Case of the Week: 4th June

June 11, 2018

At the end of a very busy ward round, we have 2 more patients left to see, and we find MJS, a 75 year old women, sat upright in the middle of the bed. She is uncomplaining and states that she is feeling well when we ask her. However, on further assessment, this lady has a respiratory rate (the number of breaths you take a minute, which should be between 12 and 18) of 56, and oxygen saturations of 74% (normal is above 94%)!

 

She has a condition called heart failure.

 

The heart, with each beat, receives blood from the body, which is oxygen deplete, and pumps it to the lungs, for re-oxygenation. Heart failure is usually a very chronic disease process. The blood vessels supplying the heart with blood are blocked with fatty deposits and reduce the amount of blood (and hence, oxygen) the heart receives. Over time, the heart muscle becomes weaker and fails to function as a pump. As such, during exacerbations, the blood trying to get back into the heart with each beat becomes congested and ‘backs up’ like a traffic jam. To try and relieve this pressure, the body removes some of the fluid from within the blood vessels and deposits it in the surrounding tissue.

 

This is normally seen in the ankles first (gravity driven) but in more severe exacerbations, this can accumulate all the way to the thighs, and in patients who are mainly seated, around the buttock area.  We refer to this fluid accumulation as pitting oedema. This process also occurs in the lungs and fluid seeps out of the blood vessels into the lung tissue making it harder to breathe and harder to oxygenate the blood when it is there. This process is called pulmonary oedema.

 

This lady had pitting oedema not only to both groin areas, but it extended to both buttocks and up her back to the bottom of her shoulder blades. I had never seen such extensive pitting oedema before. She also had evidence of severe respiratory failure secondary to pulmonary oedema with clinical evidence of fluid filling both lungs. The HIPZ and local team worked quickly to give her oxygen and start diuretic medications – drugs to try and encourage her kidneys to produce more urine which reduces the overall amount of fluid in the body.

 

I was very worried that this lady was so unwell that she would not survive this exacerbation. I asked after her every day and reviewed her several times and I am so delighted to say that she was well enough to be discharged about a week later. 

 

One of the frustrations of trying to manage chronic conditions such as this in Kivunge, is that the supply / ability to fund the medication she needs to be on to try and maximise the heart function she has left and reduce the potential for this to worsen further, are not sufficient. She was sent home with a 10-day supply of medication that she should be on for life. I am sure will we see her again in time, but for now, she is better and at home, and we are all grateful for that. 

 

What continues to astound me here at Kivunge, is how uncomplaining the patients are. It is quite common for patients, as sick as this lady, to not call for help and even to say that they feel well, when clearly, she was fighting for every breath and must have felt dreadful. Why this is, is clearly beyond my comprehension presently, but does make me a lot of more suspicious that the ‘well’ patient is not often so well! 

 

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