A 75 year old woman with pedal edema

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This is a case of a 75 year old woman who came with the chief complaints of pedal edema and shortness of breath since one month

History of Presenting Illness

The patient was apparently asymptomatic 8 years back. Then she developed fever for which she went to a local RMP for treatment and was incidentally diagnosed with diabetes. Since then, she’s on medication and has had regular check ups every few months.

There is no significant event that occurred during the past 8 years but then one month back she developed pedal edema up to her knees. She also developed shortness of breath grade 4 and facial puffiness. She also has decreased urine output

She was taken to the hospital and was diagnosed with a kidney problem and then she was referred to our hospital for dialysis.

She received her first round of dialysis on June 11th. She has not been able to walk since then and still has shortness of breath.

She has come back for her 2nd round of dialysis on June 23rd and is on oxygen support.

As of now, the patient is not able to preform her routine daily activities and has generalised weakness and not able to walk. She is living with her son now since dialysis.

Past history:

Diabetes since 8 years.

Not a known case of hypertension, asthma, CAD, epilepsy

PERSONAL HISTORY:

-Mixed diet

-REDUCED APPETITE

-Adequate sleep

-Regular bowel movements

-micturition: Pt HAS DECREASED URINE OUTPUT

GENERAL PHYSICAL EXAMINATION:

Pallor- Absent

Icterus - Present

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal oedema - as of now, it is not visible

Vitals:

Temperature- afebrile

Pulse rate- 82 beats per minute

Respiratory rate- 22 breaths per minute

B.P- 140/80 mm hg

SpO2- 99% on 5 litres of oxygen

SYSTEMIC EXAMINATION

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:

Breath sounds- decreased breath sounds in left

Vesicular breath sounds are normal

Central nervous system- Patient was conscious, coherent and cooperative

Speech was normal.

No slurred speech

-No abnormality detected

REFLEXES

Right and left biceps triceps supinator ankle and knee show grade 2 Reflex

Investigations:

Provisional diagnosis: CKD

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