VIDEO
TRANSCRIPT
Intro :-
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”!
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”
