Case+3+-+Chronic+Cough

This page has been edited {$pagerevisions} times. The last modification was made by user:{$revisioneditor} on {$revisiondate}

Its Tuesday morning and the line at the OPD (outpatient department) is already full with over 60 patients waiting to be seen for the morning only. They cue by arrival time as a triage system has not been yet rolled out here (staffing and training) -- hence the unfortunate, heartbreaking reality of a mother waiting through the cue to present a deceased 12 mo Down’s syndrome child in clinic last week. The complaints begin to run together as clinical officers and medical students power through. In the absence of time and diagnostics so much medicine here is protocol based – a habit of which medical educators are attempting to battle, ie not all cough equals amoxyl.

This gentleman is a 48 y/o male with a persistent cough. He holds his health passport -- a small brilliant book each individual from babies to elderly possess. The older you are and the more medical problems, the more books. These books theoretically contain each and every medical encounter note (albeit brief), as well as other med information such as vaccination status and OB history. The books are simple and paperback, yet we find intricate homemade coverings from newspapers to plastic bags (reminding me of junior high book covers), underscoring the seriousness with which patients take responsibility for these mobile medical records. When they are forgotten at home, public scorn.

And so as the medical student and I peer into this man’s 'booku,' we see visits dating from 5 months ago with complaint of cough, three in total.

First visit: PNA, amoxicillin course prescribed Second visit: persistent PNA, erythromycin prescribed. HIV negative status (tested) Third visit: PNA, again. Amoxicillin, again. And a sputum sample for TB: negative.

Patient describes a dry cough accompanied by morning fevers, night sweats, and weight loss over the last 6 months. Besides the cough he describes a distinct sensation of shortness of breath both at rest and with exertion. States he has no known TB contacts. No nausea or vomiting, no diarrhea. He is not a smoker, nor does he have any history of asthma or GERD. No known occupational exposures, but has been living amidst woodburning cooking fires for most of his life.

T 37.0 P 80 BP 117 / 70 RR 24 Gen: A and O x 3, NAD. Mildly cachectic gentleman, appearing stated age. NAD HEENT: no oral lesions, sclera anicteric Neck: no JVD, no LAD Pulm: CTAB, no crackles or wheezing. Good air entry b/l CV: distant heart sounds with disctinct S1 and S2, no m/r/g Abd: soft, nd, nttp. Mild hepatomegaly, but no overt fluid wave Ext: no peripheral edema

A work-up--albeit limited--was decided given his mild tachypnea and persistent complaint: FBC: Hgb 9.9 (MCV 83), WBC 3.3, Plts 158 HIV: negative

Xray:

How do you describe your findings?

As cardiomegaly is observed, you decide to grab your handy sonosite. POC echocardiogram was performed with the below image:

-Which view are we in? (where is the probe?) -can you identify the chambers? -any pathology in this scan?