The puzzling edema solved

The answers, both on this blog and on twitter, showed great thought processes. Here is how I discussed it with my team, and the data we used. The patient had peripheral edema, but had a good oxygen saturation and no dyspnea. We had a previous echocardiogram that showed very mild pulmonary hypertension, so we did not believe that this was the reason for worsening edema. Next I asked for an albumin level, and it was 2.9 down from 3.9 two weeks earlier. Why would the albumin be so low? Low albumin must be: 1. Decreased protein intake 2. Decreased albumin production (i.e., cirrhosis) 3. Increased losses – either urine (nephrotic syndrome) or stool (protein losing enteropathy) The urinalysis showed no urinary protein. The patient had no evidence of cirrhosis. So I asked the team about the patient’s food intake. I went “old school” and asked for patient weights. The patient had lost 5 kg over the 2 weeks. At the bedside the patient looked and acted depressed. She said that she did not like the nursing home food and was not eating well. To confirm we checked a pre-albumin and it was significantly low. An echocardiogram showed that the LVEF had improved to normal! A CXR showed no pulmonary edema. Lower leg doppler studies showed no thrombosis. This rather straightforward problem shows students and residents how careful thinking can help direct us to the correct diagnosis. Diagnosis requires clear organized thinking. I hope this story is helpful to res...
Source: DB's Medical Rants - Category: Health Medicine and Bioethics Commentators Authors: Tags: Attending Rounds Source Type: blogs