75F HFrEF CKD HTN DM

 

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

HISTORY

A 75-year-old female was born and raised in a lower socio-economic family along with six siblings. Her education extended only to primary school, after which she discontinued her studies. At the age of 17, she married a non-consanguineous partner. She conceived a year after marriage but experienced a stillbirth. Two years later, she conceived again but had a miscarriage. Three years after that, she successfully gave birth to a healthy girl.

Twenty years ago, her husband died suddenly from cardiac arrest. Following his death, she moved in with her daughter. Six months after her husband’s passing, she developed hypertension, which was followed by diabetes three months later. Fifteen years ago, she lost her elder brother. Six years ago, she presented to our hospital with abdominal pain, nausea, vomiting, and loose stools, and was diagnosed with cholelithiasis, which was managed conservatively.

Two years ago, she experienced shortness of breath lasting ten minutes, and upon visiting our hospital, was diagnosed with heart failure and renal failure.

Patient complains of loss of appetite since 5 days

Associated with constipation

DAILY ROUTINE

6:30am wakes up

6:30-9:30am. Goes to washroom, wash utensils, prepares breakfast 

9:30-10am Breakfast

10:30am-12:30pm. Takes nap

12:30pm wakes up and have lunch, usually rice and curry

2-4:30pm: takes nap

4:30pm: does household chores like washing utensils, folding clothes, vegetable cutting

7:00-9:00pm watch TV serials

9:30pm- Dinner

10:30pm- Bed time

Abdominal girth : 90cms

Mid arm circumference L 26cms R 26cms

Hip circumference 97cms

Waist circumference 80cms

Total body Weight 47kgs

CHIEF COMPLAINTS:

A 75 YEARS OLD FEMALE CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 1 WEEK.

 

 

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET IN HYPOGASTRIUM TWISTING TYPEASSOCIATED WITH BLOATING OF ABDOMEN MORE AFTER EATING ASSOCIATED WITH NAUSEA.

No H/o cough, cold, burning micturition 

No H/o pedal edema, increased or decreased urine output

No H/o orthopnea, PND, palpitations

No H/o loose stools, nausea, vomitings

No h/o fever, headache , giddiness

VITALS 

Temp:98.6F

PR: 78bpm

RR:18cpm

BP:120/80mmhg

Spo2:98% at RA

GRBS:125mg/dl

Investigation

POST LUNCH BLOOD SUGAR27-05-2024 11:38:AM169 mg/dl140-0 mg/dl

BLOOD UREA 64 mg/dl

SERUM CREATININE 3.2 mg/dl

SERUM ELECTROLYTES (Na, K, C l) SODIUM139 mmol/L

POTASSIUM4.4 mmol/L

CHLORIDE102 mmol/L

LIVER FUNCTION TEST (LFT)

 Total Bilurubin0.67 mg/dl

Direct Bilurubin0.18mg/dl

SGOT(AST)10 IU/L

SGPT(ALT)10 IU/L

ALKALINE PHOSPHATASE218 IU/

TOTAL PROTEINS6.4 gm/dl

ALBUMIN3.69 gm/dl

A/G RATIO1.36

HBsAg-RAPID Negative 

Anti HCV Antibodies- Non Reactive 

COMPLETE URINE EXAMINATION (CUE) 27-05-2024 

COLOURPaleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN+++

SUGARNil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS4-5

EPITHELIAL CELLS3-4 REDBLOODCELLSNil 

HEMOGRAM :

HB - 8.2 GM/DL

TLC - 4900 CELLS / CUMM ;

N/L/E/M/B = 75/18/6/5/0 % 

PCV - 25.1 VOL %

MCV - 79.9 FL

 MCH - 26.1 PG

 MCHC -32.7 %

RBC - 3.14 MILLION/ CU MM 

PLATELET - 1.40LAKHS / CUMM

SMEAR : NORMOCYTIC NORMOCHROMIC 

CREAT CLEARENCE :10ML /MIN

eGFR: 15ML/MIN

USG WAS DONE ON: 27/5/24

IMPRESSION : GRADE 2 RPD CHANGES IN RIGHT KIDNEY GRADE 3 RPD CHANGES IN LEFT KIDNEY

BILATERAL RENAL CORTICAL CYSTS 2D ECHO WAS DONE ON: 27/5/24 EF:44%

FS:22%

MODERATE MR+ ,MILD AR+,TRIVIAL TR+ RWMA+ , RCA AND LAD HYPOKINESIA ; NOAS/MSMODERATE LV DYSFUNCTION+

GRADE 1 DIASTOLIC DYSFUNCTION+ ; NO PAH/PE/LV CLOT

DIAGNOSIS

HEART FAILURE WITH REDUCED EJECTION FRACTION

CHRONIC KIDNEY DISEASE

ANEMIA OF CHRONIC DISEASE

HYPERTENSION

DIABETES

TREATMENT 

1) INJ HAI SC/TID

2) TAB CINOD 10 MG PO/OD 1-0-1

3) TAB MET XL 12.5 MGPO/OD

4) TAB NODOSIS 500MG PO/OD

5) TAB ECOSPRIN 75 GOLD PO/HS 6)TAB DYTOR 5MG PO/BD

7) TAB PAN 40 MG PO/OD

8) TAB ONDANSETRON 4MG PO/TID

9) TAB BUSCOPAN 1 TAB PO/SOS

10) INJ EPO 4000 IU S/C TWICE WEEKLY

11) INJ ZOFER 4 MG /IV/SOS

12) TAB CILNIDIPINE 10 MGPO/OD

13) TAB METOPROLOL 12.5 MG PO/OD

14) TAB SODABICARBONATE 500MG PO/OD

Analysis

1. **Impact of Socio-Economic Background:**

   - The patient’s lower socio-economic status and limited education may have influenced her health literacy and access to healthcare, affecting her overall health outcomes.

2. **Reproductive Health Challenges:**

   - The patient's history of stillbirth and miscarriage, followed by a successful pregnancy, highlights potential reproductive health issues that may need careful monitoring and support.

3. **Effect of Bereavement on Health:**

   - The sudden death of her husband 20 years ago was followed by the onset of hypertension and diabetes, suggesting that significant emotional stress can contribute to the development of chronic conditions.

4. **Chronic Disease Management:**

   - The patient's history of hypertension, diabetes, heart failure, and renal failure indicates the complexity of managing multiple chronic conditions, especially in an elderly patient.

5. **Acute Health Episodes:**

   - Her diagnosis and conservative management of cholelithiasis six years ago, and more recent heart and renal failure, demonstrate the need for vigilant monitoring and timely intervention in elderly patients.

6. **Recent Symptoms:**

   - Current complaints of loss of appetite and constipation indicate potential new or worsening health issues that require further investigation and management.

**Outcome:**

The patient continues to experience complex health issues, highlighting the importance of comprehensive and continuous care, particularly in the context of her socio-economic background and multiple chronic conditions.

Case 11

### Thematic Analysis of the Case

#### 1. **Coding:**

   - **Chronic Illnesses:** Hypertension, diabetes mellitus, heart failure with reduced ejection fraction (HFrEF), chronic kidney disease (CKD), anemia of chronic disease.

   - **Acute Symptoms:** Abdominal pain (twisting type), bloating, nausea, constipation, loss of appetite.

#### 2. **Categorization:**

   - **Cardiometabolic Complications:** Hypertension, diabetes, and heart failure are interconnected, leading to reduced ejection fraction and worsening kidney function.

   - **Gastrointestinal Symptoms:** The patient's abdominal pain, bloating, and nausea are suggestive of a potential gastrointestinal issue exacerbated by her existing chronic conditions.

#### 3. **Theme Identification:**

   - **Compounding Chronic Conditions:** The patient’s long-standing hypertension and diabetes have progressed to multi-system involvement, particularly cardiac and renal dysfunction.

   - **Aging and Quality of Life:** Despite multiple health conditions, the patient maintains a structured daily routine, reflecting how aging impacts disease progression and lifestyle adaptation.

#### 4. **Theme Representation (Learning Points):**

   - **Chronic Disease Management:** Coordination of care for elderly patients with overlapping chronic conditions is crucial, particularly for managing heart failure and kidney disease.

   - **Impact of Chronic Illness on Lifestyle:** Elderly patients with chronic conditions often face challenges in maintaining daily routines, highlighting the need for individualized care plans focusing on improving quality of life.