Friday, November 22, 2013


    I have  almost always believed that when patient says something , we as physician should believe in it . I think patients know their bodies and can direct us to correct diagnosis , if we pay enough attention .Now there are exceptions to the rule . But in many cases patient will be right .Now there are patients who may have 'drug seeking behavior or they may be 'malingering ' . But these are exceptions to the rule . I have tried to practice , what I believe .So this one story is how I almost did not believe , but still follow my dictum and got the diagnosis .
    I was called for a consult on this 31 years old female who was admitted with cough and had diagnosis of pneumonia ..She was somewhat obese lady who had delivered about 9 or 10 months . She had gastric bypass for obesity and had lost more than 100 lbs , She had no other history . Her main complaint was that she had pain on left side . The CT scan done had shown no clot in the lung and had shown the pneumonia . Her physical examination showed that she was wheezing and could not take deep breath due to pain . She was started on antibiotics . She did not have much fever . I started her on a short course of steroids and continued the antibiotics .Sometimes when patients have pneumonia , they have pleurisy , and so they get pain . Next day when I saw her , she was better . I had also given her some inhaler and treatment for asthma type symptoms and she felt much better . We continued the same treatment for the next 2 days and then as she was better and had no fever and had all 'cultures ' negative switched her to oral medications and discharged  her .
     She was put on antibiotics and short course of steroids . She came back in in less than 2 weeks . She had completed the course of antibiotics and the steroids and then started with the pain , lot of cough and so decided to come to hospital . The chest X-ray was better and there was a repeat CT scan and that showed 'improvement ' in the pneumonia . Her white cell count was normal ( which goes up with infection) , her X-ray and CT scan was better and there was no positive culture . We restarted her on antibiotics and consulted Infection Specialist .He suggested to do a bronchoscopy . I did not think I was going to get any more information , but I did it . There was lot of inflammation in the bronchial tubes . All the cultures , including vial cultures and TB and mold , came OK . I did check on her immune globulin.Sometimes when patients have deficiencies of these special proteins , they can get frequent , unusual infections . But they came back as normal . By now her X-ray was almost normal and there was no wheezing . Her white cell count was normal . I had also done a test for lupus and it was OK too . Her cough continued and she now had pain on both sides of the chest due to coughing Now she started having headache . So I did sinus X-ray . It was normal too .So now I was lost . I had told her that she had pneumonia and may have asthma and the cough will continue for next 2-3 weeks. Once the inflammation was better then the cough will go away . The pain was muscular , due to coughing .So then started saying that she was having problem with the swallowing. She had never told me or any other doctors about this . When I asked her how long she had this problem , she told me 4 or 5 weeks .
     I was not sure what to do . We had planned to discharge her .and all her tests were OK and the finding that were abnormal were now normal . I almost thought that may be she is afraid to go home , may be there are issues at home or may be the new baby care is too much . But I reminded myself . I MUST PAY ATTENTION TO THE PATENT'S COMPLAINTS ! I ordered the swallow study . To my surprise , the study showed that she was ASPIRATING . Which means , when she was drinking the liquids , it was partly going in her lungs . I was shocked . I had no explanation as to why she was doing this . We see this quite commonly in elderly patients or patients with stroke or Parkinson's disease , but at age 31 one I had no thought I thought of myesthenia or multiple sclerosis .In  these conditions one could have swallowing difficulties . I ordered the test for Myesthenia Gravies and ordered the neurologist to see patient . I also asked for the MRI of the brain . The neurologist specifically asked to look for Chiari malformation  and he was right The MRI DID SHOW THE CHIARI 1 MALFORMATION .
     So the puzzle was solved . She had Chiari one malformation , in which it can press on certain nerves , which in turn can cause difficulty with swallowing and this can lead to aspiration . This caused the pneumonia . The recurrent aspiration of liquids (some are acidic ) caused the inflammation and so she continued to have the cough.    . 

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