Lower extremity edema, edema, weight gain

61 year old white female complains of a 3-month history of lower extremity edema, a 10-15 pound weight gain, facial edema, and bilateral hand edema. In addition, she complains of severe fatigue, dyspnea on exertion,   lower extremity weakness,  and abdominal bloating. 

She underwent a right total knee replacement for degenerative joint disease in Feb 2004, 3 months prior to visit.    There were no complications.

Her doctor started her on hydrochlorothiazide/triamterene without improvement in her symptoms

She went to an emergency room 1 week prior to her visit for worsening shortness of breath.

The following tests were normal: CBC, Chemistry profile, CPK, CXR, and BNP. 

1. Ramipril 10 mg po qd
2. Montelukast 10 mg po qd
3. Fexofenadine 180 mg po qd
4. Tomoxifen 20 mg po qd.
   

1. Hypertension
2. Breast cancer (intraductal) ,  node negative treated with lumpectomy and radiation 2002
3. DJD

1. Right TKR 2/2004
2. Right breast lumpectomy 2002
3. Cholecystecomy

Positive for polyuria and polydipsia with a dry mouth

Negative for chest pain, pnd,orthopnea.

Negative for cough or wheezing. 

1. VS:           BP:  140/ 80  P: 80   Respirations:  16   Temperature: 98.8  Weight: 159 pounds
2. GENERAL  well-developed, well-nourished, well-groomed with normal habitus, no deformity
3. HEENT: Moderate flushed facies with some periorbital edema, otherwise normal
4. NECK:  *no JVD, no thyromegaly
5. HEART: *PMI non-displaced, regular, S1 S2 normal, no S3, S4, murmur, click, or rub.  
6. LUNGS:  clear to percussion and auscultation
7. BREAST: breast without skin lesion, discoloration, mass- right breast lumpectomy scar
8. ABDOMEN:  soft, nontender, no hepatomegaly, no slpenomegaly
9. EXTREMITIES: bilateral lower extremity swelling of feet and ankles, left greater than right, knee incision on left well healed.  Swelling both hands,
10. NEUROLOGICAL: alert and oriented, CN 2-12 intact, motor, sensory, reflexes, cerebellar intact
11. PELVIC : bimanual exam - no mass appreciated
12. RECTAL:nontender without mass; stool brown and Hemoccult negative

1. Diffuse peripheral edema with shortness of breath and no heart failure. 
   • R/O DVT – would not cause facial nor hand swelling, but in view of leg findings and dyspnea, must rule this out as she is s/p TKR. - Venous Doppler
   • R/O Hypothyroidism - TSH
   • R/O Nephotic Syndorme - UA
   • No evidence of Right heart failure - no JVD, hepatomegaly -nlCXR
   • No evidence of hepatic disease -normal coags and lft's
   • Drug - edema has been associated with montelukast as well as abdominal bloating - will consider stopping it.  She has stopped the nsaid that could also result in edema.
   • Inflammatory/Immune - check ESR, CRP - doubt
2. Hyperglycemia – check fasting and 2 hour post prandiol.  Also check HgBA1C
3. H/O Breast Ca - intraductal - treated with lumpectomy and radiation; node negative - on tomoxifen for 2 years –negative mammogram 1 month prior to visit -  refer to oncologist
4. The patient returned for follow up in 1 week. 

Because of the low TSH and borderline thyroid functions, an MRI was ordered.  Her MRI did demonstrate scattered lacunar infarcts bilaterally.  The pituitary gland was normal as was the hypothalamus and the stalk.   

A diagnostic procedure was done and a diagnosis was made.