Story of a 70 year old Lady with Labored Breathing

 

 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 12^th 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 12^th 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 ( 7^th 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 9^th 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

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 13^th 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 5^th 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 5^th Intercostal Space.

Parasternal Heave : Present

Palpated at 2^nd 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

 

 

 INVESTIGATIONS :

BLOOD WORK :

Evidences

NOTE : TROPONIN I : 69.7 Pg/ml

RADIOLOGICAL IMAGING :

Chest Xray taken on 12.6.22

Chest Xray taken on 13.6.22

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A 30 year old female follow up patient with Cough & Dyspnea

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 and I shall be presenting this case for my Prefinal Practical Examintation. ( 30th March 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.Simran Ma'am ( Intern ) , Dr.Nikitha Ma'am ( Intern ) , Dr. Sai Charan Sir ( Resident ,General Medicine )

for helping me ,and guiding me about the case, when the patient came to us 2 months back and also now.

I have taken certain inputs from the elog about this same patient which had been prepared in the past ( link attached herein )

The link to a e log made by me about the same patient has also been attached below.

https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html

http://nikitha0510.blogspot.com/2022/03/dermatomyositis.html

https://drsaranyaroshni.blogspot.com/2022/01/29-year-old-lady-with-joint-pain-and.html

INTRODUCTION :

 Here we shall discuss about a patient who is a 30 year old lady hailing from  a village in the Southern part of India .

TIMELINE OF EVENTS  : 

For the previous sequence of events in the patient please refer to the blog links shared above.

PRESENT COMPLAINTS: 

March 15,2022

30 years old female homemaker by occupation was admitted to the General Medicine department with the 

CHIEF COMPLAINTS OF : 

       Cough , dyspnea since the past 4 days , got aggravated the night before.

High grade fever since 1 day.

     - B/L joint pains  associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days

-  

HISTORY OF PRESENTING ILLNESS : 

Patient was apparently asymptomatic 12  months ago. 

 Then she developed symmetrical b/l joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg 

Associated with morning stiffness.

Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 

C/O generalised pain.

C/O Difficulty in walking.

C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, 

C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

C/O vaginal discharge since 10 months. It was initially curdy white which later changed to watery discharge. Associated with itching. 

C/O weight loss of 4 kg over the last 10 months.

C/O oral ulcers and genital ulcers since 10 months.

-C/O Dyspnea on exertion ( MMRC- 3), gradually progressive since 6 months.

-she visited many local RMPs,received pain killers  as there is no improvement, she visited our Healthcare institution two months back .

DAILY ROUTINE OF THE PATIENT :

The patient lives in a family of 3 ..(of late the family has expanded) which constitutes her husband ,her mother in law and herself . They follow Islam.

A usual day in her life :

4.40 am : wakes up and bathes

5.00 am : Prayer 

 5.15 am : She doesn't sleep but lies on her bed and rests for another one or two hours since the work load is not enough in the household to begin her chores at 5 am itself

7.30 am : washes dishes from the last day, washes clothes,  makes the morning tea for herself and her family members

9.00am : gets food ready for her husband who goes out for work after breakfast 

9.30 am : Serves breakfast for her mother in law and herself

Rests for a while

11.00 am : Prepares for the day's cooking

Rests for a while

12.00 noon : cooks for the day

1.00 pm : Serves lunch for her husband who comes back during afternoon 

2.00 pm : Serves lunch for her mother in law and herself

3.00 pm : Rests 

4.00 pm : Prayer

5.00 pm : Makes tea for everyone in the house 

In the evening mostly all of them sit down and watch television 

7.00 pm : Preparations for dinner

8.30 pm : Serves dinner for the family and then for herself

10.00 pm : Sleeps

How the Disease affected and changed her daily life 

The disease manifested  almost around January last year when she began having joint pains, 

At the level of her daily life ,she expresses she began feeling tired and fatigued very easily

Where by after very short spans of work or chores she felt like lying down and taking some rest before the next work , 

Whenever she did a little bit of work , her joints seemed to become " tight " and painful .

The Lassitude was to an extent so much so that she yearned that there was someone who would get everything ready for her and get it for her at bed itself such that she wouldn't have to get up.

Please note : The words have been put just as expressed by the patient such that the intensity and nature of her problem is interpreted better .

NOTE :  THIS E LOG SHALL BE PREDOMINANTLY PICTURE BASED .

Menstrual h/o:   Age of Menarche : 11 years

                Bleeds for 3 days in a 28 cycle,  regular , no pains, no passage of  clots.

Marital h/o:  Marital Life - 14 years, Non consanginous marriage 

                 Primary infertility (Nulligravida) 

Has recently adopted a girl from her sister-in-law. 

Family h/o:  No similar complaints in the family 

A quick glimpse of the findings of Dermatomyositis

 Treatment given in January 2022 : 

And 1.tab.wysolone 50mg po od

2.syp.mucaine 10ml/po/tid

3.tab.ultracet 1/2 po/QIT

4.candid cream for L/A is advised

Patient was referred to other health centre for muscle biopsy.

Patient went to health centre,her ANTI NUCLEAR ANTIBODY IMMUNOFLUOTESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA,histones.

HRCT WAS DONE ON 21/1/22

IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular distribution-s/o pneumonitis .Corads-4

She didn't undergo muscle biopsy as the doctors there advised it is not necessary 

THEY PRESCRIBED:

1.TAB.CALTEN

2.TAB.AUGMENTIN

3.TAB.NAPROXEN SODIUM

4.TAB.FOLVITE

5.CANDID CREAM

6.TAB.WYSOLONE

7.TAB.ESOMEPRAZOLE

8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.

After presentation in March 2022

Note :  Presence of increased facial hair in male pattern since 1 month.

Loss of hair. Aggravated.

Diagnosed with hypertension and Diabetes Mellitus.

Fever Charting

Persistent fever spikes 

General physical examination : 

Respiratory system examination

Inspection 

Symmetrical chest

Decreased air entry on right side

V shaped line seen below the neck 

Palpation 

Tactile vocal fremitus increased In lower part of right lung 

Percussion 

Dullness heard over right infrascapular,right  inframammary areas other areas are resonant

Auscultation 

Normal vesicular breath sounds heard 

Decreased air entry in right infrascapular ,right mammary and inframammary areas

Chest xrays 

JANUARY 2022 : 

MARCH 2022 : 

LOWER LOBES CONSOLIDATED.

Sputum culture : 

Since patient was having cough with sputum which was moderate in amount and whitish yellow in colour, sputum was sent for culture

Which showed 

Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species 

PROVISIONAL DIAGNOSIS DERMATOMYOSITIS FLARE UP WITH BILATERAL LOWER LOBE CONSOLIDATION & PULMONARY NOCARDIOSIS..

Sensitive antibiotics were started but suboptimal response was obtained hence a doubt was raised if the Nocardia was cultured due to some contamination of the plates , and hence BRONCHOALVEOLAR LAVAGE was done.

Culture reports from the same are still awaited.

LINK TO THE VIDEO OF THE PROCEDURE : 

https://youtu.be/Q4L1HcPtI9o

29.03.2022

Primary impression: 

Department of Microbiology

thin, long, slender AFB resembling Nocardia seen under microscope from sample of both lungs. Final report is to be awaited.

Even BAL fluid gram stain and zn stain revealed Nocardia in BAL sample of both the lungs (Rt > Lt

 Department of Pulmonology  :

Thick secretions noted while performing the procedure.

 

REVIEW OF LITERATURE

 :  https://pubmed.ncbi.nlm.nih.gov/16224246/

( interstitial lung disease vs. Lung complications in immunocompromised patient under treatment )

https://www.dovepress.com/clinical-features-of-pulmonary-nocardiosis-in-patients-with-different--peer-reviewed-fulltext-article-IDR

( incidence of pulmonary nocardiosis in patients with immune compromise )

A 78 year old lady with skin manifestations and jaundice

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 .

 

 DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Introduction :

Chief Complaints:

The patient being discussed here is a 78 year old lady hailing from the eastern part of India , who presented with the complaints of itching all over her body since 6 months and jaundice since 15 days.

History of presenting illness : 

The patient was apparently asymptomatic 6 months ago when she experienced itching all over her body which was insidious in onset and kept increasing gradually , It began on the anterior aspect of the forearm and then kept spreading.

It is also understood that since the itching over her skin began, over the time ,her skin became darker than it was previously.

It was also noted by her family that her appetite had become less and that she had lost some weight as well.

Due to all these findings, 15 days back,  on consultation with the local physician, some blood works were done and the Liver function test values were found to be deranged.

Daily Routine : 

Even at the age of 78 years , the patient as described by her son is extremely active throughout the day and prefers herself to be self sufficient in all her daily chores.

She gets up in the morning at 5 am ,freshens up, and does pranayaam for 1 hour , next she reads some Holy scriptures for 1 hour , after which she consumes a cup of tea , 

She again engages in Puja related work for another 2 hours after that , and then at around 10 o'clock has breakfast .

The time from breakfast to lunch at around 1.00 pm is spent differently on different days, on sp.e days she reads the newspaper, or engages in conversations with her neighbours,in some other days she goes out and completes some small chores nearby. 

After lunch she takes some rest .

In the evening she spends time talking to her family, or watches the television

Has dinner at 9.00pm and sleeps by 10.00 pm

Note : She is a hypertensive on medications since 30 years.

Notes about the patient : 

Ultrasound Report : 

BLOOD INVESTIGATIONS: 

Grossly deranged liver function test panel : 

Ct scan report : 

Impression : Periampullary mass

? Periampullary Carcinoma

Enlarged lymph nodes around 2nd part of duodenum

Porcelain Gall bladder.

A 32 year old man with multisystem pathologies

 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 .

 

 DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Acknowledgment :

https://drkulkarnimd.blogspot.com/2022/02/30m-with-post-renal-transplantation.html?m=1

I have taken certain inputs from the elog about this same patient which had been prepared in the past ( link given above )

INTRODUCTION :

 Here we shall discuss about a patient who is a 32 year old man hailing from Eastern part of India .

TIMELINE OF EVENTS : 

 Complaints present in the patient as of today ( 27th February 2022 )

Presently the patient does not have any symptom or  complaint,only that he is worried about his raised Serum creatinine

Daily Routine of The Patient : 

Back in 2019 : 

He used to work as a courier service delivery agent.

His day used to begin at around 7 am .After waking up,he used to freshen up ,complete his breakfast and leave for work at 9 am..he used to deliver the packages till 1 pm and get back home for lunch

After lunch he would again resume his work till 5 pm and return home, the evenings he would usually be at his home itself,watch some television, run errands for the family or his sick father for that matter before dinner and then sleep by 12.00am

ROUTINE NOW :

Since November 2021

After around 6 months of his transplantation, he joined a nearby cyber Cafe as the person in charge for doing the works like.. filling up online forms, getting printouts for the customers.

He chose the work place very near to his house such that the physical exertion in travel would not be too much, 

He gets up in the morning at around 7.30am, freshens up, takes some light breakfast and reaches his workplace by 9 am , he stays in the cyber Cafe till 12.30 pm, comes back home, has his lunch and takes some rest,  he gets back to work at 4.30 pm and wraps it up by 8.30 pm after which he returns home , He usually does not go outdoor anywhere else after returning  , he watches television with his mother and completes dinner , gets to sleep by 11pm

How the Disease deranged the daily life : 

From the timeline of events , we see that since 2016 he has been having some secluded events for which he had been receiving only symptomatic relief but there were no definitive investigations performed to derive the root cause 

 In 2019 , till the day he felt uneasy and vomited a lot amount of blood , he had been continuing his work as a delivery agent in the courier delivery service , that morning he had been feeling somewhat uneasy and had told his friend to accompany him on his bike which he used to take to work,  he also returned home slightly early due to his uneasiness 

Just before lunch , he complained to his mother of having headache and a weird sense of uneasiness which he couldn't explain, minutes after this he vomited dark tinged blood that was clotted , the amount was so much so that the mother had a syncopal attack after seeing it.

He had a hospital stay of 4 days after this and then he was sent home.

He took rest for about a week because he used to feel weak and then rejoined his work, Also at this time his father was hospitalized ,hence he had to do to and fro journeys from the hospital to their house which was around 4 hours in local trains 

He also couldn't leave his job because they were in huge monetary constraints and needed every penny together to cater for the medical needs of his father

Although when I ask him now he admits feeling weak all through the day in those times but still continued work.

But it was October 2019 , when he felt severely ill with complaints of shortness of breath, chest pain and grossly deranged renal parameters for which he stayed at a hospital for 1 week and then got admitted in our hospital. 

He began getting hemodialysed.

Since then , his daily work life routine came to a stop, his disease made him stop his work all together .

A middle aged man with a progressive disease

 I am Saranya ,a final year MBBS student.

Greetings to all my readers;

In this elog I shall document about one of my patients who I came across in order to document about his complaints and the related history behind it

Please note : Care has been taken to hide personal details of the patient in order to safeguard his privacy

These findings have been obtained via tele communication with the patient , and the patient has been adequately informed to keep his local physician in loop in case of any medical emergency.

Disclaimer : The written record might seem lengthy but I hope you to be patient and read through the history given in the images below 👍