Post 3: Anita

Leg of dermatitis patient with possible leprosy.

Abdomen with hypopigmented patch of above patient.

Elderly female with MI that we transferred to the ICU.

Post #3:Anita


 Today we saw a couple of interesting cases again. On the inpatient ward, we were rounding with one of the senior physicians when we met a man, a sadhu, who was apparently complaining of odynophagia and hemoptysis. It sounded like he probably did have some oral candidiasis, and was being treated with hydrogen peroxide and an oral antifungal, and the symptoms seemed to be improving. The male head nurse was kind enough to go back with us and interpret for us so we could obtain a more detailed history and complete a physical exam on the patient. It turns out the patient was not having any symptoms of hemoptysis, nor of hematemisis. By the time we saw the patient, his oral candidiasis did look as if it had improved as there was no evidence of infection present. It seemed that his symptoms were improving, but when we asked him why he came into the hospital, he proceeded to show us his legs. Below is a picture of his legs. The patient claimed he had had various bouts of this skin condition for the past 12 years, it used to cover his body, but was getting better. He also had a hypopigmented patch on his torso. We thought this might be leprosy and went home to google pictures on the internet, and came up with a few differentials, but the most likely one seemed to be leprosy. We asked the attending doctor the next day, he seemed to think it was just an unspecified dermatitis, and he noted there was no palpable poplitleal nerve. Neither of us were able to find much out about this physical finding, but it does not seem the lack of such a finding precludes the diagnosis of leprosy. However, in this resource limited setting, a punch biopsy so easily ordered in the US was not possible.

Another interesting case we saw was in the emergency room. There was a 25 year old male the junior doctors said was having an MI with S-T elevations on his EKG and symptoms of chest pain. Upon inspection of his EKG, it turned out he had diffuse S-T elevations. Upon questioning the patient, it sounded like he might have had a viral URI recently, and upon physical examination, he had diffuse wheezes. This was most certainly a case of viral pericarditis, and not a STEMI in an otherwise healthy 25 year old male. We advised the physicians to stop the heparin infusion immediately and explained our reasoning with them. Chest pain in men very quickly becomes angina regardless of circumstances, and shortness of breath is always COPD. Contrast this with another case we saw of a 70 year old woman with known coronary disease (she had had a left heart cath in Delhi showing 70-80% stenosis in her circ and LAD- cath was done for an NSTEMI). Because the patient had known coronary disease, the junior doctor didn’t believe her current symptoms of shortness of breath and chest pressure could possibly be ACS and so she was treated with lasix for a minimal amount of pulmonary edema on her chest xray. When examining her current EKG with prior EKGs from the hospital in Delhi, the patient did indeed have some deepening of ST depressions in V5 and V6, and new depressions in V4. We explained to the physician that a prior history of coronary disease didn’t preclude her from having another MI, but in fact increased her chances of it! We prompted him to start a heparin infusion and proceed with standard NSTEMI medications, and to check a troponin. The troponin assay here is either positive or negative unfortunately; a test strip like a pregnancy test over the counter. There is no quantitation of troponin leak. The patient’s troponin was indeed positive, and she was transferred to the ICU for closer monitoring.