Case of the Week #2

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Case of the Week #2

6 Oct, 3:30 PM

welcome on they have to make chicks welcome all of you here so today is the second episode of our case of the week series which happens every Thursday at 9 00 PM our sincere intent and hope for this series is that this helps all of us with a diagnostic ability and a case presentation skills especially for our residents we want this to be like a One-Stop section of the app where you can come and quickly brush upon for your exams or just your routine learning so today we have our mentor and faculty Dr celebendry Who's pulmonologist and Transplant physician at ESA hello hello Max Hospital Global Hospital in Massena Hospital in Mumbai presenting the case we have our resident Dr harshita Mishra who is a resident resident of respiratory medicine at ltmmc and science Hospital Mumbai hello Dr harshita hello hello yeah yes uh so uh post the intro we're going to have a short quiz dear doctors this is to help us all brush up on our basics of pulmonology so I hope you all are all ready and excited let's get this started yeah on your right hand side you should be able to see the quiz screen and uh yeah let's roll this is your phone so better audio quality you cannot use the comment feature when question is displayed on the screen for obvious reasons don't reload for every correct answer you'll get plus four points and you lose one point for every incorrect answer so choose the answers as quick as you can you have 20 seconds and scroll down to view all the options if the questions are long just scroll down round one is called warm up here you go which of the following diseases is included in the umbrella term COPD [Music] calculating the scores you should be able to see the right answer on the screen foreign think of it like a fastest finger first solution kind of a situation so as fast as you can foreign moving on to the next blue bloaters are sealed in thank you the correct answer is C chronic bronchitis I hope you got that right investigation of choice to confirm your diagnosis in COPD foreign this brings us to the end of the warm-up round let's see the leading doctors here so Dr ziel Dr gurmeet and Dr Jessica Arora after round one these are the doctors who are in the reading spots let's quickly move on to round two shall we it's called Foundation I hope you're ready how can you differentiate between emphysema and chronic bronchitis [Music] it's getting more competitive now doctor this is round two okay it was option number B let's move on to the next identify this important clinical sign paradoxical in drawing of lower intercostal muscles during inspiration yes who was signed sixty percent got it right that's nice let's move on to the next choose the type of emphysema with the highest risk of spontaneous view motorized [Music] yes option b paracetyl let's move on to the last question shall we also you can scroll down to see all the options I hope you're clear on that role of steroids and COPD treatment is [Music] [Music] that was option number c reducing the information and exacerbation let's have the winners of round two shall we okay that's Dr lipaneshwar Reddy Dr Vishal yadav and Dr ziel Mithani congratulations now we're going to have the final winners of round one as well as round two so this is the final scoreboard and the winners are the Dr Vishal yadav Dr ziel methani and Dr mithuneshwar Reddy congratulations dear doctors metrics will get in touch with you for your surprise gifts we're thankful for your participation and we're very happy that you all have actively participated and we hope to see you all again in the continuous quizzes that we are going to have uh all the piece so we're going to get in touch with Dr Vishal Dr Zeal and Dr neshwar shortly post the session uh as of now we will continue with a session we could also take a snap of it if you like uh doctors I'm sorry let's read already passed you should be able to see a snap item uh just for your reference plan you could take a screenshot of your winning scoreboard there Dr Vishal Dr Fazil and Dr Milton with that let's close the quiz shall we let's get back to this enriching discussion that lays ahead of us uh Dr salvindri has covered a lot of basics in pulmonology which you will be able to see in a replay section under the club foundations of medicine uh this will help all of us brushes on our Basics and all of you doctors did wonderfully in our quasia handing it over to Dr harshita Mishra who will be presenting a very well known case in pulmonology with our experts and faculty and mentors okay it's not an exam okay we are just going to discuss this case right yes sir thank you um I'll start with the case uh my patient a 40 year old male came with complaints of breathlessness in three days cough with expectoration since three days and swelling in bilateral legs since three days patient was apparently all right 20 years back when he developed breathlessness on walking uphill which gradually progressed to such an extent that he could not keep up with his peers on walking since the past two years breathlessness gradually progressed to being uh present on walking or at for around 100 meters since three days and patient is breathless at rest since one day patient has no history of breathlessness on lying down no history of waking up in the middle of the night suddenly which had announced deathlessness no history of diurnal or seasonal variation of deathlessness no history of any postural variation of represents patient has complaints of cough with Canty mucoid expectanty whitish expectoration since the past four days which is around 100 to 20 10 to 20 ml per day not found swelling no blood in sputum no positional or diagonal variation in the cuff no aggravating or relieving factors are present patient has complained of bilateral lower limb swelling since two days which is gradually increasing there is no history of pain in the legs or redness over the legs no history of local rise of temperature no history of any diagonal variation and most of any positioning variation as well patient has no history of chest pain now instead of fever sore throat rhinitis no history of any loss of weight loss of appetite patient has no history of decrease during output patient came with above complaints to in our OPD and he was admitted and treated with injectable medicines and oxygen according to the patient he has a history of pulmonary tuberculosis in 2018 he had taken six months of anti-tuberculosis treatment he has history of similar complaints of breathlessness in March this year as well March 2009 when did he have tuberculosis how many years ago he had tuberculosis in 2018 sir which is five uh four years ago sir and at that time he was treated completely at completed six months of anti-tubercular treatment patient also had similar history of breathlessness in March 2022 and he was treated with some injectable medications and nebulization patient was discharged on inhalers and he has been using inhalers on and off since the past 10 years he has been getting inhalers from local local doctors no pass history of diabetes no history of diabetes hypertension ischemic heart disease cerebrovascular accident no history of any tuberculosis contact recently no history of respiratory illness in the family a patient is married having five children living in a rental single room with three roommates he is a pan mender by occupation and according to modified Swami scale he falls in the low middle class group he's having adequate amount of sleep appetite is normal having mixed diet and regular bowel and bladder habits patient is vaccinated against covid-19 he's a tobacco chewer and since four to five years but denying any other addictions a patient does not have any virtual or any environmental smoke exposure on examination uh one second now I want to become a nasty examiner okay because there are two types of examiners those who always you know praise the student and gives very poor marks and and there's those who are who sound very nasty and the student feels okay now I have made really bad answers and they find that they are actually got good marks okay so I will be somewhere in between so I'm making a little things lighter for you so now at the end of History you know there are people who ask okay at the end of History what do you feel is happening in that patient's lung so if I ask you that what do you feel is the impression which you would like to give us um so my first uh differential uh patient is according to me suffering from obstructive airway disease uh my first differential would be chronic obstructive pulmonary disease and my second um um differential could be bronchial asthma sir um so okay anything else or these are the two things which you would like to presently hold on at the end of the history uh so at present my differentials would be chronic obstructive obstructive airway disease firstly chronic obstructive pulmonary disease and the second difference okay so I when I say very good does not mean they are always right okay they may be wrong your answers may be wrong but I still say very good so now you please tell me what points do you feel are in favor of saying that this is chronic obstructive pulmonary disease um so Chronicle um so first is the uh history of long-standing breathlessness a patient is having long-standing breathlessness um secondary uh patients breathlessness um has been improved on taking um inhalers uh and his exacerbations are reduced on taking inhalers um thirdly patient has a history of uh tuberculosis so that could be um it could be secondary to um an infection infection like tuberculosis my points favoring uh bronchial asthma would be that so you told me three points which according to you favor COPD one you said that patient has got a long-standing history second you said that he gets better with the treatment of bronchodilator and third you said that is that here history of tuberculosis also so patient is having bilateral pedal edema so that could be a that is one of the commonest complications that we see with patients of COPD that they can land and write out failure so that can also give us a so so now I'll I'll try to understand what's happening with this gentleman he is a non-addict at least he's not a smoker he's a puncher right he's not a smoker yes no sir right so the the most most common though it is not the common there are many other reasons of COPD but one of the reasons of cigarette of smoke of COPD is being a smoker which is not there in this person right yes because when you say that I feel this could be copied there has to be uh understanding as to why is this person developing COPD without that explanation we cannot have a differential diagnosis like there has to be because that will obviously come in history no investigation is going to tell you what is the cause of its COPD that is going to be on History taking only yes so since you have considered that this could be COPD yes sir have you considered what could be the reason why he is developing COPD uh sir um there could be because this symptom started at a younger age group which is he's currently 40 year old and his symptoms started at 20 years of age um there could be a com it could be a genetic cause of COPD um secondly he could have had environmental exposure to smoke which he was um currently he's not giving history but which he was um unaware of uh thirdly that he could have because he's a panchur he's a pan seller pan vendor uh he could have been exposed to a lot of uh passive smoking uh from the people who come at the pan stolen have cigarettes also um so so I take your second and third explanation valued that okay he is a pan seller so he's maybe working in a place where people are smoking and they are standing there is exposed to the uh BD smoke or the cigarette smoke but what intrigues me is that his age of onset right 20 years now if you say that it could be genetic then there was nothing since childhood till 20 years of age right and when you are implying it to be genetic you are probably talking about alpha 1 trips in deficiency right because that's one of the reasons which we know could be a genetically mediated cause of COPD yes sir but then for 20 years there was no symptoms at all related to that yes which is again something which is a little mind-boggling as to why should we develop after 20 years of his age and let's assume that you are saying he got exposed to a passive smoking but that too at the age of 20 means he must be exposed to it for a few years or more years before that because for us to say that he's got empty SEMA or COPD or chronic bronchitis and to become symptomatic there is a definite time Gap from the time he got exposed to XYZ substance and then he develops a disease and gives rise to some symptoms yes it's such a very younger age which you are presenting a case of COPD right so there are a few you know unclear areas in your diagnosis of COPD except that yes there could be a exposure to dust or maybe to exhaust or outdoor air pollution not knowing where his childhood went is important like where was his childhood was he staying in a village was he staying in a place where there was Chula cooking and would smoke in his Hut or in the place where he was staying because in case that is happening so since the age of say eight years or nine years or 10 years he has been exposed to that kind of environmental pollution and that could have possibly led him to develop early changes of COPD at a age which is very very young even in today's era when we talk of COPD yes agreed 40 is one of the age groups where we definitely get a patient of COPD that's still the commoner age group is still on a higher side yes right so this is one gray area where we need to keep our keep in our mind that are we really dealing with COPD if yes then what could be the trigger or Reason of this okay so I hope I'm not confusing you just trying to explain the way you need to think about when you present any case this is just an example of what you're presenting right now second differential is your point of asthma see now COPD and Asthma are like you know significantly different uh parts of obstructive airway disease but here we are differential diagnosis we are considering either it is COPD or asthma so what points are in favor of asthma according to you um so actually the points which were in favor of asthma were that patient uh actively uh was patient had symptoms since 20 years he had a history of pulmonary tuberculosis in 2018 but before that also he was having symptoms of breathlessness and he actively was not a smoker so that is why I thought that that could also be a one of the differentials that patient is actively not smoking but I kept it as my second differential because there were a lot of points against it also that he was not having any sore throat rhinitis since childhood he was not having any wheezing episodes so and that is why it was not my first difference okay so let me put it this way let me put it in a different way suppose you have another patient yes who actually has asthma okay I am telling you that the diagnosis is asthma in that patient in the second patient what would be his way of breathlessness type of breathlessness if you know that okay um some patients with asthma use usually have a breathlessness which is associated with episodes of wheezing and chest tightness and there is also a diagonal variation in breathlessness they usually come with early morning breathlessness and a cough and they also have um episode of um uh sore throat rhinitis which is there since many patients give childhood also asthma patients give history of sore throat and rhinitis they also give family history that either the mother or father was suffering from asthma so in such situations but usually the early morning breathlessness associated with chest tightness and wheezing episodes gives us more so Dr harshita you know I just explained to you what happened right yes the characteristic difference between an asthmatic and a COPD is the reversibility of the symptoms yes that is the characteristic what you said that there could be genetic causes or early mornings or causes or sore throat or Diamond variation Force these are fair enough these are important reasons triggers but the characteristic of breathlessness in asthma is its reversibility when I say reversibility it means that if your patient says Dr Saba had breathlessness for last couple of weeks I got treated and I was absolutely asymptomatic for the last three years and again I started getting this wheezing in between that I was I almost forgotten that symptom I never felt that I had listened now that is asthma okay okay that is asthma so there has to be an element of period of normalcy attacks of breathlessness wheezing for because of some trigger is treated again becomes asymptomatic then some trigger comes again symptoms wheezing again because so this wasn't happening in your patient no sir so that means that there is a disease process which has started as acute become Subacute and now it has become chronic but it was not a process which was acute asymptomatic acute asymptomatic acute asymptomatic so if if you are not presenting it as paroxysmal attacks with reversibility then I don't think we should be utilizing the world as asthma in our differential diagnosis okay having said that there are certain patients who begin an asthma and gradually over the period of years they develop irreversible Airway obstruction so they start behaving as COPD like chronic persistent asthma they start behaving as COPD but the history in the beginning is like an asthmatic yes but then your patient is not fitting into that as well because in the initial period of his life he never gave that history of certain episodes and exacerbations so even in that respect we cannot consider that okay this fellow is now presenting as a COPD but actually he started off as a asthmatic correct am I getting you getting yeah so so even that I don't feel is fine let me put you a third query let me see how much you can answer this okay this patient has come to you in your clinic you have started your clinic first Clinic okay and you are sitting there and the first patient comes this is your patient and you tell him okay see I feel this is COPD he has his relative along with him and that relative asks you sorry madam interstitial languages so what would be your explanation or why are you not thinking of IIT um so I am currently not thinking of ird because uh in um in ild also um if I'm to think of ipf that occurs in a later age group and it has a causative factor of smoking so uh which the our patient is not giving a history of smoking um that is why I did not think of ipf's uh currently that is that is that usually one one reason of an eye there are autoimmune causes of ilds yes um so I I can think of it um I thought of if it could be hypersensitivity pneumonitis I did not think because patient is not giving any history of any exposure uh to indoor pets or uh um pigeon um or droppings and uh autoimmune iodizer um I haven't with a patient okay I'll tell you I'll tell you one thing which again is a little confusing for me is about his history of because you mean you have said that the cough is there see now that we are all discussing this based on our third person who has told you what he has been able to explain so not that every patient is a good historian means they don't give a proper history they don't answer correctly there are very vague answers at times that's why we may be a little you know at a difference of thoughts as to what exactly is happening but cough is there since last three days only he's been having breathlessness for last 20 years yes but the history of cough you have made a mention that history of coffee is there since three years I mean three days so it has never been come up like he's got cough off and on it was reduced yeah uh sir when I had asked whether the 20 years he refused but in the episode of breathlessness which he had in March at that time also it was associated with cough but that got completely resolved and three days prior to coming to our side before that he was not having any cough sir uh so there was one prior episode of cough which was associated with the breathlessness episode in March 2022 but I don't know how you're going to explain that at the end of your findings or examination because that is something which you are not able to at least I am not able to understand and see as I said you know certain things certain things the patient may not be able to tell you exactly how serious it was or how much it was but you need to you need to correlate few things when you come to a diagnosis like I don't feel there are patients of 20 years history who never have a cough for last 18 years or 19 years and then cough only since last three four days even if it is COPD even if it is ild even if it is pulmonary edema even if you are talking of any kind of a lung problem lung pathology unless unless there is kyphosclerosis which is giving rise to a restrictive lung disease and the patient is having you know more of breathlessness but even then 20 years is a very very long history yes where the patient should be ideally having intermittent episodes of respiratory infections it may not be that coffee is continuous but they would be getting lower respiratory infections they are predisposed to infection so yes there has to be that so I think you should red flag that history about three days and change that bit tweak a little so that you get away from The Examiner okay so keep that in mind fine so these two three possibilities we are considering then on examination you are mentioned I'm sorry on examination patients are sitting comfortably upright with IV line and C2 in the right hand is conscious oriented to time place in person he is average bill height is 167 centimeters weight is 65 kgs and BMI is 21. patient is a febrile pulses 112 beats per minute in the right radial artery with regular rhythm normal volume Force tension and no radio radial and radio femoral delay that pressure is 120 by 70 millimeters of mercury in the right arm in setting position respiratory rate is 22 per minute grade 3 clubbing is present in both the hands there is no parallel ecterosinosis lymphadenopathy bilateral pitting type of PD edema is present in the knee um upper respiratory tract the tonsils are normal uvula is midline tobacco stain teeth are present poor or oral hygiene is maintained and no deviated nasal septum or no polyps are same uh on inspection the shape of the chest appears normal chest movements are bilaterally equal uh Trail sign yeah can I can I just stop you for a minute yes yeah so see when you examine now going back to your possible explanation of why the patient could be having COPD one of the reasons you said it could be genetic yes and then we thought it could be Alpha One anterior option so now you know there are certain clinical signs which may say that this is marconoid feature so there is Alpha encryption so when you examine this patient then keep those things in mind they may be asked by The Examiner or not as per the examiner but when you utter that a one of the reasons could be genetic that to an emphysema patient then the height matters IRS palette matters yes the wind the the extremity span matters so all these things need to be remembered when you're just doing the general exam yeah sorry continue yes on inspection the shape of the chest appears normal chest moments are bilaterally equal Trail sign is negative if x impulse is not visible no supraclavicular Halloween is seen no intercostal retraction see subcostal angle is appears obtuse no shoulder drooping scene spine appears normal spinous scapular distance appears bilaterally equal no dilated beans cars or sinuses seen and cricos terminal distances uh two finger on palpation inspector findings were confirmed on palpation no local rise in temperature no tenderness apex beat is palpated in the left fifth intercostal space just middle to the mid-clavicular line chest movements are bilaterally equal anterior posterior diameter is 24 centimeters so transverse diameter is 28 centimeters with the ratio of 0.85 just circumference is 90 centimeters with right and drift hemithorax measuring 44 and 46 centimeters respectively chest Excursion is two centimeters tactile vocal parameters is equal on both sides on percussion clavicular percussion is resonant remember what all you said that's why I stop you after some time so uh one is that you mentioned that there is clubbing present yes now 40 year old Club is present respiratory disease I'm not going into non-respiratory causes of loving there are many you know very well so what what tells you that what is happening to this patient why is that loving um so clubbing could be because of superlative lung diseases like bronchic disses um my first um first disease that I could think is bronchial patient has had a history of tuberculosis and it could be a complicated it can be a complication of tuberculosis um second is uh so firstly I would think of bronchic cases other superlative lung diseases are lung absence um and malignancy but the history is not suggestive of those diseases so my uh the first disease I would think of is bronchitis so now let me put you in a fix first is that you said that I could I think this could be COPD there was no mention of bronchic cases in your differential diagnosis on history at least yes on General examination you said there is grade 3 clubbing yes sir and you fell feel that that it could be usually clubbing is seen in bronchi accessories or Superior lung diseases so how are you going to sort of you know join the bridge so um classes um probably patient uh was having um COPD the bronchic nasus has come up as a complication of the tuberculosis it could be a post tuberculosis complications uh in this patient are you sure you're trying to build the bridge or making it more wider so so Dr harshita now let me say that see when I ask you doesn't mean you are always correct right so now bronchic cases was there even in any history which was suggestive that the patient has bronchitis um no sir no history no history because history has to be called lots of expectorations not there so we can't even utter that sir there could be wrong possibly bronchial cases because I feel there is loving but now the history is not suggestive of bronchic cases but clubbing is suggest your bronchitis is so now you know you are you are like not able to explain how to justify these things so let us let us try to make it a little easy for all of us even for me it was the same when I was in mbbs or whatever you are doing around I was very confused about this clinical science but one thing is certain that there is no Clarity on the mechanism of clubbing except one Theory which stands true is chronic hypoxia yes sir right so chronic hypoxia induces new uh what we call as neo-colonization or new cell formation and that causes the bogginess softness of the nail bed and the angle changing so if we say that there is chronic hypoxia then any lung disease which is chronic which is long term and leading to Chronic hypoxia will also be a cause of clubbing yes sir are you getting it yes now do you feel your patient has a chronic disc three yes sir yeah do you feel he must be having chronic hypoxia yes yes because he is having exertional breathlessness he is having gradually Progressive exertional breathlessness that means he must be having gradually Progressive chronic hypoxia yes sir and that is one of the reasons why there could be clubbing okay understand so now we are able to close the gap that we have heard a patient forget the diagnosis of COPD we have a patient who is developing chronic hypoxia and he's also got clubbing which is possible right and presently with the given history the commonest reason why he is developing is because of obstructive airway disease disease so bronchitis is not in the picture at this point of time neither is superlative lung disease neither employment neither lung addressed by by that particular explanation uh one more thing which you said on examination yes now I am going putting a step forward what what do you feel is the reason of the pitting edema Peter edema um could be a complication of uh the lung disease the patient could have landed in a right heart failure or permanent situation correct now let me let very good this is a perfect way to answer there is pulmonary there is called pulmonary which is again because of chronic hypoxia happens after pulmonary hypertension yes correct now pulmonary hypertension right ventricular enlargement can also be a sort of evaluated on clinical examinations yes so you will have to think about the raised it is jvp you will have to think of diastolic shock you have to think of parasternal heat which you need to remember you must have examined I am sure but I am just trying to so that the others also are along with us in this discussion that when we have a patient of chronic hypoxia when we have a patient with bilateral fetal edema and we are at some point of time going to mention that it could be core pulmonary then in your systemic examination we need to pay attention to the loud P2 we need to pay attention to diastolic him we should need attention to the parastern and leave so it makes sense about the right ventricular hypertrophy and right ventricular enlargement all right yeah now we propose it to your palpation of perfection yes uh Christmas is resonant bilateral lung fields are resonant in all areas the right heart borders purpose retro sternally and left heart border is corresponding with the apex beat in the in the causted space our liver is focused in the right fifth intercostal space in the mid-clavicular line right six sorry uh seven intercostal space in the mid axillary line and Ninth the recostal space in the mid scapular line a tidal percussion was present are the liver span was two centimeter drop space was done in percussion um on auscultation bilateral breath sounds were a vesicular and equal expiratory were heard bilaterally in memory intramammary axillary interscapital and interest capular areas bilateral mid-inspiratory repetitions were heard in infra mammary auxiliary and interest capular areas which were coarse in nature vocal resonance was equal on both sides forced exploratory time was eight seconds other system examinations the cardiovascular system uh allowed P2 was also no additional murmurs were hospitalated in central our system examination more focal neurological deficit was sensor and per abdomen was soft no organomes um very good so so now you finish the examination also right yes so now now everything fits into place how much is your final diagnosis now um so I would uh my final diagnosis is um chronic obstructive pulmonary disease uh with um bronchic acids course repetitions are I think it is foreign but okay now let me ask you in a different way other than bronchic dresses yes what would be the causes of repetitions leave it wrong like this so repetitions can be present in uh interstitial lung disease they can be present in um any console with the consolidation or pneumonia um repetitions uh can also be heard in um an A5 post fibrosis a post tuberculosis fibrosis um okay now you are answering perfectly you are doing very well I'll still like to probe further if at all the Airways okay the Airways contain secretions there's a lot of mucus and we oscaled it over it yes repetition oh yes sir I've been here preparations right yes because because every bubbling of secretions patiently inhaling air goes in there is bubbling of secretions and we hear that inspiratory sound which is called as preparation now if there is secretions in the bronchi yes which I mentioned is Airways I am now labeling them as brown fan yes now the bronchi is pouring secretions into the bronchial tree because of inflammation of the bronchial mucus glands then what will you label this disease as the bronchitis right so if we put it again one two three is that there is a patient who has got chronic hypoxia there is a long-term history there is clubbing also present on examination there is bilateral wheezing also and there are bilateral repetitions also so what could be the possible disease with the patient is going through chronic obstructive pulmonary disease chronic bronchitis will be more precise if we are talking of secretion however however even emphysema presents with crepitations it is not that emphysema means no repetition even empathy Mark and present or rather presence with repetition okay so rather than you mentioning that since there are computations I still think of bronchic cases it would be more wrapped to say that this could be a patient who is having COPD as a baseline disease is come with the exacerbation yes that's why he is a hypoxic in three days that's why he become more breathless since three days because everyone exacerbation and that exacerbation led to inflammation of the bronchial mucosa which led to narrowing of the airway when there is narrowing there is wheezing so we could hear the bilateral bees at the same time the mucosa was getting inflamed so there was mucus also and that was contributing to the repetitions yes so then we are still sticking to our plan of action COPD so you need to just have to justify this but justify logically yes that it could be still COPD and I'm still sticking to my standard it is chronic obstructive pulmonary disease right so bronchiectasis let's try to forget for today night tomorrow what you want to think you can think right with when you say diagnosis it would be COPD with exacerbation with with complications we stick to that but how will you confirm your diagnosis that's what the people want to know so confirmation of COPD is always done on spirometry but in acute exacerbation states are uh we want other patients uh might have a falsely lower values of spirometry Sir um initial investigations that I would like to do would be an RTG broadcast analysis a complete blood count I would like to get an xrhs done for the patients and based on that sir I will go with the further investigations okay you have the X-ray or you you have this yes okay uh putting up the chest text right uh doctors you can zoom in if uh you'll want to zoom into the extent here just putting it up okay so Dr harshita you know see the questions matter I mean this is how what my examiners is used to you know to teach me that if you are asked how will you confirm the diagnosis you need to tell the name of the test which confirms your diagnosis right now ABG you said is an important investigation and we are of course going to do an ABG cdec is an important investigation we are going to do a CBC no doubt but what gives you more information towards a diagnosis will be the structural change which happens yes and that will be seen on an X-ray so the first yeah will be seen on the first would be obviously we will do an x-ray CHS because suppose you see multiple honeycomb being appearance multiple CIS bilateral or localized yes you can say okay this patient oh I missed the history it was not proper but actually is actually in favor of bronchic cases and so on correct so x-ray is a very very important test uh investigation in this not to confirm COPD rather it is to confirm or rule out the other decisions yes right so in this x-ray do you feel anything is abnormal um so uh this is um x-ray behavior of my business that's fine abnormal sir um so first is that uh there is there are cystic opacity is actually presence here in the left side left lowers on left middle zone and right lower Zone also prominent prominent Bronco Escalon markings are also seen there is no evidence of any hyperinflation sir uh cardiomechanism apparent cardiomically also is is present okay you know I will I I'm still not convinced about that cystic changes now I will ask you one more thing yes okay cardiomegali let's leave that because it seems to be an expiratory plate doesn't seem to be an inspirational difference one two three four five so I feel he may be you know probably he's not taken a deep breath and held the breath and all those things maybe it is cardiomegali because we are dealing with a patient with a cardiac ailment as well so yes yes there is a cardiomegali cardiothoracic ratio is definitely altered yes but if I if you if if I ask you yes in a different way this patient is having left lower low bronchial cases okay I am putting it in a different way okay let lower low bronchic acid which is chronic means it's been there for last eight years or nine years or seven years what changes will you expect in that area changes in terms of the diaphragm changes in terms of the trachea changes in terms of the heart being shifted what changes do you expect which would be present sir uh we will see uh tram track appearance of the we can of the air visor uh then uh there could be fibrosis so there could be pulling of the uh mediastinum to the ipsilateral surface same side so now diaphragm is not pulled close to appears in the center yes sir all examination you said the shoulders were at equal level equal levels so none of them are fitting into your diagnosis of bronchiectasis or a chronic disease which is shrinking the lung or pulling the lung understood so we are somewhere you know uh sort of falling down whenever we say that this is bronchitis neither in history neither on examination and neither or maybe examination you said that because there was coarse repetition bilaterally but then if you have a course repetition bilaterally in the right side there are no cysts seen so yes so so this could be a confusion confusing uh case at this point but still we'll put our bet on COPD as the first diagnosis and I would still not you know put my money on bronchic decision anyway I will think that this is COPD with an exacerbation with right heart pressure okay anything else you want to show us about any other reports yes I hope the CT scan doesn't show bronchitects so actually it is then the history wasn't proper then yes there you go at Dr Hester you can swipe yeah when you're ready yeah uh Yes actually in this weekend uh this is the clinically yeah so this is the HR plate of our location uh we can say um I am bilateral areas of uh um sub-bronchitis are present sir and areas of air trapping are also seen uh in the right side yeah Mosaic elevation is seen so on the right sided right lower lobe we can see so and also sir in the um so in the upper lobes there is only air trapping sir no evidence of any bronchic classes but starting the middle Loops are in the right middle Loop we can see some bronchial title changes and in the bilateral lower lobe also more towards the left side we can see some static changes along with it numerical so your cities can picture confirms that there is bronchial cases definitely bilateral bronchitis now um I will ask you one question do you feel this bronchate test is started after the history of tuberculosis so what do you think well sir I feel it started after tuberculosis because we do not see evidence of chronic bronchic tassels so probably that it was not present for a very long time a patient had a component of chronic obstructive pulmonary disease but the bronchitis component has started after tuberculosis okay so now you would like to put your diagnosis COPD with bronchiectasis with exacerbation with car pulmonal and right heart failure correct yes but then maybe that that patient's history was not correct or he the patient rather did not give you a proper history because you know I I would I don't think anyone would agree that patient of bronchiat test is that to bilateral bronchitis yes and no history of cough for last 20 years yes too difficult to sort of you know have that sort of connection with the CD scan picture but we take your points and there's always a learning experience so bronchiectasis bilateral now how old how are you going to plant the treatment um so treatment would be first to uh first if the patient is coming in exacerbation sir we need to look at the ABG and the CDC first if the patient has is come in type 2 respiratory failure then we need to put the patient on a non-invasive mode of ventilation uh for time being sir we will also look at the counts of the patient if the patient is having leukocytosis we will put the start the patient on injectable um so these are the blood reports of the patient okay so now from this reports what will you do uh so this um a hemoglobin is normal so that is my leukocytosis 13 280 with a neutrophilic predominance here so we will start the patient on injectable um antibiotics because the patient is having grateful breathlessness we would also like to relieve the acute exacerbation by starting the patient on injectable steroids or nebulizations with bronchodilatus and we start the patient on nebulization with salbutamolicium and injectable or steroids like hydrocortisone so that we can start for the relieving the initial information um we'll put the if the patient is hypoxicillin we will I put the patient because in this case the ABG is corrected so uh we will put the patient on moisture Oxygen by a nasal peroxide to delete the hypoxism um after uh um we will also do his putum reports uh sputum culture uh will be will censor routinely and because patient has had a history of a tuberculosis and is having cough even though it is an acute history we would like to send a sputum sample for Gene expert also see um okay so uh Dr harshita one question I had in mind is uh something to introspect I'll place this patient in a different picture let me see if you can scratch your brains yes Yes Man no specific cause of his obstructive airway disease yes okay no specific cause but he has got bronchiectasis yes his IG level is high yes sir anything which you should be ruling out or thinking oh yes I would like to a rule out uh allergic aspergillosis in this patient uh PC system bronchitis Central bronchic acids and patients of ABP and I would like to do an absolute eosinophil count of the patient and would further go on with investigation of total IG preferably taken out before the steroid sample is being administered to the patient if the total IG levels are erased and cut off that we are better so good good I just wanted whether you know you have that thought in your mind at some point because these things abpa I think everyone should know that that ABP is something we shouldn't miss out in patients with asthmatic history or patients with bronchitises especially having hyper reactive Airways so please don't forget that this patient could be actually having underlying ABP so something which is very important so now you're treated very well I think your antibiotic manage management oxygen management will be perfect I want to know from you how will you manage this patient on OPD basis now he's stabilized yes he is not going to reverse in terms of his airway disease what will be your prescription when you want to tell him for a long term maintenance therapy yes sir on long-term maintenance therapy I would like to prescribe meter dose inhalers to the patient on subsequent OPD follow-up I will uh every time the patient is following up with me in the OPD I would like to check the technique and of the inhaler whether the patient is taking the enemas properly or not I would also like on OPD basis to get a spirometry done for the patient so that I can assess the level of obstruction in the patient um also um um I would like to um add I would like to enroll the patient pulmonary Rehabilitation so with the adequate nutritional support just a physiotherapist or an emotional social support for the patients I would like the patient to have this regular vaccinations because it is a case of coating um influenza pneumococcal vaccination a covert vaccination pertussis vaccination and data vaccination which has been included and today also you have done is uh uh no sir in this patients but we would like to get a two-day a good answer for the patient to look for uh the degree of the pandry artery hypertension very good so I think the urban you know summarize it everywhere very well now only one aspect remains in the treatment plan is for long term bronchiatasis there is also a recommendation for either nebulized antibiotics yes or macrolyte microwave prevention and this candidate I think is a is an optimal candidate because bilateral bronchial cases he is going to get an exacerbation young patient so the more exhausted patients he has his lung capacity will drop in further so we need to follow him up and educate him about uh macrolite therapy privately and then further on managing from there onwards anything else you want to tell us about this case reports or anything you want to show the history was a little confusing so I think of all of the audience have also you know liked the discussion which you give and I'm sure you'll meet a good doctor in the future thank you so anything from the audience uh they want to ask any questions to her or they want to discuss Ed so we're all thanking our lucky stars just to be able to sit here and witness this amazing discussion that was going on between the two of you it was like a sponge we are all absorbing from each of you thank you so much uh Dr as well as Dr Patel thank you thank you sir thank you so much to that is why oxygen since the spo2 was 92.8 if that's what I don't know can explain I'm sure um sir we have um so we have seen many patients who are a little tactically um in the initial phases of their admission oxygen support helps them in that attacking yourself saturation was 92 sir but a patient had come in a cutex acid patients for a brief period of time only we had put them on moisture and is becomes and when the Target near resolved we had removed oxygen so so it's like what you said is very beautiful it's very nice but the the Crux of the issue is that you use more scientific words because it's a question coming from a doctor so we need to explain them scientifically so your answer should be to reduce the work of breathing yeah so you explained it perfectly but the sentence you to be used was to reduce the work of breathing and second the more the muscle work more latex will that lactic acids will get generated so there will be easy muscle fatigue particularly So to avoid these things considering the tachypnea the respiratory rate was high patient was put on oxygen so that the work of breathing will reduce two more questions how much time we should should we give derivative orally acidro or dairy is questioned by Dr Lee said how much time should we we should give derifying orally how much time means how much duration yes so in COPD theophylene has shown to have action in terms of bronchodilation it has got ionotropic action it increases the diaphragmatic contractility it also has a minor diuretic effect but the main therapy in uh even COPD remains anticholinergic inhalation therapy okay so we have got good inhalation techniques and good devices now and always a theophile in uh Agonist is a adjuvant to the annihilation therapy we should never give only Dairy file in or only acid profile in and treat the patient of COPD so once you start the patient on theophylins of course you need to monitor the progress you need to do a spirometry see the symptom Improvement and you can always get the patient back to only the inhalation therapy and stop the theophyll so that will depend on the clinical assessment and the spirometry Improvement any sign of RV enlargement in chest x-ray so Dr harshita what do you feel you are you and I are in one team oh no [Music] uh I just felt it is cardiomechanism um yeah so less likely to be right ventricular enlargement on this x-ray someone asked about your xenophilia so eosinophilia we consider that if the absolute eosinophil count is more then it's considered as yosynophilia if it is more than 350 some book stock of 500 but 350 and above is considered a significant uh eosinophil count and again in our country many causes of eosinophilia especially warm infestation parasitic infestations they can or even drug-induced geosynophilia is known the medications can lead to eugenophilia so we need to consider those as well so yes uh 2D Echo wasn't done uh did I catch that right wasn't done the patient requested or discharged by prior to that but we are planning on doing it on opening basis okay see I hope the dancers questioned of Korea uh yes so with that we can wrap up thank you so much Dr salil as well as Dr harshita this was a super interesting discussion uh we still have couple questions coming in doctors you all will be able to see the replay of the discussion in the replay section should we continue and take a couple of more questions yeah okay is the main person here she should be ready yes yes I'm just taking uh what are the Target saturation levels you would like to maintain in COPD patients with and without core pulmonary are the target saturation level that I would like to maintain is 88 to 92 percent you know COPD patient so that the patient has that resting hypoxemia Drive present in the patient and that goes without uh if the if the patient is having Corporal mineral or not I think um yeah absolutely right that's fine what you said is right so Baseline saturation of 89 to 90 and one of the reasons why we start load long-term oxygen therapy is there is a nocturnal desaturation or there is the desaturation along with pulmonary hypertension so this gentleman is most likely to have pulmonary hypertension but I think a target of 88 to 90 is what what is the one which is recommended in these patients foreign


Here's another fascinating episode of the fantastic show 'Case of the Week'! Join us as Dr. Harshita Mishra presnts a very commonly seen pulmonology case and our host, Dr. Salil Bendre will guide us in reaching a diagnosis through highly logical investigations and a comprehensive clinical exam. It's a massive feast for all residents across the nation. Say no to exam anxiety and embrace the #JoyOfLearningMedicine. Stay tuned on October 6th at 9 p.m IST.


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