He was admitted sometime late in the night. The doctor on night duty had called me and told me about this patient. He said that a patient with no history of asthma has come with severe respiratory difficulty. The pulse oximeter showed unusually low value of oxygen level in blood. ECG showed only an increased heart rate and X-ray Chest was hazy on either side.
" Sir, What could it be?"
'Let the blood results come and let me see the patient in the morning”. I replied.
The patient was 46 years old, working in one of the Metro Cities. He came to his hometown here 5 days ago. He was having cough and breathing difficulty for about 2 weeks now and was getting some treatment with mild relief. There was on and off fever and severe fatigue. He was suffering from Diabetes for last 2 years, but not on any regular medication nor was doing frequent blood sugar tests. He had lost weight considerably in last few months.
His clinical examination showed white patches on his tongue with chest showing features of pneumonia. With Oxygen administration in high pressure he was much better than the time of admission.
His blood sugar was high and Liver function Tests were slightly deranged. The WBC count was low with lymphocytes predominating suggesting a non-bacterial cause for pneumonia..X ray Chest showed ground glass like haziness.
What is this?.............
Sub acute onset of illness, severe breathlessness and low Oxygen level, fungal patch on the tongue, low WBC count, ground glass haziness on Chest X ray............
Yes, I want to test his HIV status.
He has features of Pneumocystis Pneumonia, caused by a fungus found in patients with very low level of immunity, mostly HIV positive patients.
Patient was drowsy and was not in a state to give his consent for the test. I talked to his wife and got an oral consent. Did she want to say something? Or was I imagining?
The rapid test for HIV antibody was positive. I called the wife again and told her about the result. Then she told me everything. Yes they know he was 'positive’. She was also 'positive' too. He was seriously ill 2 years ago and was found to 'positive'. He took medications for about a year and was much better. Against doctor's advice he suddenly stopped the Anti retro-viral medicines and started some alternative system of medicine with the hope [that someone gave him] that he will be completely cured. He slowly became ill again and is now in this state.
I have heard this story many times. Modern medicine being based on scientific evidence based medicine will not claim cure for conditions, which has no cure. But most of the illnesses can be well controlled with continuous medications. This is true not only for HIV/AIDS but also for other chronic illnesses like Diabetes, Hypertension, Coronary Heart Disease etc.
After taking modern medicine treatment for some time many people try to experiment other systems of medicines/practitioners because they falsely claim complete cure. Finally after worsening of their condition and realizing there is no permanent cure they come back to modern medicine. By this time much damage to the body would have been incurred.
He is critically ill now. If he had continued on medicines advised for him under modern medicine treatment he would not have been fighting for his life like this.
Who should be blamed here?
Sunday, September 27, 2009
Monday, September 14, 2009
What could be her diagnosis? Part 2
She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.
She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.
By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.
Is it a ruptured ectopic pregnancy?
A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.
I know the Gynaecologist must have ruled it out already before referring to me.
Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.
Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.
Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.
What could be her diagnosis?
This was my post last week.
What did I do? I began to go thru the data again in my mind.
After 5 days of fever she developed shock. So an infection must be the cause.
Bacterial or Viral or Malaria?
Low WBC count usually rules out Bacterial infection. The pattern of fever and lack of history of travel to Malaria prone areas should rule it out. [Mercifully Kerala has almost zero cases of indigenous Malaria. All our Malarial fevers are imported from neighboring States].
So it must be a viral infection. Many viral infections cause low WBC count and low Platelet count. But only a few can cause Shock. In this rainy season such a viral infection producing shock can only be Dengue Shock Syndrome.
Any other clue that suggests Dengue infection?
Yes the moderate amount of free fluid in the peritoneal and pleural cavity. [Abdomen and chest]. This is classically seen in DSS due to increased capillary permeability causing plasma leak in to those spaces.
The low platelet count can cause bleeding if it falls below 20000.Then it is called Dengue Hemorrhagic fever.
The diagnosis is by detection of the virus by RT-PCR, which is very costly and the result may reach my place only after a week or by detection of antibody against the virus, which may become positive only after 7-10 days.
As the treatment is symptomatic with pumping in of large amount of fluids and if needed platelets and plasma, I did not send a blood sample for antibody detection at that time.
I started the treatment earnestly. Fortunately the relatives had confidence in my institution and me. Her urine output improved in a day and after about 3 days of pumping in of so many bottles of fluids and plasma her blood pressure started coming up.
Initially her PCV [packed cell volume] was high due to plasma leakage and blood concentration. Later it began to fall showing the treatment is effective. Rarely fall in PCV may also be due to bleeding. So a careful watch for bleeding is required.
I send the blood sample for diagnosis only on the 3rd day of admission. By that time she was shifted out of ICU. When the result came as positive for Dengue infection she was well in to the road of recovery.
When she was discharged on the 9 Th day of admission her Ultra sonogram showed a normal live foetus and no free fluid in the peritoneal and pleural cavities.
I have seen several patients with features of Dengue fever this season. All most all of them recovered without going in to shock as I pushed lot of intravenous fluids suspecting Dengue in all patients with high fever, headache, no joint pain, low WBC and low platelet.
There is a significant increase in Dengue fever cases this year in South India as evidenced by news reports. Large number of cases has also been reported from Sri Lanka.
I am hoping that all my patients with Dengue fever will recover fully like the patient in the story.
She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.
By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.
Is it a ruptured ectopic pregnancy?
A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.
I know the Gynaecologist must have ruled it out already before referring to me.
Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.
Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.
Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.
What could be her diagnosis?
This was my post last week.
What did I do? I began to go thru the data again in my mind.
After 5 days of fever she developed shock. So an infection must be the cause.
Bacterial or Viral or Malaria?
Low WBC count usually rules out Bacterial infection. The pattern of fever and lack of history of travel to Malaria prone areas should rule it out. [Mercifully Kerala has almost zero cases of indigenous Malaria. All our Malarial fevers are imported from neighboring States].
So it must be a viral infection. Many viral infections cause low WBC count and low Platelet count. But only a few can cause Shock. In this rainy season such a viral infection producing shock can only be Dengue Shock Syndrome.
Any other clue that suggests Dengue infection?
Yes the moderate amount of free fluid in the peritoneal and pleural cavity. [Abdomen and chest]. This is classically seen in DSS due to increased capillary permeability causing plasma leak in to those spaces.
The low platelet count can cause bleeding if it falls below 20000.Then it is called Dengue Hemorrhagic fever.
The diagnosis is by detection of the virus by RT-PCR, which is very costly and the result may reach my place only after a week or by detection of antibody against the virus, which may become positive only after 7-10 days.
As the treatment is symptomatic with pumping in of large amount of fluids and if needed platelets and plasma, I did not send a blood sample for antibody detection at that time.
I started the treatment earnestly. Fortunately the relatives had confidence in my institution and me. Her urine output improved in a day and after about 3 days of pumping in of so many bottles of fluids and plasma her blood pressure started coming up.
Initially her PCV [packed cell volume] was high due to plasma leakage and blood concentration. Later it began to fall showing the treatment is effective. Rarely fall in PCV may also be due to bleeding. So a careful watch for bleeding is required.
I send the blood sample for diagnosis only on the 3rd day of admission. By that time she was shifted out of ICU. When the result came as positive for Dengue infection she was well in to the road of recovery.
When she was discharged on the 9 Th day of admission her Ultra sonogram showed a normal live foetus and no free fluid in the peritoneal and pleural cavities.
I have seen several patients with features of Dengue fever this season. All most all of them recovered without going in to shock as I pushed lot of intravenous fluids suspecting Dengue in all patients with high fever, headache, no joint pain, low WBC and low platelet.
There is a significant increase in Dengue fever cases this year in South India as evidenced by news reports. Large number of cases has also been reported from Sri Lanka.
I am hoping that all my patients with Dengue fever will recover fully like the patient in the story.
Sunday, September 6, 2009
What could be her diagnosis?
"Doctor, I have a patient in shock [very low blood pressure]. Please see her and give your opinion".
The Gynaecologist of my Hospital was asking me on the hospital phone.
"How come you were called first"? I asked. A patient in shock is my area.
'She happened to be 3 months pregnant" was the answer.
I was soon in the intensive care by the patient's bedside.
She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.
She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.
By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.
Is it a ruptured ectopic pregnancy?
A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.
I know the Gynaecologist must have ruled it out already before referring to me.
Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.
Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.
Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.
What could be her diagnosis?
The Gynaecologist of my Hospital was asking me on the hospital phone.
"How come you were called first"? I asked. A patient in shock is my area.
'She happened to be 3 months pregnant" was the answer.
I was soon in the intensive care by the patient's bedside.
She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.
She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.
By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.
Is it a ruptured ectopic pregnancy?
A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.
I know the Gynaecologist must have ruled it out already before referring to me.
Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.
Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.
Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.
What could be her diagnosis?
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