Saturday, November 23, 2019

ONE AND MANY

   In medicine we were taught that when you see a patient, try to have ONE diagnosis to explain the problem or the symptoms.So we were allowed to develop differential diagnosis.So each one should be in position to explain as many symptoms as possible with each diagnosis. That does not mean that there is only one condition but this habit tends to make thought process such that one tends to know as many symptoms as possible.of each disease. This brings me to the patient that I was going to tell you about .
     I saw this patient as semi emergency. She was admitted with some nausea and she had no fever . she has not sob but she had some vague chest pain with exertion . so she was worked up . The chest X- ray was normal.She had history of high blood pressure and had coronary artery disease  and so she had work up done too. She was thought to have coronary artery disease, She also had some diagnosis of scleroderma.She had cardiac cauterization   and she had blockage  and so she had stent done The cardiologist called me as her oxygen level was low when he started the procedure  and it continued to be low .

      She looked OK from his standpoint and the procedure went well  and she had no complications.But since  her oxygen was low he called me . I talked to nurse  and then I saw her few hours after the procedure.She looked comfortable  and did not feel short of breath.But she had rales or congestion in the lungs on physical examination. I had ordered the Chest X-ray and that had shown congestion and that was not there in the chest X- ray that was done 2 days ago. I had also ordered the blood test for the congestive heart failure  and that was quite high, Normal is 800 and hers was 15000.She had denied  any problem with swallowing. She had echocardiolgram- ultra sound of the heart  and that had shown to be normal . So I was not sure why would she had congestive heart failure . But when I heard that she also had scleroderma , I also thought about the abnormality in esophagus that can cause aspiration. As I mentioned we try to or we should try to have ONE diagnosis as the explanation. But she was on lot of oxygen  and I had to treat her . So I decided to treat for BOTH the congestive heart failure and aspiration I started her on water pill to treat water in lungs and also antibiotics  and steroids for possible aspiration pneumonia .
      I saw her next day and I had done new chest X- ray . She was doing much better  and her oxygen need was much lower  and the X- ray was not clear but was better. So she had both-Aspiration  and Congestive heart failure .
       By the way no one had mentioned scleroderma in their notes! .                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

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