Diagnostic dilemma . . .

About a week back, we had a 65 year old man come to outpatient with a history of breathlessness since the last 6 months which increased over the last 2 days. He was so breathless that he could not lie down and it was obvious that he had not had a good sleep since some time. He had a saturation of about 10% which increased to 85% with 5 litres of oxygen.

He was quite confused and made quite a scene on the first day of admission.

On examination, he had bilateral fine crepitations in his chest with a decreased air entry on the right side and other features suggestive of a right sides pleural effusion. On Chest X-Ray, he had right sided pleural effusion and later ultrasound revealed ascites too in addition to dilated portal vein.

His blood examination results are as follows –

Hemoglobin: 10.5 gm%

Peripheral smear: Mild hypochromic microcytic picture with a total count of 15000. Differential count of P87L12M1. Toxic changes present. Adequate platelets.

Serum Creatinine: 0.8

Post prandial blood sugar: 147 mg%

S. Protein: 6.1 gm%

S. Albumin: 3.0 gm%

ESR: 7 mm/hr

We did a pleural tap results of which are –

Total count: 4752 cells

Differential count: L99P1. There were occasional atypical cells with hyperchromatic eccentric

nucleus and blue cytoplasm. ? Plasma cells

Protein: 2.1 gm%

Sugar: 101 mg%

The ascetic fluid was not that much to do a tap.

We treated him with antibiotics and diuretics. He did not have fever and he’s slept well.

He is too poor to go any further. The question is about his further management. We would have liked to do a bone marrow, which we do not have facilities for . . .

Would like feedback asap . . .

Breathless . . .

Few days back, one of my friends reminded me that I'm yet to post much about patient management at KCH. There have been quite a many . . . but I've been busy . . . 

Today was a significant day for the hospital as we had more than a 200 outpatients (227 to be exact) for the first time in 2015. 

Very similar to one of my first posts when I was at NJH . . . a small account of some critical patients. Though the volume is not yet up to NJH levels, I'm sure all five cases would interest you . . .

5 patients . . . all of them breathless . . . a glimpse into patient care today . . . I'm sure an medicals student would have been overwhelmed . . .

1. AAH, a 70 year old gentleman who had been with us since the last few days. Surprisingly, he had been going from hospital to hospital with a pneumothorax since the last 2 months. And after he came here, he was not allowing us to put a chest tube. The relatives initially told us that if we can give them a guarantee, we could insert a chest tube. I was not very confident considering that his pneumothorax was 2 months old. However, within 48 hours of his admission, he became quite sick that the relatives realised that it may be better to give us a chance. The procedure was uneventful and he is doing well. 

2. BH, a 60 year old gentleman came in with history of fever and cough since the rains 10 days back. He attributed his illness to the wet weather. He was not very much willing to take our diagnosis of a miliary tuberculosis. In fact, he continues to be so sick that he needs regular oxygen. 

3. CH, a 50 year old gentleman came to OPD today. He was in severe pain and was breathless. He had a X-Ray Chest taken 3 days back. There was a effusion. An aspiration showed empyema. The interesting aspect - he wanted to take a second opinion with some doctor he knew before starting treatment here. He promised to return tomorrow.

4. DDH - a 35 year old young man was brought in a confused state, gasping and frothing from the mouth. He had tried to commit suicide by hanging. The relatives had cut down the rope and brought him. He appears to have some amount of brain hypoxia. We've tried our best to refer him for elective ventilation. They are too poor to even afford the vehicle to Varanasi. I wish we had a better ventilator. He's till in the ward. He's a bit better, but, I'm sure that a ventilator would have done him a lot of good. 

5. SH - a 80 year old elderly lady was brought with breathlessness since 2 months. Since 2 days, she developed severe left sided chest pain. An ultrasound showed cholelithiasis as well as a massive pericardial effusion. I wonder how she's still alive. The relatives were given the option of taking her to a higher centre for pericardiocentesis. They've left after quite a long discussion on further course of action. I've a feeling that most probably, she would be brought back to us in a couple of days. 

I'm sure many will ask on how to help out . . . 

Well, 227 with 3 doctors (one Junior doctor, one Clinical Pathologist and one Community Health Physician) and one nurse practitioner is no small work. I wish we had more experienced hands to help out. 

And of course, some more equipment in the ward . . . the immediate need - couple of more multipara monitors and couple of ventilators . . .

More of that sometime later . . . 

The big killer . . .

Come spring, and we have quite a spurt in the number of patients with respiratory diseases. And quite a good number of them would be tuberculosis patients . . . A selection of cases .. .. ..

The first one, a young lady who has been on and off treatment. The first 3 X-Rays here are her's taken over one year. It's very obvious that the second film is a bit better than the first one . . . but that was when she had stopped treatment after she was feeling better after about a month of treatment. Then, she was quite sick after the winter. And the third X-Ray was taken after that.

The next one is that of a middle aged lady who also has been on irregular treatment. 

The one below is that of a young man, who had been sick for about 5 months now. He had stopped tuberculosis treatment after 2 months as he was feeling better. Now, he has about one third of his total lung left. 

And the final one- A 10 year old who has been sick for almost 1 year. He has been sick on and off. The main finding . . . he weighs a measly 15 kilograms. 

The common links between all the 4 patients . . .

All of them are poor and there is a major issue with food security in all the four families. 

I've written quite a lot of poor nutrition last year. As the number of poor patients who access our facility increase, the strong association between poor nutrition and disease is very much evident. 

We've focussed quite a lot on Human Immunodeficiency Syndrome which is a cause of an immuno-compromised state (all 4 patients are HIV Negative). I wonder how long will it take for healthcare providers and policy makers to understand that the most common cause of an immuno-compromised state is M A L N U T R I T I O N . 

Chest tubes . . . Respiratory Medicine . . .

One of the most favorite of all my posts has been about the sort of X-Rays that we find at NJH. And to a certain extent it gives you an idea about the burden of respiratory symptoms that we have to deal with at NJH.

Last week, was a bit extra busy with respiratory medicine – we had 3 patients in the wards at the same time with chest tube in situ.

The first to come in was a 70 year old lady with history of pain abdomen for about 6 months with on and off fever. He was being managed elsewhere as cholelithiasis. It was only when one of our doctors wanted to check out her abdomen that he realised that she was becoming breathless. And a cursory examination was enough to come to a conclusion that there was pleural effusion. And it was massive. She made a fast recovery. We removed about 8 litres of fluid. Thankfully, it was clear.

The next one was a young man who had come couple of weeks back and we had diagnosed hydropneumothorax. We had told him about the need for admission and a chest tube insertion. Unfortunately he did not agree immediately. However, he came back after 2 weeks. He’s also made a remarkable recovery.

The third patient was a young unmarried lady who had been sick for about 10 days and was being treated at many places by all sorts of people. Here, it was pus which we drained on putting the chest tube. She has also made a remarkable recovery.

All the three patients have been started on antituberculosis treatment.

Talking about antituberculosis treatment, I just cannot stop talking about the danger of multidrug resistant tuberculosis that is lurking in almost all third world countries. Yesterday, we had a middle aged man with history of treatment with anti-tuberculosis drugs for five times over his lifetime and this was his X-Ray Chest. He was so sick… and terribly breathless.

When I write about Respiratory Medicine, I always think about a bronchoscope that lies unused in our hospital. I pray that we would have a Respiratory Medicine specialist who would be able to strengthen our services and take the hospital to greater heights.

I end this post with this X-Ray which shows a homogenous opacity in a 80 year old lady. We’ve sent her for a CT Scan . . .