Part 1 – Choose 2 of the 5 cases
The following activity includes several case presentations of edema. Make a diagnosis for each case, remembering the following questions:
Is the edema acute/sudden or chronic (e.g., duration, progression)?
Is it unilateral or bilateral? Is the edema generalized or localized?
Is it pitting or nonpitting?
Is it dependent?
In addition to edema, what other characteristics are associated with the edema (e.g., redness, pain)?
What is the pertinent past or coexisting medical history? What medications is the patient taking?
You may want to refer to chapter 3 and chapter 4 to help determine the diagnosis.
Case 1
45-year-old Mrs. Rodriguez is complaining of intermittent mild bilateral feet/ankle swelling for the past 2 months, but it is worse on her right leg. She denies leg pain, but she does describe her legs as feeling heavy at times and reports standing for long periods worsens the swelling. She notes her veins are getting larger in her legs. For the past 8 months, she has been experiencing intermittent numbness in her feet and reports her left knee has been achy. She is a server at a busy restaurant and sometimes works 10-hour days. She denies any fever, warmth, erythema, or trauma.
Past medical history: obesity (BMI 31); type 2 diabetes mellitus.
Medications: metformin.
Physical examination: vital signs are within normal limits; exam is unremarkable except for bilateral tortuous veins in both lower extremities, which are worse on the right leg, and decreased sensation in both feet.
Note: Assume history and examination is within normal limits if not listed.
Activity
Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 2
68-year-old Mr. Quincy is complaining of left leg swelling for the past 2 weeks. The swelling started while he was on a cruise. The swelling is intermittent and below the knee to his foot. He describes a cramplike pain in his left calf. Lately, both legs have been cramping while walking, but it resolves when he sits. He denies any fever, warmth, erythema, or trauma.
Past medical history: iliofemoral deep vein thrombosis of his left leg after he had left hip replacement for osteoarthritis 9 months ago; treated with rivaroxaban for 6 months; stable angina; obesity (BMI 31); dyslipidemia.
Social history: quit smoking 4 years ago but resumed one-fourth pack per day 1 year ago.
Medications: simvastatin; aspirin; metoprolol.
Note: Assume history and examination is within normal limits if not listed.
Physical examination: vital signs are within normal limits; right leg is within normal limits except hairless, shiny skin; left leg has 1+ pitting edema in the pretibial area and foot; mild pain with left calf compression and one small tortuous vein on the medial aspect of his calf; left leg is also hairless and shiny. A venous duplex Doppler ultrasound of his left leg was done and reveals no deep vein thrombosis.
Activity
Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 3
85-year-old Mrs. Delaney has bilateral ankle and foot swelling for the past 3 weeks; she states her feet hurt and her shoes feel tight and describes this swelling as the first occurrence; she denies fever, erythema, warmth, or trauma.
Past medical history: aortic valve replacement; hypertension; dyslipidemia; osteoporosis.
Medications: amlodipine; benazepril; atorvastatin; alendronate sodium; aspirin.
Physical examination: vital signs within normal limits; exam unremarkable except for grade 1 systolic ejection murmur at the left sternal border, second intercostal space with no radiation, and mild (< 1+) pitting edema bilateral ankles and feet.
Note: Assume history and examination is within normal limits if not listed.
Activity
Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 4
78-year-old Mr. Smith is complaining of increased swelling in his lower legs for the past 3 weeks. He states it worsens when his legs are hanging down and gets a bit better when he elevates them. The swelling started about a week after he left the hospital for an episode of pneumonia. He states his legs occasionally swell, especially when he eats too much salt, and the last time it happened was about 8 months ago. He reports taking a water pill for a while but not lately. He noted that he feels like he has put on a few pounds this week and feels a bit more tired and short of breath. He has had to sleep propped up with two pillows. He denies leg pain, fever, warmth, or trauma.
Past medical history: anterior wall myocardial infarction 2 years ago; hypertension; heart failure with reduced ejection fraction; dyslipidemia.
Social history: 1 pack a day smoker for 30 years—quit 2 years ago.
Medications: sacubitril/valsartan; metoprolol; rosuvastatin; aspirin (which he forgets to take).
Physical examination: vital signs — temperature 98.5°F; pulse 70 beats per minute, respirations 22 per minute; blood pressure 150/80 mmHg; pulse oximeter 96%; weight increase of 5 pounds in 1 month; cardiovascular exam remarkable for an S3 gallop; lungs with bibasilar fine inspiratory crackles; bilateral lower extremities pretibial to feet with 2 + pitting edema; and mild pain when depressing skin.
Note: Assume history and examination is within normal limits if not listed.
Activity
Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Case 5
40-year-old Mr. Jason is complaining of right leg swelling, pain, erythema, and warmth for the past 2 days. The swelling started after he accidentally cut the front of his leg with a pocketknife while fishing.
Past medical history: hypertension.
Medications: amlodipine.
Social history: drinks four to five beers on the weekends and has smoked one or two cigarettes a day for the last 15 years (he states he is trying to quit).
Physical examination: temperature 100°F; pulse 88 beats per minute; respirations 18 per minute; blood pressure 140/92 mmHg; examination unremarkable except for edematous anterior right leg with open linear wound approximately 1-inch long; wound with scant purulent drainage; and area is warm and tender with blanching erythema that extends 3 inches around the wound.
Note: Assume history and examination is within normal limits if not listed.
Activity
Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?
Part 2:
Students are to complete Part 2
A 70-year-old woman was recently treated for pneumonia with antibiotics. After 1 week on antibiotics, she started developing severe diarrhea of 6–7 loose, watery stools per day. The diarrhea has been present for 3 days. She also has a decreased appetite, feels nauseous, and has not been drinking a lot of fluids. She feels very weak and dizzy. She lives alone, so she called 911 and was brought to the emergency department. She is diagnosed with diarrhea, presumptive Clostridium difficile.
Patient medical history: Clostridium difficile 2 years prior.
Physical examination: temperature 99.0°F; pulse 100 beats per minute; respirations 24 per minute; and blood pressure 90/50 mmHg, which dropped to 70/40 mmHg when seated. Examination unremarkable except for dry mucous membranes and generalized mild abdominal tenderness with palpation.
Laboratory findings reveal:
Chemistry panel: sodium 135 mEq/L; potassium 3.4 mEq/L; chloride 100 mmol/L; HCO3- 12 mEq/L; blood urea nitrogen 40 mg/dL.
Creatinine: 1.2 mg/dL.
ABG: pH 7.22, PaO2 85 mmHg, PaCO2 20 mmHg, HCO3- 12 mEq/L.
Activity
Analyze the ABG and determine the acid–base disturbance.
Calculate the compensation response and determine if it is appropriate.
This item is optional. Calculate and interpret the anion gap.
Discuss the diagnosis.
Develop a treatment plan.
