Moody Murmurs: Clinical Correlations.

Everyday is a part of a learning curve and I'm beginning to realise this as I see new cases everyday and attempt to understand how to workup a case. It also gives me the opportunity to interact with consultants, formally and informally and learn a lot about their practice and approach towards patients.

Take the case of Mr L, a 60year old man with uncontrolled Diabetes who presented with cough with expectoration and fever. Suspecting a Right Lower Lobe Pneumonia, he was treated with antibiotics initially but when he did not improve, he was treated in isolation as a Covid Suspect (which thankfully turned out to be negative). The CECT showed that it was a case of necrotizing pneumonia of the Right Middle and and Lower Lobes with partial collapse. The Pleural fluid analysis revealed it to be a exudative fluid and the cell type and ADA helped to exclude Tuberculosis. Furthermore, considering the site of pleural fluid being as high up as the apex of the lung, he was not a suitable candidate for ICD insertion (Intercostal Drain, he was taken up for surgery ( Thoracotomy + Decortication and Right Middle Lobectomy). Several findings could be elicited on examining him such as pedal edema, clubbing, decreased air entry on the right side, woody dullness on percussion and vesicular breath sounds on auscultation.

Another Patient Mrs K with a pre-existing heart condition (including a valve closure surgery) was admitted for pneumonia and she too was tested for Covid-19. Luckily, her reports too were negative and the following day, I was off in an ambulance (with siren and all) towards Fortis in North Bengaluru where the patient was being transferred to be treated under own cardiologist and team.

Sometimes, when you're the first point of contact for the patient presenting in the hospital ( either in the OPD or in the ER), you tend to follow up closely, to know how they are doing. Take the case of Mr A, an elderly active gentleman who was brought with history of giddiness and on examination, had elevated BP. He had been having hyponatremia for a while now, although he remained asymptomatic. It was thought to be drug induced by previously seen clinicians. His renal excretion of Na+ was elevated. He was also on the Anti-arrhythmic Amiodarone for "ectopic beats", but a Holter monitor (24hr ECG) revealed that he, infact had Sick Sinus Syndrome. He was suggested for a pacemaker in future, in case of syncopal attacks and his elevated TSH showed that the probable cause for his (euvolemic) hyponatremia was taken to be his untreated Hypothyroidism. Ideally, he would require to be reviewed periodically if his hyponatremia resolves with the appropriate dose of Thyroxine; if it does not, then SIADH (Syndrome of Inappropriate ADH secretion) would be the alternative cause for his hyponatremia.

Causes of Hyponatremia as per Harrison

Sometimes, there are situations where you really cannot do much. Mrs S, a young woman with a daughter in her 20s, came with complaints of decreased appetite and weight loss. Her abdominal distension due to ascites made it more evident that there was an underlying malignancy. The initial blood work revealed elevated CA-125 and a CT scan showed an ovarian carcinoma but the report ( thickening of the stomach wall) also prompted for an Upper GI Endoscopy which revealed the original Carcinoma of Stomach which had metastasized as Krukenberg Tumour. I did an ascitic tap to drain nearly 2.5Litres of fluid, we started her on multivitamins and other supportive (palliative measures). The late stage of detection did not help either, so neither chemo or surgery were options which would guarantee an improved quality of life.

An interesting case that we saw in the OPD was of Mrs. P, who had been having cough for over 6 months(!). With no co-morbidities like Diabetes or Pre-existing COPD, she was taken through a battery of investigations and had completed courses of antibiotics, none of which, had yielded any answers. She tested negative for Tuberculosis and a bronchoscopy guided biopsy got some specimens which were faintly suggestive of a neoplasm (a second Pathologist opinion only gave an "acute on chronic inflammatory changes"). A PET-CT report said it was a hypermetabolic lesion with SUV 4.5 (Still a bit lesser than the cut-off to consider it a malignancy). Here, the radiologist picked up what could possibly be the "Finger in Glove" appearance of ABPA (Allergic BronchoPulmonary Aspergillosis). While the fungal cultures from Bronchoscopy had not yielded any Aspergillus, it could have been narrowly missed considered how quick the bronchoscopy has to be (extremely uncomfortable for the patient) so she has been started empirically on Voriconazole. Further work up would, in fact, be necessary and this led to a discussion on whether a CT guided Biopsy or Endobronchial Utrasound Transbronchial Needle Aspiration (EBUS-TBNA) would yield better results. D Ma'am then asked to read up on the approach to non - resolving pneumonias and it showed that a step-wise protocol is followed. We also read an article from UpToDate for possible etiologies of non-resolving pneumonia and the differences in their presentation.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644829/

Mrs A, presented with cough without expectoration and with massive pleural effusion seen radiologically. With a history of pulmonary TB in her primary contact, it was not hard to find the cause of her (pleural) Tuberculosis (this is STILL EXTRA-Pulmonary!). But the conundrum was that her Pleural Fluid analysis from GeneXpert showed "Indeterminate" for Rifampicin. Rifampicin is one of the crucial drugs in the regimen of Tuberculosis treatment as per RNTCP and Resistance to this would mean that it would be considered as MDR-TB (MultiDrug Resistant Tuberculosis). So we inserted an ICD, sent pleural fluid again for analysis (this time LPA too). Only after verifying the resistance would she be started on the whole line of drugs that come under MDR TB treatment, until then she would be expected to continue on the HRZE regimen itself.

There was also the case of Mrs N who was brought to the ER with severe breathlessness. She had grade 4 pedal edema, raised JVP and on further examination, her right lung had decreased/absent air entry compared to left and she had a loud P2 as well. Looking through her previous reports, we gathered she had a history of Tuberculosis as a teenager which has caused the Right Destroyed Lung/Fibrothorax evident on X-Ray, overtime, the increased load on the single functional Left lung leading to Congestive Cardiac Failure. She was immediately put on BiPAP to reduce the carbon dioxide load as shown by an immediate ABG. The sudden need to be put on oxygen, the medications to manage her CCF and her sudden immobility did take her by surprise but we tried our best to boost her morale and give her confidence that she would improve.

Right Fibrothorax/Destroyed Lung

Apart from the battery of pulmonology cases, there have been stroke patients, chemo cases coming in for day care and a Carcinoma stomach operated (for the second time) and almost discharged when he had serosanguinous discharge at the operative site so he was re-admitted and taken up for Emergency OT for Burst Abdomen. There was also a patient who presented with renal colic and was almost shifted to OT for URSL and DJ stenting but backed out in the last minute after his pain was relieved (I'm still not very sure which is the ideal analgesic). There have been cases to ponder over and cases to work up to reach a diagnosis and the availability of the facilities is a big plus of a private setup.

Nevertheless, talking to the consultants here has, in itself, been a great experience. Dr M, an reknowned orthopaedic surgeon who practices here as well as outside the country spoke about the need for ethical practice, operate only when absolutely necessary and to earn the respect of the patients by not indulging in fraudulent practices. Sometimes, it is easy to get carried away by the herd, but it takes resilience to go against the tide and stick to our ethics. Here's hoping that these words will mean as much to me in the coming years as well. D ma'am shared her experience of PG days and suggested how important it is to read everyday, even if, only just for a short while. It's important to have a good rapport with your colleagues and seniors even if it isn't always a pleasant work environment (especially if you will need to get chances for any procedures!). Dr S3 picked up that I was nervous early on and asked me the reason. When I said that it was because I was afraid I would make mistakes at my first workplace, he said that I would definitely make mistakes at some point or the other but I'll have to learn from them, as time goes by. It was indeed reassuring to hear this!

Watching the burden of ill-health from close quarters is often worrying. One cannot escape old age but one can hope to live it with dignity. One cannot keep diseases at bay forever but one can definitely lead a healthy lifestyle and prevent illness to a large extent. Beyond this, medical science has made progress to alleviate the pain, decrease the progress of a condition or sometimes, remove the causal factor of the disease. Some other times, what we do, is probably buy more time.