75 year female born to a lower middle class family, normal delivery, milestones achieved normal. Educated till 7th standard and stopped thereafter as she has to travel to other town for high school and as it is not safer for girls to travel she discontinued her studies and started working in green fields.
She lost her mother at a very young age due to seizures . Her father bought a woman to home so her aunt adopted her 5 sisters and married them off. She was married at age of 10 but stayed at her mother’s home till she attained menstruation till age 12. During that period her aunts son used to often quarrel and let them out of their home and when they go back to their dad’s home her dad used to drink and drive them away from home. Patient had to face the wrath since childhood. After moving into mother in law home she used to go to work in fields and also look after household chores. She had two daughters and one son. 25 years ago she had generalised body swelling went to hospital and diagnosed with hypothyroidism, initially used 100mcg gradually tapered and now she is on tab thyronorm 50mcg since three years.Her husband died at age of 53 due to heartattack ,25 years ago . After the demise of her husband she took all the responsibilities upon her shoulders, started selling cotton and raised her three children. She had sleepless nights and started taking clonazepam 0.5mg initially she could sleep with 0.5mg but now she got tolerance to it and still has insomnia. 23 years ago she had neck pains and generalised weakness went to hospital and was diagnosed with hypertension. In second wave of covid she lost her elder son in law due to covid which broke her. Since then she started living with her elder daughter as support. Recently she married her grandson and moved back to her place and started living alone. Three years ago patient had knee pains went to local hospital and underwent TKR .Three years ago in a general checkup she was found to have heart block and advised angiogram after which she was started on oral antiplatelets since then. One year ago her daughter in law had her second pregnancy after 9 years, as the whole family was anticipating for son to continue the lineage , the mother had eclampsia and had to undergo emergency caesarean, baby died 10 mins after birth in our hospital. She cried sitting under tree for one whole month for the unfortunate events happened to her.
Since 4 years patient occasionally complains of multiple joint pains, symmetrically initially started in bilateral knees, now progressed to wrist elbow and metacarpals. She came to our op for general checkup.
Case History and Clinical Findings
CHIEF COMPLAINTS-
LOW BACKACHE SINCE 3 MONTHS
HOPI -
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS AGO , THEN SHE HAD H/O TRAUMA [ FALL FROM CHAIR ] ON LOWER BACK. SHE THEN HAD PAIN WHICH IS OF DRAGGING TYPE
, RADIATING TO BOTH LOWER LIMBS, MORE DURING WAKING UP AND RELIEVES TO SOME EXTENT AFTER WORKING AT HOME.
H/O RIGHT KNEE PAIN, B/L ELBOW PAIN, RIGHT WRIST PAIN. H/O SLEEPLESSNESS NO H/O FEVER,CHEST PAIN , SOB, PALPITATIONS, SWEATING,.
NO H/O LOSS OF APPETITE, CONSTIPATION, LOOSE STOOLS, HEAT OR COLD INTOLERANCE.
PAST HISTORY -
K/C/O HTN SINCE 5 YEARS ON TAB TELMA-H[40/12.5] PO OD
K/C/O HYPOTHYROIDISM SINCE 30 YEARS ON TAB THYRONORM 50mcg H/O LT TKR 3 YEARS BACK
K/C/O CAD SINCE 3 YEARS S/P CAG ON T.CCORDOGR EL AND T. ROSUVASTATIN 20 MG
HYSTERECTOMY 30 YEARS BACK
PATIENT IS C/C/C
NO PALLOR ,ICTERUS, CYANOSIS ,CLUBBING ,LYMPHADENOPATHY ,OEDEMA OF FEET
BP 120/70 MMHG
PR 82 BPM
RR 20 CPM
TEMPERATURE 96.8 F
CVS:S1S2 NO MURMUR
RS: BAE NVBS
PA ; SOFT NON TENDER
ORTHO REFERAL WAS DONE ON 10/05/24 I/V/O EDEMA OF LEFT KNEE POST TOTAL KNEE REPLACEMENT SURGERY.
DIAGNOSED : SUBCUTATNEOUS SWELLING OVER LEFT PROXIMAL LEG UNDER EVALUATION.
Investigations
RFT 08-05-2024 04:51:PM
UREA17 mg/dl50-17 mg/dl
CREATININE1.0 mg/dl1.2-0.6 mg/dl
URIC ACID3.8 mmol/L6-2.6 mmol/
CALCIUM10.0 mg/dl10.2-8.6 mg/dl
PHOSPHOROUS3.0 mg/dl4.5-2.5 mg/dl
SODIUM141 mmol/L145-136 mmol/L
POTASSIUM4.1 mmol/L.5.1-3.5 mmol/L.
CHLORIDE104 mmol/L98-107 mmol/L
LIVER FUNCTION TEST (LFT) 08-05-2024 04:51:PM
Total Bilurubin0.57 mg/dl1-0 mg/dl
Direct Bilurubin0.20mg/dl0.2-0.0 mg/dl
SGOT(AST)16 IU/L31-0 IU/L
SGPT(ALT)12 IU/L34-0 IU/L
ALKALINE PHOSPHATASE117 IU/L
TOTAL PROTEINS7.2 gm/dl8.3-6.4 gm/dl
ALBUMIN4.6 gm/dl4.6-3.2 gm/dl
A/G RATIO1.79
HBsAg-RAPID08-05-2024 04:51:PMNegative
Anti HCV Antibodies-RAPID08-05-2024 Non Reactive
COMPLETE URINE EXAMINATION (CUE) 08-05-2024 04:51:PM
COLOUR: Paleyellow
APPEARANCE: Clear
REACTION: Acidic
SP.GRAVITY:1.010
ALBUMIN: Nil
SUGAR: Nil
BILE SALTS: Nil
BILE PIGMENTS: Nil
PUS CELLS: 2-3
EPITHELIAL CELLS: 2-3
RED BLOODCELLS : Nil
T3, T4, TSH
T3. 1.12 ng/ml1.87-0.87 ng/ml
T4. 11.22 micro g/dl12.23-6.32 micro g/dl
HAEMOGLOBIN 12.7 G/DL
TOTAL COUNT 7000 CELLS /CU.MM
RBC - 4.31 MILLIONS / CU.MM
PLATELETS - 2.63 LAKHS /CU.MM
IMPRESSION - NORMOCYTIC NORMOCHROMIC PICTURE.
TOTAL CHOLESTEROL - 121 MG/DL
TRIGLYCERIDES 106 MG/DL
HDL - 34 MG/DL
LDL - 70 MG/DLVLDL - 21.2MG/DL
Treatment Given
TAB ULTRACET PO/OD
TAB PAN40 MG PO/OD
TAB TELMA-H 40/12.5MG PO/OD
TAB CLOPIDOGREL 75 MG PO/HS
TAB ROSUVASTATIN 10 MG PO/HS
TAB THYRONORM 50 mcG PO/OD
TAB SHELCAL-CT PO.OD
Advice at Discharge
TAB ULTRACET PO/OD X 5 DAYS
TAB TELMA-H 40/12.5MGPO/OD
TAB CLOPIDOGREL 75 MG PO/HS
TAB ROSUVASTATIN 10 MG PO/HS
TAB THYRONORM 50 mcG PO/OD
TAB SHELCAL-CTPO.OD X 15 DAYS
Learning Points
1. **Early Life Challenges:**
- The patient faced significant early life hardships, including the loss of her mother and instability at home, which likely influenced her resilience and coping mechanisms.
2. **Impact of Socio-Cultural Norms:**
- Discontinuation of education due to safety concerns and early marriage reflects the socio-cultural limitations impacting women's education and personal growth in her community.
3. **Chronic Disease Management:**
- Diagnosed with hypothyroidism 25 years ago, she has been on long-term medication, adjusting dosages over time. This illustrates the importance of continuous management and monitoring of chronic conditions.
4. **Stress and Mental Health:**
- The death of her husband, subsequent family responsibilities, and loss of close relatives have led to chronic insomnia, initially managed with clonazepam, but with tolerance developing over time. This highlights the need for holistic approaches in managing mental health.
5. **Multi-morbidity in Elderly:**
- Over the years, she has developed hypertension, undergone total knee replacement (TKR), and been diagnosed with a heart block, requiring ongoing medical care and medication. This underscores the complexity of managing multiple health issues in elderly patients.
6. **Emotional and Social Support:**
- The loss of her son-in-law during the COVID-19 pandemic and the tragic events surrounding her daughter-in-law's pregnancy have had a profound emotional impact, demonstrating the critical need for strong social and emotional support systems.
7. **Arthritis and Mobility:**
- The progression of multiple joint pains, initially in the knees and now affecting other joints, suggests a likely diagnosis of arthritis, requiring further evaluation and management to maintain mobility and quality of life.
**Outcome:**
The patient continues to manage a complex array of health issues while coping with significant emotional stressors. Her story highlights the importance of comprehensive care that addresses not only physical but also mental health and social support needs, especially in elderly individuals with multiple chronic conditions.
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