60 year female born and bought up in lower socioeconomic class with two sisters. Milestones achieved normal.She is an illiterate and childhood was pleasant.Patient parents are farmers, she used to engage in daily wage labour work from Childhood. At age 18 she had consanguineous marriage, married to her brother in law. After marriage she has two abortions during her gestations. ?placenta abruptio. Third pregnancy was stillbirth. She had her fourth pregnancy , healthy baby boy was born. She raised and educated her son all by herself.
15 years ago she had pedal edema and decreased urine output, went to RMP and regularly took injections after which her urine output became normal. But once she wasn’t relieved with her symptoms and consulted doctor , found out her right kidney is small/shrunken and was advised for renal transplantation. Because of financial issues she did not undergo transplantation. Two years later she lost her mother due to old age. Three years after her mother Demise she lost her husband in a RTA( Tractor vs Bike). She wasn’t unable to handle the situation and became regular alcoholic. Three years after that she lost her husband her younger sister also met with RTA while coming back from farm and lost her life.
10 years ago she had multiple joint pains which eventually led her to walking with a support.
7 years ago she married off her son (love marriage) who later had three daughters
3 years ago patient had sudden onset of left upper and lower limb weakness with slurring of speech , took her to local hospital and was diagnosed with CVA and Denovo hypertension
Intermittently she has recurrent Urinary tract infections , conservatively managed.
1 year ago she had swelling itching and painful toe of left foot, diagnosed as cellulitis and amputation of toe was done.
Since 15 days patient had complains of productive cough, loose stools watery in consistency 5-6 episodes per day. Resolved. Since two days patient has high grade fever associated with chills and rigor associated with burning micturition and shortness of breath grade 4 and was bought to our casualty for further management
DAILY ROUTINE
Usually stays outside home where she can use washroom conveniently, and has a bed setup near the entrance. Since she cannot walk without support she doesn’t walk much and this is her routine
Wakes up at 6am, freshenup and get her grandchildren ready (from cleaning butts to their dressing)
Has tea at 8am
11am- Have some food usually rice and curry
12pm-2pm she takes nap
2pm- has lunch and takes nap
4pm -she sits in chair and gossips with her hometown friends who visits her home, pass time with her grandchildren and go to bed by 10pm
Her daily routine doesn’t include any physical activity, mostly she spends her day chitchatting and spending time with her grandchildren. She neither watches TV or engage in household chores.
ECG
CHEST X-RAY
**Learning Points:**
- **Impact of Socioeconomic Status:** The patient’s life and health outcomes were significantly influenced by her lower socioeconomic status, which affected her access to education, healthcare, and financial stability. These factors contributed to delayed medical interventions and inadequate management of chronic conditions.
- **Chronic Health Issues and Their Complications:** The patient experienced multiple chronic health issues, including renal problems, recurrent urinary tract infections (UTIs), hypertension, joint pain, and a cerebrovascular accident (CVA). These conditions were compounded by her inability to afford recommended treatments and follow-ups , leading to progressive deterioration of her health.
- **Psychosocial Stress and Alcohol Use:** The patient faced considerable psychosocial stress from multiple personal losses, including the deaths of her mother, husband, and sister. These events contributed to her becoming a regular alcoholic, which likely exacerbated her health problems and impaired her ability to manage her chronic conditions effectively.
- **Healthcare Accessibility and Outcomes:** The patient’s journey highlights the critical role of accessible and affordable healthcare. Despite intermittent treatment for various conditions, the lack of consistent, comprehensive medical care led to poor health outcomes, including the need for toe amputation due to cellulitis and ongoing struggles with recurrent infections and complications.
- **Importance of Continuous Care:** The patient’s recurrent and untreated health issues, such as UTIs and joint pain, underscore the importance of continuous and comprehensive care. Early and sustained medical intervention could potentially have prevented the progression of her conditions and improved her quality of life.
**Uncertainty:**
- **Diagnostic Challenges:** Given the patient’s complex medical history and multiple comorbidities, accurately diagnosing the root cause of her acute symptoms (e.g., productive cough, high-grade fever, burning micturition, shortness of breath) can be challenging. These symptoms could be related to an underlying chronic condition or a new acute infection.
- **Therapeutic Efficacy:** The effectiveness of past treatments, especially given the patient’s history of irregular medical care and self-management, remains uncertain. The potential impact of her alcohol use on the management and progression of her chronic conditions also adds complexity to her case.
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