Concluded Case

44 yr old lady ,not a k/c/o DM/HT/Dyslipidemia c/o dyspnoea on exertion for the past 3 yrs along with 10% weight gain. On examination bilateral pitting pedal edema present more so on the right leg (photo attached) vitals are stable and all the systemic examinations normal. Also attaching the photo of her dry,coarse skin,mostly due to hypothyroidism P.s:Can pedal edema be severe enough to cause medial deviation of the toes??(photo attached) If not what are the reasons for it??

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Dear Vaibhav, Good morning dear warm regards to you. Clinically this seems to be a case of 1) SOB, Dyspnoea on exertion R/O CCF CRF CAD Pulmonary pathology. 2) Hallux Varus Very common like the incidence of HV in T2DM is around 40%. So first R/O T2DM. 3) Pitting oedema is unusual in Hypothyroidism, usually it's non putting in nature. Still then you have to R/O Hypothyroidism HTN Dyslipidemia Anaemia. Hallux varus may be some times congenital in origin too. RA also should be ruled out. Order the following investigations please. FPG 2 Hr PG HbA1c CBP Thyroid profile Lipid profile RFT ECG 2D Echo X Ray Both feet AP & Lateral. Treat as per the diagnosis. The reasons for the foot deformity is 1) Neuropathy 2) Arthropathy. Thanks again dear Vaibhav for allowing me to answer your question.

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Dear Vaibhav, Good morning dear warm regards to you. Clinically this seems to be a case of 1) SOB, Dyspnoea on exertion R/O CCF CRF CAD Pulmonary pathology. 2) Hallux Varus Very common like the incidence of HV in T2DM is around 40%. So first R/O T2DM. 3) Pitting oedema is unusual in Hypothyroidism, usually it's non putting in nature. Still then you have to R/O Hypothyroidism HTN Dyslipidemia Anaemia. Hallux varus may be some times congenital in origin too. RA also should be ruled out. Order the following investigations please. FPG 2 Hr PG HbA1c CBP Thyroid profile Lipid profile RFT ECG 2D Echo X Ray Both feet AP & Lateral. Treat as per the diagnosis. The reasons for the foot deformity is 1) Neuropathy 2) Arthropathy. Thanks again dear Vaibhav for allowing me to answer your question.

Thanks a lot for your elaborate explanation Sir.
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D/D:-1-simple hyperventilation due to perimenopausal obesity.2-Anaemia with hypoproteinemia3-Mitral stenosis4-chronic bronchitis with bronchial asthma. 5-short stature 6-any spinal deformity like kyphoscoliosis.medial deviation of toes appears to be congenital Hallus versus.

HV developed only 3 yrs back Sir along with pedal edema.
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Needs to be investigated more for foot deformity along with hypothyroidism. CBC,ESR,RA test, CRP,Anti CCP,ANA,Vit D3,Vit.B12,Xray both feet AP n LAT. I think hypothyroidism has no connection with foot deformities.

Excellent descriptive case analysis by Dr.K.Mohan...Thanks sir.Your excellent work motivates us to excel in our field.
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Can be a case of Malabsorption causing vitamin A and D deficiency that may attribute to dry coarse skin and deformities of bones from osteomalacia. Also it may cause protein loss which may present as peripheral edema. Serum and urine proteins need to be checked with fecal examination. Consider ruling out cardiovascular renal and hepatic causes of peripheral edema.

Edema may be pitting early on in cases of hypothyroidism as well as any lymphatic obstruction.
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A 40years diabetic pt. having brain infarct with Rt sided facial palsy and Lt sided limb palsy now having headache. He takes analgesic in overdose several times but not releived. Sodium was 176 which corrected to 150. Previous history of hyponatremia episode. Headache Not cured by pregabalin.what to do now? Pt. on insulin

Dear Suraj, Take MRI or CT Brain first. R/O sinusitis too. Try Tab Amitriptyline 10 mg bed time. Cross consultation with Neuro Physician. Thanks again.
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@but we should also think about over weight and peri menopausal osteoporosis , dvt , hypoprotienemia. And ?steroid induce ......sir

Absolutely correct dear
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Anasarca investigation CBC ESR urine rt serum creatinine tsh serum protein xray chest ECG Doppler venous Doppler lower limb skin dry may be hypothyroidism separation of finger find out cause

Obesity.? Hypothyroidism.? Anemia.

Any reasons for the toe deformity that developed in the last 3 yrs Sir?
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generalised edema with dyspnoea is probably volume overload in ARF due to ischemia in cardiac or renal vessel croncally.better to go for stress test and coronary angiography.start treatment of volume overload and restrict diet ,review for HbA1c.

I agree with Dr.K.Mohan

Thanks again dear Umesh
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