extension               4/5,4/5                                      4/5

                               Ankle      Dorsiflexion-plantar flexion    4/5,5/5                                 4/5

                                               Inversion-eversion                   4/5                                        4/5

TRUNK MUSCLE;      Rolling over bed

Pain in the adductor compartment of thigh while rolling

GAIT;  wide stance gait

EXAMINATION OF SPINE;              Rt                                  Lt

Vibration              UL                        8sec                              8sec

                              LL                       8sec                              8 sec