Thursday 11 March 2021

VIDEO TRANSCRIPT- 62 years old female with cough and hemoptysis

VIDEO TRANSCRIPT

Intro :-

This is a presentation from our rural medical college hospital near Hyderabad in India and today we shall be learning around the global health challenges in resolving diagnostic and therapeutic uncertainty around a 60 Year old woman with chronic cough and shortness of breath.


slide of Objectives

Slide 2 - 3




Chief Complaint (Read as per slide)

History of present illness (Read as per slide)

Now we will see how a thorough analysis of the history helped us enlist the various differentials by identifying “where is the problem”.

Play video of bedside history analysis

Slide 4-5



    



 Moving on with History of past illness (Read as per slide)
Family history(Read as per slide)
In this beautiful illustration ,by an intern, which further helped us analyse the familial relation of the existing problems of the patient.

Display family tree pic + Video of family tree explanation in classroom teaching

 

Finally in Marital & Menstruation History(Read as per slide)

And now we shall move on to the clinical examinations of the patient which will further help us narrow down the differentials and management of the patient.

 

THANK YOU FOR WATCHING (PART 1 OVER)





General examination / GE (Read as per slide)
 
Display relevant pictures(in and out) as per the Signs and symptoms
 So the picture alongside highlights the icthyotic skin and the malnourished stature of the patient.


Video of GE plays

Respiratory examination :-




Inspection(Read as per slide)
 Display relevant pictures(in and out) as per the Signs and symptoms

Before we move further ahead with the physical examination lets us see the significance of examining certain signs on inspection
 Bedside learning video of Tracheal shift and Trail’s sign





Palpation slide-(Read as per slide)
 Display relevant pictures(in and out) as per the Signs and symptoms
Bedside learning video


And now we will see the findings from tones struck by the physicians hand on the body mortal beings
 


Percussion -(Read as per slide)
   Let’s see how those chords by the Physicians help us compare and contrast the difference between normal and abnormal findings
 Bedside learning video


Auscultation(Read as per slide) 


On systemic examination of -(Read ALL as per slide)
Per Abdomen
CVS
CNS

   




These are what we found the Investigation findings of
1. ABG
2.LFT
3.RFT

4.ECG



2D ECHO
-(Read ALL as per slide)


CHEST X RAY
 This is the AP view that was obtained post Biopsy
This is the PA view at the time of admission
 and the radiological findings explained
(read as per slide)

Class discussion video of Chest  X RAY
   

 So we could see a large opacity in the Left Lung with mediastinal shift (request CDSS)

In order to have a better clarity we used better X ray modalities – HRCT (Read ALL as per slide)




Class discussion video of HRCT



So in order to finally rule out the diagnostic uncertainities ,enlisted as differentials from Radiology, a combined decision was taken to do a Lung Biopsy
Read as per the slide , show images
Next slide of Microscopy – So here Biopsy from the lung lesion shows mostly macrophages, few  lymphocytes & plasma cells indicative of resolving or organising pneumonia. ?BOOP (Bronchiolitis obliterans organising Pneumonia)

In bronchoalveolar carcinoma usually we find leipidic growth pattern starting from bronchial wall extending in the alveoli, which is not present here. Often these necrotic cancerous cells fill up the alveoli resembling a pneumonic consolidation in chest xray.

Class discussion video on Biopsy
 Little did we know then that intention of the needle was to elicit a Pneumonia. However, it still did not zeroed us upon a final diagnosis , as the uncertainities around the etiology of this non-resolving Pneumonia(that has been there over a month) still persisted.
Some common causes happens to be Tuberculosis, Malignancy, Immune mediated conditions like BOOP(if BOOP then what could be the immunopathogenic basis of it)
However, it could also be something that the Pneumonia has been obscuring , maybe an Endobronchial Growth?
 

So let’s see what the lenses of the endoscope had for us






 

Bronchoscopy(Read as per the slide , show images)

 So here we see the bronchoscopy at different levels showing the epiglottis , glottis , the bifurcation at Carina , and those thick mucus secretion obstructing the Airway,
 But “NO ENDOBRONCHIAL GROWTH”!

 in the following discussion of microbiology we will have audio playing with relevant pictures of reports etc.

So the samples of sputum and Bronchoalveolar Lavage that were sent for Microbiological investigations grew two different organisms E. coli and Klebsiella spp. That were suggestive of  commensals.

As far as the diagnostic microbiology setup is concerned, we primarily base it on repeated isolation, plausibility and the presence of the organism in large numbers.
For example in this patient we have seen that the primary pathology was an organised non resolving pneumonia. Pneumonia is  primarily caused by pneumococci, staphylococci, haemophilus etc.

So to isolate e coli from the sample raises questions as e coli being a primary pneumonic pathogen is quite unheard of.

The second thing is our correlation with the direct smear of the specimen. The number of gram negative bacilli were not quite high which doesn't quite agree with the isolated organism. However we also must remember that patient is on long term antibiotics 
 Which would have contributed to further thinning of the organismal numbers.
Klebsiella is a feasible pathogen and it's isolation can be considered important. That's when we have to double check the other parameters such as the presence of pus cells and correlate with the direct smear. Klebsiella is also a commensal which makes it even more confounding. So probably here the low numbers of the organism in the direct smear coupled with a paucity of pus cells contributes to the conclusion that the klebsiella is also not fitting into the pathogen category

Another important feature is the presence or absence of inflammatory cells. In this case the inflammatory cells were very few on microscopy
, also no AFB was seen and we couldn't get sputum CBNAAT or mycobacterial cultures due to resource limitations and we tried ruling out viral etiologies in this Pandemic for COVID19.


Summary of Events ((read as per slide))


Graphical Timeline(This very important data maintained by the interns and PGs shows, the variation of the vitals of the patient especially the Temperature , which did not show much improvement with antibiotic therapy, however the patients overall improvement with Time , the slow resolution of the consolidation on Chest, suggested the probable wonder of the steroids over the time which has been administered to her via Nebulisation)



we looked at all possible etiologies and differentials for the patient's left upper lobe consolidation in terms of pathogenic bacteria(Like Mycobacterium tuberculosis, Pneumococci, Staphylococci, Kelbsiella, Hemophilus etc.),viral causes, we ruled out malignancy and then we finally settled into thinking it as immune mediated .Perhaps our diagnostic uncertainty is still not resolved 100% and so we wanted to share a realistic scenario with our global audience and make them realize how one may have to treat a patient inspite of persistent diagnostic uncertainty due to resource limitations and one of the ways we are looking forward to resolving the diagnostic uncertainty is through maintaining informational continuity with the patient and learning more from her response to our current therapy and a Global discussion via “Conversational discussion support system”

 


In this extensive learning experience under the guidance of Professor Rakesh Biswas Sir as a BMJ elective student during my stay at Kamineni Institute of Medical Sciences, I saw many challenging and brainstorming cases. Efficient data collection it's interpretation through discussions and literature review helped many cases, including this 62 year old female with cough and hemoptysis. Shared data through e-logs brought global inputs around the patient , where the benefit to the local treating team through enthusiastic patient centred learning, deeper thinking brought enhanced outcomes in improving the quality of life of the patient.



This is all around this patient , thank you for your patient listening.





 

 

Tuesday 9 March 2021

62 years old female with Chronic cough and Hemoptysis

Dr.ABDUL RAHEEM (INTERN)

Dr.ASHFAQ (INTERN)

Dr.GNANADHA (INTERN)

Dr.SRAVYA (INTERN)

Dr.CHETANA (INTERN)

Dr.NAVYA (INTERN)

Dr.VAMSHI ( PG1)

Dr.SAI CHARAN(PG1)

Dr.SUSMITHA (PG2)

Dr.ADITYA (PG3)

Dr.PRANEETH(PG3)

Dr.PRAVEEN NAIK (ASS.PROF)( duty on call 1)

Dr.RAKESH BISWAS (PROF.AND HOD) ( duty on call 2)



This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Here is a case i have seen:

A 62 year old female came to OPD chief complaints of cough with expectoration and SOB since one month.fever since one month.vomitings and loose stools since 4 days

HOPI:
 patient was apparently asymptomatic 20 years back later she had intermittent cough ( once in a month )which is relieved on taking medication but one month ago she had fever which was high grade with chills associated with low backache and SOB associated with cough with expectoration which was insidious in onset for this she went to hospital where she diagnosed with anaemia managed conservatively and she is on ceftriaxone. Symptoms aggravated more since 4 days , blood in sputum and wheeze present.
  H/o vomitings since 4 days which are 4-6 episodes/ day,food and water as content,non bile stained, non blood stained.
H/o loose stools since 4 days 5-6 episodes/day.
H/o loss of appetite present.
Significant weight loss present
No h/o burning micturition,melaena, headache.
Past history-
No history of hyperhypertension, diabetes mellitus, epilepsy,thyroid disorders, asthma, tuberculosis.
No past surgical history and blood transfusions.
Family history-
 - Her brother  had similar complaints, died 25 years ago.
 - Her sister has similar complaints chronic cough and SOB takes inhalers.

Menstrual and marital history-
Attained menarche 13 years of age and married at 14 years.
Menstrual cycles are regular 4/30, 
Attained menopause by 45 years of age.
No known drug and allergies.
General examination-
PT is conscious, orientated to time, place, person, cooperative.
Thin built and  Malnourished.
Skin fold thickness : 4mm.
HT-158 cm
Wt- 33 kg
BMI-13.25
PALLOR +, koilonychia +, clubbing +( fluctuation +),

No signs of icterus,cyanosis,  generalised lymphadenopathy,paedal edema.
Vitals-
Temperature-99.3F
PR- 105 Bpm
RR- 28 cpm
Bp- 100/60 mm of Hg
Head to toe Examination:
Temporal wasting present.
Shiny, bald  ,bulky, red tongue.

Greyish white patch is seen over soft palate.
Muscle wasting present: temporalis, deltoid.
Ichthyotic skin present on upper limbs and lower limbs.
?hard, mobile,2.5cm left supraclavicular lymph node present.
Lower thoracic and lumbar kyphoscoliosis present.
Lower limb : significant muscle wasting present.
Saddle nose deformity +
Respiratory examination:
Inspection-
Oral cavity- poor oral hygiene 
UR-:12- 45678. UL:12345678.
LR:123--- 78. LL :12---- 78.
Cervical Trachea appears to be central.
Trail’s sign+.
Drooping of shoulder , on left side
Broadbent’s sign +:systolic retraction in 3rd and 4th ICS.
Kyphosis seen with medial border prominence of Scapula
Dilated veins seen  over neck, right upper anterior aspect and left hemithorax.

Barrel shaped chest.
Suprasternal pulsations present
visible pulsations present in left mid clavicular line below the nipple( 4cm).
Epigastric pulsations +.
Posteriorly left side lower thoracic region - ?aortic  pulsations present.
Abdominothoracic type respiration
Resp. movements    Right.             Left.
Upper zone                   ✓.           Decreased
middle  zone                ✓.            Decreased
Lower zone                   ✓.           ✓
Accessory muscle usage present.
1.SCM
2.Scalenus

Palpation- 
Trachea- Mediastinal tracheal shift to right
no local rise of Temperature and tenderness.
Left side over crowding of ribs +.
Apex beat felt over left to left mid axillary line in 5th intercostal space (4cm).
Anteroposterior diameter(APD)- 24 cm.
Transfers diameter(TD)-24cm.(APD/TD: 1/1).
Resp. Movements.       Right.        Left.
Anterior:
Upper zone.                     N.       Decreased
middle zone                    N.        Decreased
Lower zone                      N.       Decreased
Posterior:
Suprascapular.               N.         Decreased
Interscapular.                  N.        Decreased
Infrascapular.                  N.        Decreased

Percussion-
Direct : resonant over clavicular, sternum.
Indirect :
Anterior.                  Right.               Left.
Supraclavicular.     Resonant.        Dull    
Infraclavicular.       Resonant.        Flat
Supra mammary    Resonant.        Falt
Mammary.               Resonant.       Flat
Inframammary.       Dull.                 Flat
Axillary.                    Resonant.       Dull
Infraaxillary.            Dull.                 Dull

Posterior:.                    Right.           Left.
Suprascapular.        Resonant.         Dull
Interscapular.          Resonant      stony dull
Infrascapular.          Resonant.         Flat

Auscultation- decreased air entry in both the lung areas. bilateral coarse Crepitations heard in both the lung areas.
Aegophony and bronchophony in 
                                  Right.                  Left
Supraclavicular.           ✓      tubulobronchi.
Infraclavicular.            ✓     tubulobronchi
Supra mammary    A&B.      tubulobronchi
Mammary.              A&B       tubulobronchi
Inframammary.           ✓.     tubulobronchi
Axillary.                       ✓                   ✓
Infraaxillary.             ✓.                     ✓
Suprascapular.         ✓.        Tubulobronchi
Interscapular.           ✓.        Tubulobronchi
Infrascapular.            ✓.        Tubulobronchi
Per abdomen- 
Distended abdomen, everted umbilicus present. Distended abdominal veins.
Shifting dullness present.mild spleenomegaly.
Bowel sounds heard.
? Portal hypertension
 
CVS- S1,S2 heard.

CNS- No focal neuronal deficits
 Reflex's                 Right.             Left.
Jaw jerk.                 +.                    +
Schimizu                +.                   +
Biceps.                     +++.               +++
Triceps.                    +++.               +++
Supinator.                 +++.               +++
Finger flexor.            +++.               +++
Knee.                         +++.               +++
Ankle.                        +++.               +++
Plantar.                      +++.               +++







Investigations-
ABG- 
PH- 7.24
PCO2- 32 mm hg
Po2- 79.3 mm hg
Hco3- 13.2 mmol/L

2D - Echo
Moderate Tricuspid Regurgitation(TR) + with Pulmonary artery hypertension
Mild  Mitral Regurgitation+/Aortic Regurgitation+.
Left Anterior Descending hypokinesia, Right Coronary Artery Left circumflex hypokinetic ,no Aortic Stenosis /Mitral Stenosis.
Moderate Left Ventricular dysfunction+
Diastolic dysfunction +, No Pulmonary Embolism.
USG-
B/L grade 1 Renal Parenchymal Disease changes present.

BT- 2 Min
CT- 4 Min
PR- 15
INR- 1.11
APTT- 30
Hb- 13.4 
Anti HCV- Negative
HBsAg-negative
HIV1/2- negative
DENGUE- negative
 Chest X ray-
Lung collapse on both sides with possible Cavitary lesion in Rt upper lobe

Lower mediastinal shift on right side with inwardly pulled Rt Costophrenic angle.
Treatment given-
Tab. PCM 650 mg stat
Neb. With IPRAVENT 4th hourly.
Head end elevation.

On day 2
RFT-
Urea-145 mg/dl
Creatinine-1.9 mg/dl
Uric  acid-10.4 mg/dl
Calcium-8.6 mg/dl
Phosphorus-3.4 mg/dl
Sodium-136 mEq/l
Potassium-4.1 mEq /l
Chloride- 102 mEq/L
HRCT- thorax plain
Sputum1. AFB-
               2. CBNAAT-
LUNG BIOPSY- done for mass in left upper lobe ( 4 th ICS).


Post biopsy x-ray


BRONCHOSCOPY:-
Thick secretions which were colourless from left bronchi and yellow from Right bronchi
No endobronchial growth or lesions seen
On culture and staining of secretions and brushings-
AFB and CBNAAT were negative,
No fungal growth seen.
Klebsiella from left lung and E. coli from right lung were isolated(More likely non-pathogenic)







































DIAGNOSIS:
Cryptogenic Organising Pneumonia
 
Treatment
Neb. With IPRATROPIUM BROMIDE 4 th hourly.
Tab. PCM 500 mg PO /SOS.
Head end elevation.
Day3
Two episodes of fever spikes present of 100.3 F.
Hemoptysis decreased.
Vomitings and diarrhoea subsided.
Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS IV/OD.
Tab.PCM  650 mg SOS.
Temp charting 4th Hourly.

 On Day4 
C/o generalised weakness.
No fresh complaints.
O/E 
 Vitals
TEMP-98.8 F
PR- 104 bpm
BP- 90/60 mm of hg
RR-24 cpm
 Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO  650 mg SOS
Day 5
C/o generalised weakness.
No fresh complaints.
O/E 
 Vitals
TEMP-98.4 F
PR- 98 bpm
BP- 100/60 mm of hg
RR-28 cpm
 Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
Day 6
Fever +, cough+
O/E 
 Vitals
TEMP-101F
PR- 105 bpm
BP- 110/70 mm of hg
RR-30cpm
 Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO  650 mg SOS

Day7 
Cough +, fever
O/E 
 Vitals
TEMP-101F
PR- 104 bpm
BP- 110/70 mm of hg
RR-28cpm
 Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO  650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr
Investigations-

T3N3 M0.
Day -8
 Cough +, fever subsided
O/E 
 Vitals
TEMP-101F
PR- 104bpm
BP- 110/70 mm of hg
RR-28cpm
 Treatment:
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr
Day-9
Cough +, fever  present

O/E 
 Vitals
TEMP-101F
PR- 90bpm
BP- 80/50 mm of hg
RR-26cpm
 Treatment:
INJ. AUGMENTINE 1.2 gm IV /BD( DAY-1)
Neb. IPRATROPIUM BROMIDE 6th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr
Day-10 
Cough +, fever  present

O/E 
 Vitals
TEMP-100F
PR- 78bpm
BP- 90/60 mm of hg
RR-24cpm
 Treatment:
INJ. AUGMENTINE 1.2 gm IV /BD( DAY-2)
Neb. IPRATROPIUM BROMIDE 1 resp. 6th 
hourly.
Neb. BUDECORT 1 resp. 12th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr
Day-11 
Cough +, fever  subsiding

O/E 
 
TEMP-99.4F
PR- 68bpm
BP- 80/60 mm of hg
RR-24cpm
Investigations-
 RTPCR - NEGATIVE

Treatment:
INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)
Neb. IPRATROPIUM BROMIDE 1 resp. 6th 
hourly.
Neb. BUDECORT 1 resp. 12th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr
Day-12
Cough +, fever subsiding

O/E 
 
TEMP-99.4F
PR- 82bpm
BP- 90/70 mm of hg
RR-24cpm

Treatment:
INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)
Neb. IPRATROPIUM BROMIDE 1 resp. 6th 
hourly.
Neb. BUDECORT 1 resp. 12th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr

Day-13
.Cough +, fever subsiding

O/E 
 
TEMP-99F
PR- 82bpm
BP- 90/70 mm of hg
RR-24cpm

Treatment:
INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)
Neb. IPRATROPIUM BROMIDE 1 resp. 6th 
hourly.
Neb. BUDECORT 1 resp. 12th hourly.
Tab. EVION PO/OD.
Inj. OPTINEURON 1amp in 100 ml NS 
Syp. GRILLINCTUS - BM 15 ml TID
Tab.DOLO 650 mg SOS
IVF 1unit NS. @50 ml/ hr
        1 Unit RL@ 50 Ml/ hr

VIDEO TRANSCRIPT- 62 years old female with cough and hemoptysis

VIDEO TRANSCRIPT Intro :- This is a presentation from our rural medical college hospital near Hyderabad in India and today we shall be l...