75 yr old female with pedal edema and resting tremors

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS TAKEN FROM BOTH PATIENT AND ATTENDERS 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS TAKEN FROM BOTH PATIENT AND ATTENDERS 

A 75 yr old female was brought to opd with chief complaints of 

Pedal edema since 1 year

Resting tremors since 1 year

HISTORY OF PRESENT ILLNESS

She was apparently alright 7 years ago when she was diagnosed with hypertension and was started on Tab Amlodipine 5mg + Tab Atenolol 50 mg. She has been on regular medication since then.

1 year back she developed pedal edema extending till the knees, insidious onset, gradually progressive, pitting type.

She also developed involuntary movements of right upper limb at rest which were insidious onset, gradually progressive and no aggrevating and relieving factors, 2 months later she developed involuntary movements of left upper limb also.This has been progressing and she is unable to do her regular activities.

Past history

No history of diabetes, asthma, epilepsy,CAD ,CVA.

Personal history

Appetite : reduced

Diet :mixed

Addictions:  stopped talking alcohol since 3 months

Tobacco chewing stopped 3 months ago

General physical examination:

Patient is conscious, cooperative, Oriented to Time place and person. 

Built: thin

Posture

 Gait

gait video

Tremors

pill rolling type of tremors

Vitals:

Pulse 80bpm

 Blood pressure 110/70mmHg

 Respiration 17cpm

Temperature. 98.7F

Pallor present 

Pedal edema present

No Icterus Cyanosis Clubbing and lymphadenolathy

Systemic examination.: 

CNS examination: 

Higher mental function examination

Intact

speech : slow 

Behavior : normal 

Memory : intact 

CRANIAL NERVE EXAMINATION:

Normal

MOTOR EXAMINATION: Right                  Left

                                         UL LL                      UL LL

   BULK                            N N                          N N

   TONE                        Rigidity N                   N N

Cogwheel type of rigidity in right upper limb

   POWER                       5/5 5/5              5/5 5/5       

   SUPERFICIAL REFLEXES:

   CORNEAL.                          present   present      

   CONJUNCTIVAL                 present present

 

   PLANTAR                        N                 N

   DEEP TENDON REFLEXES:

   BICEPS                              2+.                 2+

   TRICEPS                           2+.                   2+

 SUPINATOR.                       2+.                    2+

   KNEE                                 2+.                     2+

  ANKLE                               2+.                     2+

SENSORY EXAMINATION:  

Normal

CEREBELLAR EXAMINATION

Normal 

SIGNS OF MENINGEAL IRRITATION: absent 

Cerebellar functions 

Normal

RESPIRATORY SYSTEM:

-Bilateral air entry present 

-Normal vesicular breath sounds heard , 

CARDIO VASCULAR EXAMINATION

-S1 S2 heard 

-No murmurs 

Provisional diagnosis

Parkinson's disease and pedal edema secondary to usage of Amlodipine.

Investigations

Discussion 

Role of long term usage of CCBS and pedal edema

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383103/

This study concludes that a significant number of the patient under antihypertensive medication developed dose-dependent pedal edema. Vasodilatory edema in this study was associated with the presence of other comorbidities, amlodipine dose, and duration, while age, gender, type of amlodipine, and concurrent use of ACEIs/ARBs were not associated. With comorbidities, longer duration, and a higher dose of amlodipine, likelihood of pedal edema goes up. This article adds the prevalence of pedal edema in hypertensive individuals under amlodipine and relation between pedal edema and other variables