62M pedal edema with HTN and DM TYPE 2

 

62 year male pt presented with chief complaints of 

-POLYURIA since 2 months 

-BURNING MICTURITION since 2 months 

-TINGLING AND BURNING SENSATION OF BOTH LIMBS since 2 months 

-ITCHING all over the body since 2 months 

-SWELLING OF B/L LOWER LIMBS since 1month

-LOWER BACK ACHE since 10-15 days

HISTORY OF PRESENTING ILLNESS-

Pt was apparently asymptomatic 2 months back, then he developed  POLYURIA which was insidious in onset and gradually progressive, associated with burning micturition and frothy type of urine, Pt also complained of increased urine frequency at nights.

He developed B/L SWELLING OF LOWER LIMBS, pitting type and extending upto the knee, aggravated on walking and relieved in lying down position 

He developed LOWER BACK ACHE 10-15 days back, which was non radiating type ,without any tingling sensations and relieved on lying down.

PAST HISTORY:

Known case of DM type 2 since 2 years.

Known case of HTN since 2 years.

Not a known case of EPILEPSY, TB, ASTHMA, CVA, CAD and any thyroid disorders.

PERSONAL HISTORY:

Diet:Mixed

Appetite:Normal

Bowel and bladder: Regular 

Sleep: Adequate 

No addictions.

INVESTIGATIONS:

Complete urine examination:

Proteinuria +

Pus cells +

Epithelial cells +

Serum creatinine:

Serum electrolytes:

Hemogram: 

Hb-low(10.5g/dl)

PCV-abnormal(33.2vol%)

RDW-CV - Abnormal(14.4%)

RBC COUNT- Decreased (3.57millions/cubic mm)

Fasting blood sugar:

PROVISIONAL DIAGNOSIS: Pedal edema under evaluation.