I am Saranya ,a final year
MBBS student.
Greetings to all my readers;
This is an elog documenting the
patients that I witness during my Clinical Postings to enforce a greater
patient centered learning
I will be presenting this case report
as my long case for my MBBS Final year Practical Examinations and viva voce scheduled to be held on 14th
June 2022
DEIDENTIFICATION :
The privacy of the
patient is being entirely conserved. No identifiers shall be
revealed through out the piece of work whatsoever.
CONSENT :
An informed consent has been taken from the patient in the presence of the family
attenders and other witnesses as well and the document has been conserved
securely for future references.
ACKNOWLEDGMENT
I
convey my regards to Dr. Sai Charan Sir
( Resident ,General Medicine ) and Dr.Vamshi Krishna sir ( Resident ,
Department of General Medicine ) for
guiding me regarding the case .
Documentation
:
is
being done on 12th of June 2022
(Updates
will be done later in the future with dates mentioned for the same.)
INTRODUCTION
:
My
patient is a 70 year old lady , resident
of a rural district of South India
CHIEF
COMPLAINTS :
Who
presented to our hospital ( shall be further referred to as HEALTHCARE CENTRE IV/
HC IV) on 12th June 2022 at 6.00pm to the casualty with complaints
of progressing shortness of breath since the last 5 days
HISTORY
OF PRESENTING ILLNESS :
Describing
in detail the events which led her to the present day diseased state.
TIMELINE
OF EVENTS :
The
patient was leading her life asymptomatic and without any health issues 6
years back when she developed Fever for which she visited a hospital (
HEALTHCARE CENTRE 1 /HC 1 ) where she was treated for her ailment and also some
routine investigations were ordered whereby she was diagnosed with Diabetes
Mellitus .
Oral
hypoglycemic drugs were prescribed to her and since then till date she has been
taking those medications with good compliance.
1
Month ago ( 7th May 2022 ) the patient developed
loose motions which was continuing for 2 days , and regarding this problem she
visited another health institution ( HEALTHCARE CENTRE II / HC II) where she
was given medications and a few blood investigation was done.
As
of 9th May 2022
Hemoglobin
: 6.6 g/dl
Serum
Creatinine : 1.8
6
Days ago,
She developed difficulty in breathing ,which
was progressive in nature and progressed from a Stage 3 in the starting days to
the present scenario wherein she is at Stage 4
She
developed edema of her foot, leg and it progressed onto the rest of her body
and face as well.
The
edema in her foot was so much so that she had to remove her toe rings (
ornaments ) which she never removed since her marriage.
She
also complains of vomiting since the past 3 days, which is watery in
consistency, without any bile stains ( asked the patient on the basis of colour
of the vomitus )
Due
to the problem of pedal Edema ( referred by the patient as ‘swelling of the
foot’ she was taken by her sons to another hospital ( HEALTHCARE CENTRE III /HC
III ) who referred them to our Institution ( HC IV )
Schematic
Representation of the Timeline of events of the Disease Process :
INSIGHT
ABOUT THE PATIENT :
(
BACKGROUND )
The
patient is a 70 year old who lives in her village house with her son and his wife , since she got married, she used to regularly work in farm,
work was related to the crops and also feeding animals in the farm.
She
has reduced her work in the farm since the past one year , but she enforces
upon the fact that she did not do so because of any health issue or any
inability or fatigue regarding the work , but the change was only because she
felt that there were other people who could take care of all the work in an
efficient manner and it could be done well without her being involved on a
daily basis.
HER
LIFE AT HOME:
The
patient used to take care of all the household chores for years together but
since her son got married and her wife became a part of the family, she has taken charge of most of the chores .
She
has thus retired from most of her duties
HER
DAILY ROUTINE :
(
A DAY IN HER LIFE )
· She
usually gets up early in the morning at around 5 am
· Freshens
up
· She
has tea
· Being
in a village ,She walks around in the nearby farms and fields
· On
some days, she still goes to her farm and checks upon the farm work
· She
has her breakfast at around 9 am
· After
which she completes any small household chores if there are any on that day.
· She
spends some time talking to the neighbours
· Lunch
is usually at around 1 pm
· After
which she Rests for about an hour
· In
the evening times she usually spends time by herself or with the family
· She
helps her daughter in law at times with some work
· She
takes dinner at around 8 pm and
· Goes
to bed.
HOW
THE DISEASE HAS AFFECTED HER LIFE AND HINDERED HER DAILY ROUTINE
The
patient is not being able to accept the sudden fall in the kind of daily life
she usually leads , she is used to do all her own work by herself and was doing
absolutely fine but suddenly since the past one week ,she feels all kinds of
problems have come up ,she is unable to do any kind of work, she feels dyspneic
at every moment , so much so that Presently she is not being able to breath
adequately even at complete rest.
This
sudden transition has taken a toll on the patient .
OTHER
EXISTING PROBLEMS IN THE PATIENT :
The
patient complains of Decreased urine since the past 3 days
She
does not complain of any
Burning
micturition
Sensation
of residual urine( incomplete passage of urine )
Discolouration
of urine/ ( to ask about hematuria)
Frothy
urine
No
fever.
OTHER
FINDINGS THROUGH HISTORY :
The
patient takes mixed diet but has been having decreased appetite since the past
one week.
She
gets adequate sleep
Bowel
movements are Normal
Decreased
urine output since the last couple of days.
She
does not smoke or consume alcohol
She
doesn’t have any known food or drug allergies
FAMILY
HISTORY : No similar complaints in near relatives .
GENERAL
PHYSICAL EXAMINATION :
I
have examined the patient after obtaining informed consent and providing
reassurance ,in the presence of a female attendant.
Examination
has been done under adequate lighting ,with appropriate exposure , in both
supine and sitting posture.
Privacy
of the patient has been secured.
Findings:
· The
patient is conscious, coherent,oriented to time,space and person , extremely cooperative despite the dyspnea.
· She
is moderately built and nourished
·
She has TRUNCAL OBESITY
· Patient
is having dyspnea even on Oxygen supplementation
·
She is unable to complete single
sentences without pausing for a breath
· Nail
and Foot Hygiene is poor.
· Pallor
Present
· Bilateral
Pedal Edema of pitting type Present.
https://youtu.be/gtuS3RNckY8
https://youtube.com/shorts/jPDxVKMo9SU?feature=share
· Facial
Edema Present
In
a nutshell
Anasarca
+
· No
cyanosis
· No
clubbing
· No
koilonychia
· No
generalised lymphadenopathy
JVP
raised
VITALS
:
( Documented on 13th June 2022 1pm
)
Body
Temperature: Afebrile
Pulse Rate : 90 bpm
Blood Pressure : 128/80 mm Hg
Position: supine
Respiratory
Rate : 28 cycles per minute
SYSTEMIC
EXAMINATION :
Cardiovascular
System :
Inspection
:
Precordium
:
No precordial bulges.
No
engorged veins.
No
scar/sinus.
Visible
pulsations : Pulmonary Artery pulsations.
No
epigastric pulsations.
Other
findings :
Patient
is using accessory muscles to breathe.
There
is hyperpigmentation in the sun exposed areas.
Apex
Beat : appears to be at the 5th Intercostal
Space 1cm lateral to midclavicular line.
Chest
wall Defects : None.
PALPATION
:
Inspectory
finding of Apical beat correlated on Palpation, can be localized 1cm lateral to
the midclavicular line in the 5th Intercostal Space.
Parasternal
Heave : Present
Palpated
at 2nd intercostal space.
PERCUSSION
:
Cardiac
Dullness :
AUSCULTATION
:
S1
,S2 heard.
Flow
murmur present.
Note
: Cardiac Wheezing +
Diffuse
crepitations in all the lung areas.
RESPIRATORY
SYSTEM EXAMINATION :
Positive
findings : Diffuse crepts in all lung areas.
CENTRAL
NERVOUS SYSTEM EXAMINATION :
Sensory
and motor functions are intact.
No
evidence of focal neurological deficits.
P/A
Examination :
Normal
Evidences
RADIOLOGICAL IMAGING :
Ecg :
Provisional Diagnosis : Case of Anemia ,Heart Failure ,with Acute Kidney Injury under evaluation ( ? secondary to Diabetes )
Treatment plan :
Inj. LASIX 40mg IV TID
-Inj HAI SC
-T. Nodosis 500mg PO BD
-T. Orofex XT PO BD
-T Shelcal 500mg PO OD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly
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