55 year man with Lower Limb edema

55 year old man, owns a restaurant at choutuppal presented with the complaints of

Bilateral lower limb swelling since 1 month

Reduced urine out since 20 days

Abdominal distension since 7 days

Scrotal swelling since 4 days

Patient used to previously work as a farmer  and later in 2004 he and his wife started running their local bandi for breakfast at Choutuppal. He even serves breakfast on cycle. He is a father of 2 children. 

 22 years back:  He got diagnosed with pulmonary kochas for which he used ATT for 6 months 

 1 month back : 

He first developed left lower limb swelling extending upto his ankle and he later gradually developed swelling of his right lower limb and the swelling in both his lower limbs extended upto his thighs

He even had difficulty in passing stools for which he received enema outside 

Since 20 days - he has been experiencing reduced urine output 

10 days back - When he paid a visit to a hospital with these complaints he got diagnosed to be hypertensive and was started on Tab Telma H in a local hospital and was also started on Tab Lasilactone 20/50

At this point his serum creatinine was 1.6 mg/dl

And his usg abdomen showed ascites and his kidney size was normal 

Since 7 days - he even developed abdominal distension 

Since 4 to 5 days he has also developed scrotal swelling

He however has no complaints of fever, cough, burning micturation, loose stools, vomiting

No complaints of dyspnea, hematuria, frothy urine, no complaints of Chest pain, palpitations, orthopnea, PND, bendopnia or trepopnea 

He is an occasional alcoholic and occasional consumes NSAIDs after long working hours.

On examination: 

He has pallor with Grade 3 clubbing, that is parrot beak type

Bilateral pedal edema - of pitting type extending upto his thighs

JVP not elevated 

 HR of 75 bpm

Bp of 110/70mmhg

RR 20cpm

Spo2 maintaining at 99% at Room Air

GIT Examination:

Per Abdomen-

Abdomen distended with no scars, sinuses, engorged veins 

No tenderness 

Percussion-

Shifting dullness +

Bowel sounds +

Cvs Examination:

Apex beat + in 6th ICS at MCL

S1, S2+

Lungs:

Inspirstory crepts in bilateral all lung fields

Cns: 

Normal

Provisional diagnosis:

? Nephrotic syndrome

Evaluation:

Chest Xray PA view showing left sided CP angle obliteration- suggesting left pleural effusion 

Hb - 9.4 g/dl

TLC - 5300

Plt - 1.84

Normocytic normochormic picture 

CUE:

Albumin +++

Pus cells 4 to 6 cells 

Albumin 2g/dl

Serum creatinine- 3.6mg/dl 

Blood urea - 76 mg/dl

Serum Sodium - 135 meq/L

Serum Potassium- 5.1 meq/L

Serum Chloride - 101 meq/L

Total Bilirubin- 0.56 mg/dl

Direct Biliribin - 0.10 mg/dl

AST - 17 IU/L

ALT - 11 IU/L

Serum Protein - 3.9 g/dl

Serum Albumin- 2.6

24 hours urinary protein shows a protein loss of 2,622 mg/dl

Usg abdomen shows normal sized Kidneys with grade 1 RPD changes along with moderate ascites

Diagnosis:

? Nephrotic syndrome 

Known case of Hypertension since 10 days

Anemia under evaluation