A sampling of patients from today

A 63 year old male who originally came in with significant hepatomegaly, ascites, bilateral peripheral edema, also with cough and dyspnea. He had an echo which showed significant right atrial and ventricular enlargement, severe right sided heart failure, tricuspid regurgitation and severe pulmonary hypertension (75mmHg). However his ejection fraction was 55% with very mild diastolic dysfunction, meaning he did not have left sided heart failure. The conclusion was he had cor pulmonale and the team determined it was COPD-related. But he had only smoked for 10 or so years, did not have a productive cough or increased A-P diameter, and his PO2 was 58%. Also, the team only noticed this today and hence today was the first time he was started on oxygen. Now can this really be caused by COPD?? Do we not see this significant cor pulmonale with moderate smoking in the US because we diagnose and treat COPD earlier? Or is this more likely a restrictive process like interstitial lung disease that we probably won’t diagnose because we won’t (or can’t?) do PFTs?

A 22 year old man who comes with a history of pleural and pericardial effusions who comes in with dyspnea. He has no edema elsewhere but has persistently low albumin of 1.9. He has actually had a fairly extensive workup including intestinal biopsy for protein-losing enteropathy (but no stool tests…), a liver biopsy (that was lost), and a bunch of labs including normal LFTs, normal urinalyses, sputum negative for TB, and a negative ANA. We know he is hypoalbuminemic, and has no history or signs of liver disease and is not malnourished. Plus, he only gets pleural and pericardial effusions, otherwise no other edema, which is strange. He will be discharged tomorrow without an answer but feeling better after pleural drainage (and may need to get another liver biopsy because the clinic who did it lost it).

A 34 year old man with pulmonary hypertension and recurrent pleural effusions who is in the hospital because he needs oxygen but can’t afford home oxygen. Again, the doctors attributed his pulmonary hypertension to COPD (but he’s ONLY 34 and smoked for 10 years!). However, he also has hemoptysis. And bilateral opacities on CXR. Oh, and when we checked his pulse it happened to be 205. WHAT?! He probably has paroxysmal SVT or something, but while an EKG, cardiac consult, and adenosine were theoretically ordered, none happened all too quickly. We’ll see what his pulse is in the morning.

Now for some positive news. We also have a boy on our service, 15 year old, who has sickle cell disease and came in with a pain crisis. My (amazing) registrar made sure to counsel the mother on what sickle cell disease is, what signs to look out for and what precipitants to avoid. She made sure he got an appointment at the MRTH hematology clinic, where he can get hydroxyurea (new here) and get all the vaccines he needs but never got. This kind of attention to detail and coordination of care was wonderful to see!

And here are some pictures from the day:

 classic miliary TB on CXR

 cube 1 in the women's ward

 terrible bullous lung disease from TB -- chest CT

 2 things of note here: 1) this is a note from a patient (not of mine) that has some psych disorder but has taken a liking to me and continuously warns me about Saudi Arabia... and 2) note the levels of "urgency" in the bottom left