It was minutes past seven in the morning. I followed my intern into the cube to review her. Lying in bed, but not in obvious pain, she did not look sick. However, her feet were swollen up to the ankle.
The intern quickly went through the history and examination findings. The patient did not have foot injury or infection that would have predisposed her to get a skin infection, medically referred to as cellulitis-the admitting diagnosis.
“Her temperature, heart rate and blood tests are all within normal ranges,” he reported.
Adding that she was scheduled for a scan of her legs to rule out a blood clot.
She had no infection
It is unusual to have an infection of both legs in a healthy young patient without other contributing factors.
I decided to take her history afresh. She was a form four candidate from a nearby school. She narrated the chronology of her problem as I proceeded with my examination, first feeling her forehead with the back of my hand for fever, then feeling her pulse rate at the forearm.
I checked in between her toes for sores or any stigmata of athletes’ foot, the common predisposing factor to foot cellulitis. I felt the temperature difference between her feet and arms. Ordinarily cellulitis would cause an increase in the warmth of the affected body part. Her feet felt cold instead, and they were not tender.
When I pressed the skin on the inner side of her ankles, my finger left a dent. I was certain she did not have infection, I just awaited to hear any new twist in her history that could point us to the right direction.
Burning the midnight oil
She revealed that she had spent sleepless nights the previous week, seated in her chair, with her feet dipped in a basin of cold water to make sure she never fell asleep. Revising for her Kenya Certificate of Secondary Education (KCSE) exam. Literally burning the midnight oil! By midweek, she had noticed her legs begin to swell.
“I think I have figured out what your problem might be,” I finally told her, recollecting my own similar experience while in her shoes nearly two decades earlier.
You see if you stand for long periods of time, the force of gravity may occasionally override some of your blood collecting systems in the legs, leading to swelling. Especially when your foot and leg muscles are not exercised to help in the pumping of the blood and fluids back to the heart.
We call it dependent oedema. In people who are bed ridden, we find it around their buttocks.
Her dedication to her books, in respect for the national exam had made her override not just her body’s sleeping mechanism but its fluid draining one as well. For the one night she had spent in a hospital bed with her legs elevated on a pillow, the oedema had got to the ankle, down from the sheen.
She did not have signs of heart or liver disease. It would just be minutes before the blood tests would be out to shed light about her kidney function. And in an hour or less we would have a scan of her legs, just to be sure there was nothing missed out; I reassured her.
Exam in progress!
I came back five or so hours to check on her. Outside her cube was a police officer with a G3 rifle strapped across the chest, muzzle pointed to the ground. When our eyes met, she jolted, tightened the grip on the firearm, adjusted her stance and turned towards me, as if in complete adherence to the Marksmanship principles. I was thrown into a millisecond of catatonic stupor
Pinned on the veranda pole outside the ward cube was a poster: “SILENCE PLEASE. EXAM IN PROGRESS!’.
It had not yet downed on me that the national exams were already on going! Seated in her hospital bed, her legs flat, covered in sheets, I could see her scribble on her coloured exam sheets, using the meal trolley as the exam desk.
All investigations normal
All the laboratory tests came back normal and her foot swelling had subsided when we discharged her later that Friday.
The following Monday I found the same police officer outside the same cube. I learnt that another candidate had been admitted, a lady too. This one with one leg swollen. The scan had showed a blood clot in her right leg.
“The medical team will handle that. No need for surgical intervention,” I impatiently interrupted the intern, zooming past the scene in haste.
I wonder whether the Competence Based Curriculum will reduce the stakes that our candidates assign to the national exams. Even to the point of writing their exams from a hospital bed.