Case Study

GOLDEN RULES
Dr.Saibal Moitra, MD, FCCP (USA)

• The most important person we ever encounter in the hospital is the patient. They are often frightened, confused & following adminission to hospital they have little say on what happens to them. We need to give some control back to the patients. To do this, they need information from us as to their possible diagnosis & what might happen to them, & they need to be given space to express their Views.

• Listening to our patient is the most impartant thing we can do. If in doubt as to what is wrong with our patient, we should fall still & listen to the patient.

• You are the front piece of our hospital. Take pride in where you work & give your best. We should all be honest, acknowledging doubt, when doubts exist & accepting that we can only do what we can do.

• We all have to accept that we will die at some point with media hype our years it has become almost standard practice to try & eke every last once of life out of lives that have stopped living. One has to accept that there is a point when it is important to allow a patient to die with dignity.

• In the hospital there is place for everyone & it is important to find the area of healthcare that we can enjoy & can use & maximize our talents. When making this choice it is important that we listen to our heart.

Dr. Saibal Moitra, MD, FCCP (USA)
Dr. Sarmistha Chatterjee, MBBS

A 40 yrs old man admitted in this hospital Chronic alcoholic; with no documented comorbidities had presented with the following symptoms : Orthopnoea, Fatigue, Dyspnoea on exertion, Profuse sweating, Retrosternal chest pain, Presyncope.

DURATION OF ILLNESS : Dry cough *15-20 days with Fatigue &Dyspnoea which aggravated over the last 24 hours prior to admission.

PERSONAL HISTORY : Patient was found to be alcoholic & Smoker but no documented history of allergy.

On Clinical Examination we founded higher function - Drowsy yet arousable panting for breath, pulse:136bpm sinus tachycardia, BP:160\90mm of Hg, SpO2:70% with high flow O2 support, Pedal Oedema, Cyanosis, Pallor & Jaundice was absent, temperature: Normal, Clubbing was not present.

Systematic Examination: Respiratory System - Bilateral scattered coarse creps with Poor air entry & SpO2:70% with high flow O2, Cardiovascular System-S1 S2 audible with no murmur, Nervous System-Drowsy yet arousable, Gasping for breath & Accessory muscles was active.

Patient was provisionally diagnosed as Left ventricular failure
Pathological Investigation Revealed - Hb%:14.7, SGOT:118, TLC:10500, SGPT:103, Na:133.8, LDH:498, K:4.2, ALP:273, Urea:29, Total Protein: 7.1, Creatinine:1.2, Albumin:4.2, Amylase:303, Bilirubin:1.9, Lipase:39, CPK:173, CPK MB: 21.

RADIOLOGICAL INVESTIGATIONS

ECHO COLOUR DOPPLER : DILATED CARDIOMYOPATHY, LV Systolic Dysfunction, LVEF 30%.

MEDICAL MANAGEMENT : Patient was intubated and put on mechanical ventilation Sedated and paralyzed to reduce work of breathing & reduce myocardial work load Was treated with: IV Diuretics, ACE Inhibitors, IV Antibiotics, IV PPI, Beta blockers, Insulin & Fluid restriction. Patient was extubated after CPAP trial and discharged with proper advice.

Dr. Subrata Chatterjee,MD (Oncology)
Dr. Mansij Biswas, MBBS

Pritam, a 12years old came to this hospital with the complaints of limpling, pain in low back area& swelling of both legs for approx 2weeks. On exam; huge lump was palpable in lower abdomen. Motor power in lower limb muscle was reduced (2/5). There was no bony tenderness. There was bilateral pedal oedema extending upto abdominal wall. He was initially admitted under care of surgeon. During first week of admission, disease progressed. Pain in lower abdomen & low radiating to lower limbs became excruciating in nature, Bowel & high fever.

On investigations, he had anaemia increased WBC &neutrophil count & increased serum Creatinine level (2.3mb%), increased CRP. USG abdomen showed a huge retroperitoneal lump arising from pelvis & extending upto level of umbilicus. The lump compressed the ureters leading to bilat.Hydroureter & Hyderonephrosis more on rt, side.MRI L.S.Spine-SOL (suggestive of Lymphoma) involving l5, s1, s2 & adjoining pre & paravertebral area. The lesion extends through sciatic foramina on both sides.

CT guided Trucut Biopsy from Pelvic SOL-Malignant small round cell tumor(possibilities of Ewing's/PNET). Immunohistochemistry-Tumor cells express CD 99 & vimentin & are immunonegative for Cd45, CK & desmin suggestive of Ewing's/PNET.

DJ stent was placed. Patient was declared inoperable & referred to oncologist for chemotherapy.
As patient had high fever, poor General condition, poor performance status (ECOG 3), chemotherapy could not be started immediately. Blood culture & Urine culture were done & he was advised antibiotics. Mean while, patient developed anasarca.His serum Creatinine was raising again (upto 5.5mg%, S.potassium was 5.5mg% & S.uric acide-8.5mg %).

USG KUB showed loss of corticomedullary differentiation in both kidney &DJ stent in proper position. Patient had high fever, excruciating pain low back area & paralysis of both lower limds, incontinence of stool & urine. He was conscious & we were almost helpless to relieve him from his sufferings.

Lastly patient was treated with Hemodialysis with high risk consent. After dialysis, his serum creatine, serum potassium became normal & fever reduced in intensity. But, patient had that excruciating pain in lower abdomen & low back area. As Ewing's/PNET is chemosensitive & as its standard initial treatment is chemotherapy & as patient had severe pain, we planned for chemotherapy with Vincristine, Doxorubicin, cyclophosphamide with reduced dose due to his poor G.S., poor performance status & compromised Renal function. Within 1week after chemotherapy his pain decreased dramatically, abdominal lump reduced in size. He gained control over his pain decreased dramatically, abdominal lump reduced in size. He gained control over his bowel & bladder. Fever subsided. Gradually, Motor power in lower limb muscles improved to some extent & he was discharged with advice to come back on scheduled date for 2nd cycle of chemotherapy.

CONTRACEPTION
Dr. Barnali Ghosh, MD (Gynae & Obstetics)

The medical fraternity until recently was by & large comfortable with the idea of suggesting a contraceptive most suitable for the visiting couple in the consulting room, with rapid invasion of internet across all strata of our society, the situation has radically changed at least for the urban population. The acceptance, tolerance & continuation of a particular contraceptive method is now decided upon largely after a bilateral dialogue & doubt clearing session.

This is a welcome change & it makes is imperative that the physicians advising contraception are acquinted with the new entrants in the field. Contraceptives containing estrogens (E) & Progestogens (P) have always remained an enigma & have never been able to steer out of controversies, yet it's absolutely useful to keep oneself informed.

Contraceptive pills containing ultra low dose ethinyloestradiol (20µcg) & desogestrel (150µcg) or progesterone a like drosperinone are in use for quite, sometime. They are effective, have a low incidence of side effects & good tolerability .These is reasonably safe if used after a basic screening. The cost is a factor for non acceptance of drosperinone containing pills in some individuals whereas 20ucg E2 containing pills have a higher incidence of break through bleeding (BTB) resulting in non compliance.

Progesterone only pills are a good alternative for lactating women, women who cann't tolerate estrogenic side effects, women having contraindication to use of estrogen or older women. Such pills are meant for daily or uninterrupted use & a higher incidence of BTB making it unsuitable for use in women desiring regular periods.

A respite came in the form of vaginal ring contraceptive named NUVARING introduced only recently in the Indian Market. This is an once a month contraceptive which has efficacy comparable to COCs while having less side effects. It causes predictable bleeding in the ring free period & BTB is very rare. Non daily regime increases compliance & intended bleeding pattern with excellent cycle control promises to make it the contraceptive of choice for the new age women who demand hassle free mobility over & above efficacy & safety. It has to overcome two hurdles before gaining a strong foothold in the subcontinent. First, it is relatively highly priced & second, the relative aversion of our women towards vaginal route of medicine use.

The progesterone containing intrauterine device MIRENA (Levonorgestrel IUCD) has the advantage of introduction once every five years. It is highly effective & safe having minimal side effects. The high cost of LNG IUCD makes it unsuitable for use in many women whereas absence of regular period or intermenstrual bleeding makes it unacceptable to many women who can afford it. The additional advantage of LNG IUCD is reduction of menorrhagia in addition to contraceptive protection.

Charnock in House

CME Programme