By the look from the title above, you might think that I’m gonna discuss about certain brand of shampoo, I presume. No, it’s not it. :)
“Rejoiced!” is the first word that occurs to me when I first realize my feelings about my newly-designed tumblr blog. Yes, I felt rejoiced. Rejuvenated. Whatever you may call it.
The idea of changing the design itself was born when I mused as I tumblewalk (if only such word does exist) my own tumblr account. I came to a conscience in which I found that I merely concerned about my cups of tea (poetry, wordsmith, wordplay, design) and wrote about them without paying any attention towards my profession as a doctor. I admit that I seldom, if not never, write about health issues and other things like that. It seems that I unconsciously deny my fate.
Well, “what kind of man who denies his own fate?”, I said to myself. It sounds so atheistic and pathetic. I don’t wanna be one of those people who keep themselves busy finding excuses so that they don’t have to fulfill their own destiny. To me, there is no fate but what we make (as Sarah Connor might say). And denying that fate of ours is nothing but the same as denying our existence.
Quite complicated right?
Well, long story short, I decided to re-design my tumblr in order to accomplish one goal: to give more room for myself to explore my own profession, my world as a doctor, and even better, if I must, to educate people about the intangible importance of being healthy.
To reach that goal, I set up some mission in form of ‘tagged pages’. For those who doesn’t know about “tagged pages” should read about it first here. By using this facility, I manage to have several new pages namely “Ward Round”, “Morning Report”, “Emergency Room”, and “Coffee Break”. “What is it all about?”, you may ask. Allow me to explain, then.
“Ward Round” is a collection of cases an attending physicians or interns might find in the ward during their daytime work. Each case will begin as a case illustration that consists of short history taking, relevant physical examinations, and laboratory findings. Afterwards, a discussion follows. The topic of discussion will mainly focus on differential diagnosis and diagnostic work up of the case. I choose this strategy as the mainframe of this tagged page since I have observed that during my clerkship in the ward, I used to have sufficient amount of time to think about the differential diagnosis of my patients. Therefore, I somewhat try to put the practice of critical thinking in working with the differentials to solve one’s problem.
“Morning Report”. Well, who never had one? The thrills of your heartbeats during the critical moments of your presentation. The chills running through your fingers and feet as the questions flow from your scariest senior consultant. Don’t you miss that? :) To recall those memories, I present you “Morning Report”: a collection of cases an attending physicians or interns find during their period of night duty. Each case will begin as a case illustration similar to that of “Ward Round”. However, the mainframe of discussion differs. After each thorough case illustration, there will be challenging questions as your senior supervisors might ask in medschool. And, for each question, I will try to answer with a cutting edge knowledge as they might expect. Isn’t it challenging? :D
“Emergency Room” is a well documented real cases I manage during my work in emergency room. For some ethical reasons, of course the gender and other related information is changed. But, I hope it won’t change the essence of learning I would like to propose in this section. Here, we will see a short case illustration followed by a simple question that one must answer prior to conducting the next step of diagnosis. For example, I will only reveal the chief complaint of the patient and several physical examination data and then I will ask a question about the differential diagnoses one might consider in the light of the data provided.
And the last tagged page is “Coffee Break”. As you might expect, it consists of other trivial things that is medically-related or not. But one thing is for sure, you don’t have to think hard about it. It may come as a medical joke, a high-end medical technique, or even simple things in life that never comes to our mind.
I hope it can be a means to motivate ourselves to be a smarter physicians and help others to create a better way to lead a healthier life.
And, uh, about my previous posts… I’ll figure something out to keep the records. Let me do the worries. :)
Case I, 49-year-old female with fatigue and shortness of breath (part I)
49 year-old female was sent to the ER due to fatigue and shortness of breath since two days prior to hospital admission. She was brought by her daughter who appeared to be her caregiver as well. Further alloanamnesis revealed that the patient has been diagnosed with type II diabetes mellitus since 2 years ago and has been out of medication for a week. She also had recurrent episodes of retrosternal chest pain 2 days ago. Each episode of chest pain may last variably for 30-60 minutes, caused a sensation like being stabbed with knives, subsided while she was resting, and got worse with exertions. She had no history of previous heart disease, hypertension, renal disease, and liver disease.
On physical examination it was known that she was fully aware and responded adequately towards physician’s instruction. Her airway was secured, no stridor, no gargles. Her respiratory rate was 34x /minute, fast, and deep. She had cold extremities, her radial pulse was weak, and her heart rate was 43x /minute. Her blood pressure was 78/45 mmHg and oxygen saturation was 78%.
What are the problems/ possible problems of this patient?
1. Suspected cardiogenic shock
2. Suspected myocardial infarction
4. Uncontrolled type II diabetes mellitus
What findings based on case illustration above that support your assessment?
My suspicion of cardiogenic shock arose from the fact that she had possible typical chest pain. Owing to the fact that she had long standing diabetes mellitus and based on her gender, it is possible that the presentation of typical chest pain might be atypical. However, in this case, retrosternal chest pain that lasted for 30-60 minutes with sensation like being stabbed, subsided with rest, and got worse with physical exertions support the possibility of typical chest pain suggesting acute coronary syndrome (either a myocardial infarction or unstable angina). In patients with possible acute coronary syndrome presenting with bradycardia and low blood pressure, one must consider about the life threatening cardiogenic shock.
The patient had no history of previous episode of heart disease. This information might be misleading in a way that she might have episodes of silent ischemia which is very common in patients with uncontrolled diabetes mellitus and was underrated by herself or her primary physician. However, I’d rather choose to believe her and consider this as a new episode of possible acute coronary syndrome. Typical chest pain she suffered from is the sole information I had when she was sent to the ER and I consider that it is better to suspect a diagnosis of myocardial infarction.
Bradycardia was diagnosed based on physical examination. The only thing one must be aware of in patients with suspected myocardial infarction, bradycardia, and suspected cardiogenic shock is the possibility of complicating complete heart block. In 10% of patients presenting with myocardial infarction, complete heart block took place—especially in inferior myocardial infarction.
Why one should bother to think about this matter? Well, it is due to the higher likelihood of patients with inferior STEMI and AV block to have larger infarcts and more depressed right ventricular and left ventricular function than do patients with inferior infarct and no AV block.
At last, uncontrolled type II diabetes mellitus with a history of no pharmacotherapy for a week should raise a suspicion of an emergency in patients with diabetes: hyperosmolar non-ketotic state (HONK). HONK is more possible than diabetic ketoacidosis (DKA) for the patient presented with full awareness, which is not a common presentation of patients with DKA. However, in order to distinguish both disease entities, further examinations must be conducted.
Further examinations revealed that:
She had pale conjunctiva without icteric sclera. Her mouth was dry. There was no neck vein distension, no lymph nodes enlarged. The first heart sound was barely heard on the apex, there was S3 gallop, but no murmurs. On lung examination it was found that her breath sound was vesicular, no rhonchus, no wheezing. Her abdomen looked distended without any local bulging, no venous engorgement, and no pain on palpation. Her liver and spleen were barely palpable. There was shifting dullness and her bowel sound was decreased. Her extremities were cold, no cyanosis, and her capillary refill time was < 2 seconds.
What plan do you have in mind to support those diagnoses?
1. Suspected cardiogenic shock
Diagnostic plans: severe hypotension (< 80 mmHg in systolic blood pressure) that does not respond quite well upon fluid challenge, accompanied with apparent signs of congestive heart failure and well documented mechanical complications (i.e. valvular problems, aneurysms, pseudoaneurysms) or the evidence of left ventricular failure usually suffice the diagnosis of cardiogenic shock. However, due to the urgent needs to correct the underlying cause of cardiogenic shock, natural history of the disease that does not respond well with fluid challenge and aggressive vasoactive agents, and its high mortality rates (up to 80% of all cases of cardiogenic shock), I propose examinations as follows to determine the most possible and correctible etiology:
- ECG: to find the evidence of myocardial infarction or other arrhythmia as the cause.
- Echocardiography: to determine the existence of other mechanical complications other than left ventricular failure as the cause of cardiogenic shock.
2. Suspected myocardial infarction
Diagnostic plans: I would ask following examinations to diagnose the patient with myocardial infarction using the classic WHO criteria and support findings from history taking and physical examinations:
- ECG: to find the evidence of myocardial infarction and other arrhythmia
- Serum markers for cardiac damage: cTnT or cTnI
- Other measures: serum lipids, peripheral blood test, chest X-ray, echocardiography
The reason why serum lipids concentration is examined in patients with myocardial infarction is due to the evidence that hypolipidemic therapy may improve endothelial function and inhibits thrombus formation.
Chest roentgenography is of significant value in a way that it may show prominent vascular markings that reflect elevated left ventricular end-diastolic pressure. Besides, chest X-ray is also important to define which groups of patients with STEMI who are at increased risk of dying after acute event by qualitative interpretation of the degree of congestion and the size of the left side of the heart. However, one must carefully interpret the findings especially in acute and posttherapeutic state for significant temporal discrepancies may occur (the so called diagnostic lags and posttherapeutic lags)
Diagnostic plans: the only additional examinations needed to find the etiology of bradycardia is ECG.
4. Uncontrolled type II diabetes mellitus
Diagnostic plans: as I have mentioned above, it is possible that this patient may have an emergency in diabetes (HONK or DKA). Therefore, one must perform an immediate random blood glucose test to exclude such diagnosis. Apart from random blood glucose test, other measures should be taken into account to determine whether or not the patient has suffered from any complications of diabetes such as microangiopathy, neuropathy, and nephropathy. Those measures are measurements of ankle-brachial index (ABI), urinalysis with quantitative protein measurements (Esbach Method), and sensory test. But of course, these measures are of little value so long as the patient is in emergency.
In short we may conclude that a simple, quick, and focused anamnesis is required to find possible emergencies in patients presenting with mere fatigue and shortness of breath. A thorough investigation about past pertinent history such as diabetes and its related information (i.e. history of medication, patient’s compliance towards medication, record of blood glucose monitoring, etc) is of significant value if the physician is able to find the connection between current medical condition and that information.
Learning issues of this case are diagnostic approach used in patient with long standing history of uncontrolled type II diabetes mellitus sent to the ER with shortness of breath and possible myocardial infarction. In the next chapter (part II), I would reveal the results of proposed examinations above (if any) and we shall see the course of the disease in this patient.
“Listen to your patient’s signs and symptoms. They are telling you the diagnosis.” -MD Luthfy Lubis-