Medicina Bucureşti

CHIEF COMPLAINT/REASON FOR ADMISSION:
Right-sided chest pain.
HISTORY OF PRESENT ILLNESS:
This patient is a 42-year-old white female without any significant past
medical history who was referred to the hospital by Dr. ###### from his office due to abnormal CT scan findings from
##### Hospital. As per the patient, she had right-sided chest pain
which started suddenly one week ago. It was a 7/10 in severity, radiating
to the back, aggravated by cough and deep breathing. The patient also
complained of nausea and vomiting almost every day. She also had
low-grade fever and chills. She was treated by ####### Hospital
for a urinary tract infection with Bactrim and for chest pain with
Vicodin. Apparently, it did not help her pain. The patient admitted to
having weight loss but she said it was intentional. The patient denied
any urinary changes or any changes in bowel movements.
RECENT AND PRESENT MEDICATIONS: (Dosage and Frequency)
Bactrim, Vicodin, Effexor.
PAST HISTORY: (Operations, Injuries, Illness; include dates and relative
details as known- Immunization and Dates)
Anxiety.
SOCIAL HISTORY: (Lifestyle/Occupation, Marital status, Children, and Risk
Factors)
The patient is a smoker of one pack per day for thirty years. She
occasionally smokes marijuana. She does not drink alcohol and she denies
any other illicit drug use.
FAMILY MEDICAL HISTORY:
Positive for father having myocardial infarction at age thirty-eight, also
has hypertension and melanoma. Several members of her family also have
lung carcinoma, who all smoke.
PRESENT REVIEW OF SYSTEMS: (Unless otherwise noted, areas are
noncontributory)
ALLERGIES/SENSITIVITIES:
SKIN AND LYMPHATIC: No rashes.
CENTRAL NERVOUS SYSTEM (Include special senses): No dizziness. No
lightheadedness.
RESPIRATORY: The patient has a chronic smoker's cough.
CIRCULATORY: As per history of present illness.
DIGESTIVE: No changes in bowel movements. No diarrhea or constipation.
GENITOURINARY: No dysuria. No frequency.
METABOLIC AND ENDOCRINE: The patient has no history of diabetes
mellitus or thyroid problems.
HEMATOLOGIC: No easy bruising.
MUSCULOSKELETAL: The patient has pain in her right side of the chest
wall.
PSYCHIATRIC: Noncontributory.
(PHYSICAL EXAMINATION)
GENERAL APPEARANCE:
The patient is awake, alert, and oriented times three. She is in mild
distress due to her chest pain. Vital signs: Blood pressure 125/82,
pulse 84, temperature 98.8, respirations 18, pulse oximetry 100%.
TEMPERATURE: As above. PULSE: As above.
BLOOD PRESSURE: As above. AGE: As above.
HEIGHT: RESP: As above. As above.WEIGHT: As above.
SKIN: No rashes.
LYMPH NODES: No lymphadenopathy appreciated.
HEAD: Normocephalic and atraumatic.
EARS: No discharge.
EYES AND FUNDI: Pupils equal, round, and reactive to light and
accommodation. Extraocular muscles intact.
NOSE: No discharge.
MOUTH, TEETH, AND THROAT: Moist mucous membranes.
NECK: No jugular venous distention. No bruits.
CHEST: Bilateral equal expansion.
BREASTS:
LUNGS: Clear to auscultation on the left side. Questionable crackles
on the left lung base with decreased breath sounds. No wheezing or
rales.
HEART: Regular rate and rhythm. Positive S1 and S2. Positive
systolic murmur 1-2/6 in the mitral area.
ABDOMEN: Soft, mild tenderness in the right upper quadrant. Positive
Murphy sign. Decreased bowel sounds.
HERNIA:
BACK: Positive costovertebral angle tenderness on the right side.
EXTREMITIES: No edema. Positive pulses.
NEUROLOGICAL:
GENITALIA-PELVIC:
RECTAL:
LABORATORY DATA AND X-RAYS: Laboratory work and x-rays are not available
at admission time.

* Chest CT done as outopatient mentioned multiple lung nodules?


Ce credeti ca se intampla si ce ati vrea sa faceti cu pacienta?

Crackles alea sunt in right lung base, asa-i?

I i-as face un GB US, i-as da neste antibiotice sa acopere si enterococu din zona( al meu e rezistent la quinolone) si as obtine rezultatul la CT.

o sa pun pozele luni cand ajung iar in spital.

U/S am impresia ca a fost facut outpatient si nu era mare lucru pe el. De asemenea a avut abdominal CT care nu a aratat mai nimic.

Am repetat CT-ul cand am intrnat-o. Am pus cateva poze.

Hai, bre, nu fii stingy, da si tu cu o analiza, un CBC, o urina, ceva.

da, da si un ct report....

Bre, aia a fost impuscata cu shotgun?

Bre, aia a fost impuscata cu shotgun?

nu bre, alea sunt firele de la cardiac leads prinse in sectiune.

da, da si un ct report....

pai rapesc farmecul

Hai treaca:
RESULT: History: Fever or nodules
CT images of chest are obtained without contrast. There are multiple
nodular soft tissue density seen throughout both lung fields ranging from
about 6 mm up through almost 2 cm. At least 8 nodules are identified. No
calcifications. No pleural effusions seen.
Mediastinum shows no significant lymphadenopathy.
Both degenerative glands unremarkable.
IMPRESSION: At least 8 soft tissue nodules scattered both lung fields
slightly more right-to-left. No mediastinal adenopathy.

Analize initiale:
basic metabolic profile - WNL (within normal limits)
liver enzymes - WNL
beta-hCG (recunosc ca i-am facut-o cateva zile mai tarziu) - undetectable
CBC - within normal limits, no left shift
urina- trace protein, trace ketones, 1+ bacteria, many mucous threads

Ce altceva vreti sa mai stiti, si ce vreti sa faceti pentru pacienta (diagnostic si terapeutic)?

PS. la radiologie: degenerative glands probabil vrea sa fie adrenal glands

Nu se vad adrenalele pe ct de chest.

ok. deci noduli , soft tissue diseminati. no inflammatory syndrome.
hx of melanoma in FX si smoking.

Sunt determ secundare?

Da' in ficat ce are? Liver function tests, liver US?
SA-i facem si unul cu contrast inainte sa facem vreo biopsie.
S-a dus pe undeva unde a capatat ceva exotic si tropical?

Nu se vad adrenalele pe ct de chest.

ba se vad; standardul la chest CT e sa mearga jos pana la adrenale (nu am pus decat cateva imagini).

Am pus mai sus liver enzymes= within normal limits (SGOT, SGPT, Alk Phos, bilirubina), iar U/S nu a aratat nimic.
Unul dintre noduli e pe perete in RUQ, si provoaca durere in RUQ prin afectarea pleurei +/- intercostal nerve.

da, vazui ca ala pleaca din pleura, si durerea e clar de natura pleuritica . dar parca mai sunt cativa noduli care nu tin de pleura . nu pare sa fie vreun mezoteliom, n-are nici risk factors pt asta.
i-ati facut biopsie?

stai bre usor, sari cu cutitul la toti pacientii ?
Ca nu e chiar asa minora operatia.

Additional information: unul dintre noduli parea ca are o cavitate, desi imaginea nu era grozava.

pai ce facusi dadusi raportul incomplet?

nu chiar; asta era raportul ca outpatient dar cand am facut rost de CD si m-am uitat cu ochiu propriu, nu prea era evident. Mai degraba densitati diferite decat cavitate. Si oricum informatia asta nu mi-a schimbat approach-ul, era bagata doar la deruta

vad ca nu-s decat o mana de oameni interesati, asa ca o sa mai dau niste detalii.

Teoretic diagnosticul diferential ar fi asta:

Metastasis.
Abscess.
Hydatid cyst.
Fungal infection.
Wegener’s granulomatosis.
Rheumatoid nodule.
Septic embolus.
Arteriovenous malformation.


Practic cand am admis-o vorbisem deja cu pulmonologul care o vazuse in office, si suspiciunea era de malignancy.
Dar fiind atat de tanara, nu prea imi venea sa cred, asa ca am incercat sa rule out alte cauze inainte sa pornesc un workup mai agresiv pentru cancer.

- asa ca am pornit-o pe Vancomycine pentru posibil septic emboli (marea majoritate sunt gram pozitivi pe valva nativa; ea avea un murmur, si faptul ca nega drug use nu inseamna nimic)
- ceva reumatologie (ANA, RF, C-ANCA)
- blood cultures
- TEE

A doua zi dupa ce am pornit-o pe Vanco, nu a mai facut febra.
Blood cultures negative
Reumatologie negativa.
TEE (transesophageal echocardiogram) - fara vegetatii, doar un pic de MR (mitral regurgitation)

Am trimis-o la VATS (video-assisted thoracoscopy), caci needle biopsy nu e suficient de bun (daca e negativ poate sa fie din cauza de sample prea mic, deci trebuie sa te duci la VATS oricum).
Intre timp am tinut-o pe Vanco pana am aflat rezultatul la biopsie (a fost pe Vanco cam o saptamana in total).

Rezultatul la biopsie:
Suspect de COP (cryptogenic organizing pneumonia; fostul BOOP), dar au zis sa o trimitem in Cleveland pentru confirmare ca aia sunt mai experti in asta.
Intre timp am oprit Vanco si am pornit-o pe Prednisone 1mg/kg, si am trimis-o acasa in cateva zile.

Partea mai nasoala a fost ca in vreo saptamana a venit rezultatul din Cleveland, unde au vazut ceva Gram pozitiv cocci in biopsie (si asa s-a dus increderea mea in patologia de la noi pentru diagnostice mai rare).
A vazut-o pulmonologul in vreo saptamana si era bine, a pornit-o iar pe antibiotice.

Desi nici acum nu stiu care a avut dreptate, caci daca erau septic emboli sursa n-am idee pe unde a fost si parca prea nu a avut nimic altceva.

deacord cu meta si embolie septica plus micoze.
cum arata dupa tratament? in afara ca nu are febra?

Pai daca avea endocardita banuiesc ca ar fi fost mai bolnava. Eu am vazut ceva infectii respiratorii cu MRSA la persoane tinere si altfel imunocompetente, dar nimic de genul asta si nici abcese pulmonare. Eu nu conving pulmonary sa faca toracenteza la pleurezie unilaterala, ce sa mai vorbim de biopsii.


I-am trimis cardiologului pacienta cu MRSA in urina sa-i faca TEE si mi-a scris o scrisoare ca e pe Warfarina si ca nu vede de ce sa-i faca TEE. Cand si-a infectat pacerul proaspat implantat tot el s-a mirat. Lumea nu prea ia Stafilococul in serios in afara de panica din ziare.

Pai biopsia a facut chirurgul cardiotoracic pe care l-am consultat strict pentru asta.
Pe aici fac toracenteze destul de lejer, si daca nu le-ar face pulmonologii le-as face eu (sau partenerii), insa asa preferam sa nu ne calcam pe bataturi. Oricum daca e nevoie facem majoritatea procedurilor, gen linii centrale, LP, paracenteze, artrocenteze (se platesc foarte bine). Nu pun pacemakere temporare/ Swan-Ganz, si nici PICC line-uri, desi intentionez sa invat sa pun PICC-uri.

La TEE situatia e la fel si pe aici, duci lupte cu cardiologii ca se le faca. Unii sunt mai "accesibili" decat altii si ma orientez, desi nu vreau sa le dau doar grupului care e mai maleabil, ca nu prea e fair (sunt platiti aproape la fel ca un 2D-echo transtoracic dar cu riscuri clar mai mari).

FAMILY MEDICAL HISTORY:
Positive for father having myocardial infarction at age thirty-eight, also
has hypertension and melanoma. Several members of her family also have
lung carcinoma, who all smoke.

The patient is a smoker of one pack per day for thirty years.

PSYCHIATRIC: Noncontributory.

Alminteri, deşi nu am înţeles aproape nimic din ce aţi zis voi aici ("Zi-ne bre şi un IUWER da din ăla cu LOIUAERIUB nu fi RUQ"), pe cuvântul meu de onoare că am vrut să zic BOOP. (Să zicem că am nişte contacte cu pneumologia). Da nu m-am băgat că am zis că nu-s de coNpetenţă şi sigur zic prostii.