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.