Question: Hi,

My mother age 60 yrs/F, has recently about 6 days ago developed pitting edema on both legs and both arms. She was given 1. Lasilactone 50 per day
2. syrup Septran 10 ml B.I.D
for last four days. The swelling has reduced in her left leg and arm; to some extent in her right leg and arm.
She has PEG feed tube (insertion date 26 Oct 2014) and urine catheter (insertion date 29 Oct 2014).

We did following test (Please find attached reports of the same)
1. Complete blood count
2. Serum Creatinine
3. Serum Protein
4. Urine Routine and Microscopy

Brief Medical History:
1. She had recent productive cough with white sputum which lasted for three weeks and now seems to be cured about a week ago(Earlier tab AZID, tab Altacef was given as treatment which didn't seems to work. But was later cured with tab Bromhexine and syrup Ascoril Expectorant)
2. Past history of high blood pressure which was controlled using medication; but for last two weeks it was low (Systolic 95-105/ Diastolic 65- 75 with high pulse rate 100 - 115 per min). At then, she was taking Telma 80 mg which was later changed to Aten - 25mg which has now substantially controlled her pressure. Currently it shows Systolic 100- 120/ Diastolic 68- 80 with normal pulse rate 75 - 85 per min.
3. Operated case of recurrent Glioblastoma L-Temporal lobe (3rd July 2014) with last chemo cycle PCV (Procarbazine, CCNU, Vincristien) on 02 Sept 2014 - 11 Sept 2014.

Can you please let me know the cause and further course of investigation/ medication, if any, required?

Hi,

Thanks for replying.
I forgot to add little bit to symptom list.
> She sometimes has little fever about 99 deg Celsius evening time when she wakes up from bed after afternoon sleeps which eventually goes off by itself in an hour or half.
> She also feels little bit shortness of breath when she sleeps on one side on bed. I initially thought it might be because of PEG feed tube. What might be reason for the same?

Can you please answer my following queries?

1) We are taking syrup R B Tone for Iron and Vit B12 -- 10 ml * two times per day. Can you please suggest any other medication which is better than syrup R B Tone and its dosage, in case if any (like is their any need of seprate Iron tablets)?

2) "Neutrophils are increased with mild increase in leukocyte count suggesting acute infection". Does this mean same infection as UTI or is something else in blood? Do we need to do any blood test for this or urine culture and sensitivity will do the needful?

3) For Hypoproteinemia we are taking Nutrilite protein powder 20 gm (containnig approx 16 gm protein) * two times per day = approx 32 gm protein per day. Please suggest if it is fine or we need to make any changes to this dosage and/or medication?

4) We are currently using syrup Septran 10 ml twice per day, till urine culture and sensitivity results. Please suggest whether we need to change it to nitrofurantoin or fluoroquinolones. In that case what are the names of medicine for drugs nitrofurantoin or fluoroquinolones with their appropriate dosage?

Hi,

Thanks once again for consultation.
1) Can you please elaborate the medical jargon "pull or anxiety" related to shortness of breath query? What will be the temporary solution for it?

2) She has been facing dry mouth and am not sure on this one also whether it is because of PEG feed tube (as all the feed intake is through tube and hence it keeps mouth dry) or because of shortness of breath which causes respiration through mouth or both? We were applying solution Liquipred (Prednisolone) to keep her mouth wet but later stopped it over the concern that Prednisolone comes under the category of corticosteroid. So please suggest some solution for dry mouth other than Liquipred.

3) Since pitting edema is caused by low protein diet, do we still need to continue with Lasilactone 50 per day till edema goes off completely or shall we stop it and continue on protein supplement which will take care of elimnating the remaining edema? Here I am puzzled over the concern that since Lasilactone requires minimal water and salt intake, are we unnecessarily restricting the nutrient (by taking Lascilactione) when the real problem is because of low protein?

4) Do low protein also implies there are also chances of other nutrients likely to be low? Which test should be conducted to asses it? And if it comes to be low then are there any energy supplements (like protein supplement) which should be given to patients?

5) Please let us know some good medication (other than creams Fusiderm and Betadine) and its method of application for bedsore to heal rapidly? Which beds are good in preventing bed sores -- water bed or air bed (I have heard somewhere that air beds are not as effective as water beds but the later can provoke cough)?

Hi,

Thanks a lot for consultation.
1) The mouth moisturizer toothette which you prescribed is not available in XXXXXXX medical stores. Please let me know some other brand?

2) I read somewhere on the internet that pitting edema can also be symptom of liver cirrhosis. Kindly let me know whether liver function test (lft) is required for this case?

3) I am puzzled over the opinion of our family physician that --- "The patient cannot be prescribed other antibiotics as the patient has already been given enough antibiotics during cough treatment (tab AZID followed by tab Altacef from 14th Oct 14 - 26th Oct 2014). So there are chances of getting harm by using other antibiotics. Septran is relatively much safe than more toxic antibiotics and since the infection is not substantial there is no need for other antibiotics"

I really suspect this claim because the patient even after using Septran 10ml B.I.D for about six days is still getting little fever (99 - 100) indicating possibility of infection present. Kindly also let us know how many days generally it takes to cure UTI?

4) Our family physician has prescribed ibuprofen to control mild fever instead of paracetamol with the intention that later may harm liver. But I have read somewhere that NSAID's can cause nephrotic syndrome. So which is better one?

Hi,

Thanks for replying.

1) We have now being applying glycerine on tongue and lips to keep her mouth wet. Please let us know if this approach is fine or not?

2) She still constantly gets little bit temperature about 99-100 deg. What might be cause/ test e.g. viral, bacterial likely for this other than PEG tube (My concern is that this temp wasn't there from the time PEG tube was inserted but was seen only from last few days)?

3) We have been using Lasilcatone 50 one per day for last 8 days and has seen some reduction in pitting edema. How long will it take to eliminate edema completely? Will you recommend any other medicine for faster recovery?

Hi,

Thanks again for replying.

1) Even though her edema has reduced (but hasn't completely eliminated yet), today we noticed some water droplets leaking through her left leg. What might be the cause/test/treatment for this?

Note: For last two days we are applying lukewarm mustard oil and hot water bag massage for edema control along with some moderate exercise.

2) Also she had hard black colored stool for last four days. I think it must be because of limited water intake requisite for Lasilactone. Please correct me if I am wrong.

Hi,

Thanks for replying.
Today i.e. 27th Nov 2014 we again did the test (The reports of the latest tests are appended with date "27_Nov_2014").
Earlier test was done on 14th Nov 2014 (i.e after gap of 13 days between the two tests).

In 13 days following medications were added
1) syrup R.B.Tone 10 ml * 2 times per day
2) tab Lasilactone 50 * 1 per day from 13th Nov 14 to 22nd Nov 14 (total 10 days)
tab Lasix 40 mg * 1 per day from 23rd Nov 14 to 27th Nov 2014 (total 5 days)
3) Protein powder 48 gm per day
4) Ibuprofen (sometimes only when temperature comes around 99 to < 100)

with additional mix veg soup(mostly spinach, tomato, beet with some XXXXXXX spices) etc and restricted salt, water in diet.

Can you please go through the reports and let us your opinion regarding cause/further investigation/ medication regarding the same?

Note: Today there was minute productive cough which was NOT apparent for almost last 20 days.

Hi,

Thanks for replying.
1) To add a little bit she is still having hard black stool. We have NOT done GI endoscopy because we thought black stool might be because of daily intake of iron (syrup R.B.Tone 30 ml + diet like spinach soup). From the attached reports do you think that there is possibility of upper GI bleeding as we can see that RBC have dropped from 3.46 to 2.57, Hemoglobin from 10.1 to 7.7, rise in platelet count in just 13 days? Can you also please elaborate phrase "packed red cells might be necessary especially below 6g%" correlation with anemia?

2)Yes her edema has reduced substantially. As she has been on diuretic for almost 14 days does it have any effect on cbc report

indicating progressing anemia?

3) I have read on the internet that ibuprofen(NSAID) sometimes causes upper GI bleeding. Is it correct else please let us know what will be substitute for it when temp reaches 99 to <100?

4) Also reports suggest that all the liver enzymes e.g. ALT, AST, Alkaline Phosphate, bilirubin are good, even total proteins and globulin have increased substantially except albumin whcih is still the same 2.01 causing a/g ratio decline to 0.7 from 0.8. Do this need to be concern or do we need to wait for more time(as its only 13 days from last test) for albumin to increase its level?

Hi,

Thanks for replying.

1) Our family doctor also suggested this as upper GI bleeding. He prescribed antacid syrup Gelusil and drug RCK 3 times * 3 days to stop bleeding (and to continue syrup R.B.Tone). He suggested blood transfusion is NOT required. But I am worried that anemia should not progress further. Please let me know whether this line of medicine treatment is capable of resolving the issue? Please let us know if you know any other better medicines for this.

2) We are currently using syrup R.B.Tone 10 ml morning and syrup Dexorange 10 ml night per day. What is the good dosage for patient having RBC count 2.57 and Hemoglobin count 7.7? Please let us know if any other medications e.g. Iron tablets, etc, in case if required.

3) As she is on continues diuretics for almost 15 days and therefore is some minor declination in electrolyte count (attached report "electrolyte_serum_first_pg_27_Nov_2014.jpg"). As we know that generally while on diuretics salt intake is restricted/limited. Please let us know whether using electrolyte powder will be helpful to elevate the count or will it interfere with the mechanism of diuretics?

Hi,

Thanks for replying.

1) Please let us know after how many days do we need to do reticulocyte count test after start of the medicinal treatment (v.i.z gelusil and proton pump inhibitors) for upper gi bleeding ? Do any other test e.g. stool test, other blood test is required in this case?

2) I remember around one month ago when she was having cough (she had white productive cough four weeks ago which does NOT seems to be present for last 20 days, except two days back which got cured overnight with Tab Bromhexine), at one night when she was sleeping on one side she expelled some white sputum through mouth and later after few hours some brownish fluid along with sputum. We thought it might be undigested feed that we gave to her through PEG tube since it resembled in color with feed. But such thing happened only once (on 29th Oct 14) and never before and again. Black hard stool started appearing after approx 20 days gap from that incidence i.e from 18th or 19th Nov 14 till now. Do this brownish thing with sputum has any link with upper gi bleeding?

3) Also I have read on internet that some bacterial strain 'H pylori' can cause upper gi bleeding. Can this past cough (even though it was white which is considered non infectious), little bit temp (99 to <100), upper gi bleeding has somewhere the cause in H Pylori? Please let me know in case, if any test is required for H pylori or we can rule out this one?

4) For last two days after getting out of bed from noon sleep she had temp 100.2 deg which drops slowly on its own WITHOUT medication. Even though the temp drops slowly which takes few hours to bring temp to normal, there exist some inflammation and restlessness in that period. So should we use paracetamol 1/4th tablet to alleviate inflammation as high dose is considered to cause liver problem or some other medication or NO medicine is needed in this case?

Hi,

Thanks for replying.
1) On 14th Oct 2014 Hemoglobin : 10.1 and RBC : 3.46
on 27th Oct 2014 Hemoglobin : 7.7 and RBC : 2.57.

Start of Iron treatment was from 14th Oct 14 to till date.
Start of upper gi bleeding treatment (RCK with antacid) was from 28th Oct 14 to till date.

From last two days the hard black stool has changed its form to grey color paste.
Does this color and form change indicate anything related to bleeding?
Is it the right time to do tests like cbc, reticulocyte count to check for the same? Will Prothrombin time test will be helpful in diagonisng in this case?

2) Since for last two days she some productive cough. My concern is regarding giving cold sponge bath which I suspect that it might increase her cough and therefore can you please let me know some another alternative for paracetamol and ibuprofen or it would be fine to use cold sponge bath?

Hi,

Thanks for replying.

To update her edema has dropped substantially but breathlessness (which I think must be because of cough) appeared two days ago.

1) Yes, you seems to be correct that diet was little low in fiber (as for last few days we have given some limited fruits and vegetables due to concern of cough).

Yesterday her stool was hard grey with some mucus so after that we have now started using Nutrilite soluble fiber powder supplement. I have read that RDA for 60 yrs sedentary female is 19 gm /day. We are giving 7.5 gm * 2 = 15 gm/day. Do you think the dosage we are giving is good enough and should continue it?



2) After her second surgery she has some little declination in cognitive ability and therefore she is not able to cough out sputum from mouth on her own. Earlier this seems to be the reason when her cough was not getting relived even with using antibiotics. So we used Tab Bromhexine 8 mg * 3 times per day and syrup Ascoril Expectorant 5 mg * 3-4 times per day, which made sputum less vicious and got expelled from mouth when she was sleeping on one side. Surprisingly this simple thing cured her cough two times within no time.
Now this time we have been using Bromhexine and Ascoril Expect for last five- days but are not getting intended results as earlier. Earlier and now both times cough is white productive one. Do you know any other good medicines/ expectorants or should we continue with the same?

We have ruled out using the option of nebulizer as she may not able to use it appropriately and suction machine as it might cause harm to esophagus.


3) Today when I was cleansing her nasal passage debris due to congestion with tweezers there appeared some tiny injury while cleansing. I think that tweezers must have wounded nasal passage. It was very minute. Then I cleansed it with water and now it is not apparent. Should I apply some medication like neosporin powder or betadine soln or any other cream.

Hi,

Thanks for replying.

1) From last night she started developing symptom of 'breathing with hiccup like sound' (note: it is not hiccups but while breathing it sound like hiccup) which is always continuous. We initially thought that some phlegm might have trapped in her throat and thus causing disturbing breathing but later found that it was continuous from last night till today and is haven't gone yet. Note that she still has white sputum cough. What can be cause for this one? Note that we changed feed tube one day before the incident so I am little worried that feed tube insertion might have created some issues. Also note that my mother has nasal feed tube (earlier in this thread I was wrongly referring it as PEG tube. Sorry for confusion).

2) We have started fiber supplement. Stool color is still dark gray. Today on 11 Dec 2014 we did cbc (please find reports attached "cbc_11_Dec_2014.jpg"). As it can be compared from two reports ("cbc_27_Nov_2014.jpg" with "cbc_11_Dec_2014.jpg") PCV increased from 22.9 to 25.6, RBC have increased from 2.57 to 2.79 but surprisingly Hemoglobin decreased from 7.7 to 7.3 (Hb, MCV and MCH). I have heard that RBC and Hb are interdependent and follow similar trend. We were even giving iron supplement viz syrup Dexorange having 32 mg * 2 times a day = approx 65 - 70 mg a day for last 25 days. How can this happen? Should we increase iron intake dosage or bleeding is still there or should we still give time for Hb to increase or is it related to something else?

Hi,

Thanks for replying.

Update:
Stool color is changing towards brown.

1) Following medications were added from 27th Nov 2014

Calcium supplement 800 mg per day ----> was added to compensate for Ca deficiency (Ca level was 7.7)
syrup Gelusil 10ml * 2 times a day ----> was added to reduce acid reflux but bleeding now seems to be stopped

As calcium and antacid can potentially hinder absorption of iron and hence I think it might be one of the reason for less rapid Hb growth.

Please let me know if following 1) to 8) dosage are adequate?

Ca and antacids are reduced as follows

1) Calcium supplement -- 500 mg per day
2) syrup Gelusil -- 5 ml one time at night to prevent acidity.

Along with this Vit D3, K2 for better absorption of Calcium in bones

3) Vitamin D3 (cholecaliferaol) -- 2000 IU per day
4) Vitamin K2 -- 100 mcg per day

Also anemia is caused by other nutrient deficiency along with Iron like Vit B12 and folic acid, please let me know if following dosage are correct

5) Iron -- 100 mg per day
6) Vit b12 -- 1.5 mg per day
7) Folic acid -- 1.5 mg per day
8) Vit C -- 300 mg per day for better absorption of iron


2) The hiccup breathing sound went away next morning but her respiratory rate is almost 32 breaths per min. I am not sure whether respiratory rate of 32 breathes per min is because of cough congestion (it seems to be the prominent reasons as it from the time of cough) or low Hb count or little edema that is left or nasal feed tube or something else.

We have started using Nebulizer. Medicine used for cough decongestion in Nebulizer is

Levonin 0.31 mg * 2 repsules = 0.62 mg * 2 times per day

Please let me know if Levonin along with its dosage is fine or we should use other medicine/ inhalation solvent like normal saline. The only concern is that she cannot voluntarily expel sputum through mouth and hence we are expecting sputum to expel on own like through stool or while sleeping. Please let me know if you know any other good technique for this e.g. bulb aspirator (which is used for children). We avoid using suction machine as it can make throat injury.