Case 41 – History


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Case 41

Recent weight gain


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Brief Past Medical History

The patient was a middle-aged Caucasian woman with diabetes on a variable insulin regimen and weighing approximately 180-190 lbs. near the time of death (although heavier in past); borderline hypertension; status post hysterectomy (2003 for ovarian cancer), cholecystectomy, appendectomy, and umbilical hernia repair with removal of umbilicus; status post “nonmoving” deep venous thrombosis in the legs six years prior.

There is a history of deep venous thrombosis in the father.


Recent Events

The patient had rapid weight gain from water buildup in the past approximately 2 months.

She was admitted to the hospital approximately one month prior for stress (“adrenaline,” per family) and a productive cough.

Work-up included a cardiac evaluation which was “not perfect” but showed “nothing significant.”

She was managed medically with resulting weight loss and transferred to rehab.


Home course

At time of discharge from rehab, the family notes she was 10 lbs. heavier than her weight upon admission to rehab; and also left rehab with a “cut on the leg.”

They also reported that they were told the patient needed new, additional medications.

They reported these new medications were not ordered nor provided to them, despite their efforts to follow up.

The patient spent the week with receiving her usual (prior) medications, but not any of the new medications.

Within a week of discharge from rehab, the patient had a witnessed cardiopulmonary collapse at home.

Paramedics were called.

The patient received unspecified advanced life support measures but died.

This history is provided by the family.


Next: External exam

Discussion Questions

1. What is your assessment of the history?
2. What is the differential diagnosis of fluid weight gain?
3. The history is provided by the family. How can you tell which parts might be more reliable and which parts might be less reliable?
4. What is the differential diagnosis of a cause of death here?
5. What conditions on your list would be dependent on receipt of medications?
6. Whose responsibility is it to ensure the patient leaves rehab with prescriptions?
7. How do you interpret the family’s self-efficacy given that an entire week passed without them getting the new, required medications? Would they be “right” to blame the physician for being unable to get ahold of the new medications?
8. What steps can a family take with an “unresponsive” provider? What other interpretations are there than that the provider was “unresponsive”? What practical, procedural, accidental or inadvertent reasons might cause a provider to seem “unresponsive”?
9. If, on further exploration, the provider stated that she provided the necessary prescriptions to the family at the time of discharge, how would this change your interpretation of the history? Would you think the family was lying? What other interpretations might there be?
10. What role might guilt or anger play in a family’s decision to request an autopsy (when they are responsible for the care of a loved one, but the loved one dies)?