Monday Clinic at Joy Hospice

So Monday Clinic.

Tidying up after the weekend. 

Time for Jan to minionize ( to make into a minion ) me.

So the wards , patients need to be seen, treated.

So recaps. 

My 60 yo gentleman with cryptogenic cirrhosis/hepatomegaly with nephrotic range proteinuria passed before receiving the first dose of high dose steroids . Apparently , he turned over in his bed that evening and passed . In some ways, perhaps it was for the best . He had been bounced around various clinics/hospitals with unclear diagnoses and finally came to us, a small clinic with limited resources. Perhaps we could get a diagnosis in Kampala , the Capitol. This may cost the famil millions of shillings. Even with a diagnosis , treatment may be a significant burden to the family or even feasible. This is a sad thing to realize , but humbling none the less. 

Today's patients 

Outpatient consultation

40 something year old lady with a massive goiter of at least 6 years . She initially presented in 2008 with a painless thyroid mass. This had become progressively larger and larger . In the most years after several pregnancies, it had become painful. Acutely, this lady is starting to have airway issues while sleeping . I managed to find myself a bruit hidden In her giant goiter. In short, I sent her to the Capitol for ENT evaluation , imaging and thyroid tests. 

After explaining this to her husband, he seemed confused on discharged and didn't understand why we didn't give her any "pills" for the goiter... So we sent her home with ibuprofen. 

Outpatient consultation 

40 something year old lady with two year history of burning chest pain , worsening with activity and feelings of "heaviness" at times . Basically, I worked my way through her long history. She had various diagnoses throughout her various other clinics : neuropathic pain, neuropsychological pain, thoracic spondylosis . At one point she had a sed rate of 95. At one point someone told her that she had peptic ulcer disease. In short, a tough one to figure out. I knew I could rule out h.pylori in clinic. If negative, I'd empirically treat with a ppi and Tramadol for musculoskeletal pain ( she had point tenderness over the sternum) .  Now, the kicker is if she truly has angina ...well what do I do? I can do a single lead ekg in the office (which I did , sinus tach, see below for what this device looks like) . What I can't do: stress test, lipid panel   And cardio referral may or may not be helpful . Jan asked me what I thought about an echo ... And I was like..well unless its crazy abnormal , it may not help and cost the patient . As such, we will work up what we can , follow up and move forward .

Outpatient consultation 

60s year female with valvular chf . She has mitral and aortic regurgitation . After digging, I found out she has significant pillow orthopnea. Basically we beta blocked, afterload reduced with an ace and fluid managed with diuretics. Of course ...even in the states, there's always a balance with valvular disease. Too little preload means no output. Too much equals overloaded lungs. So I told our team to do serial weights with her visits and try to find her euvolemic state and base our management on that and clinical appearance / functional status. 

Inpatient follow up 

60s something year old female who was admitted with acute malaria. Her history was a bit muddled and there was documented ccf history, history of malaria and copd possibly. So she comes in with uti symptoms an shortness of breath  and is found to be malaria positive . So in classic Joy Hospice style, I tell Dr Jan I'm going to reinvent the wheel and start from scratch . So what I get is a history of a lady with progressive shortness of breath and chronic hypoxia as documented in her chart. Her prior exams had mentioned digital clubbing . Previous imaging showed evidence of right hear failure/cor pulmonale.  So with this info, I examined this very spirited lady and appreciated dry,Velcro sounding crackles throughout her lung fields.  She had a slightly enlarged liver . Her legs were free of edema . Her nails showed significant clubbing and she had evidence of faint cyanosis to her lips/mouth. Sats on our pulse of we're around 80-85 . Despite all of this , she felt okay and wanted to go home. She ambulated without problem . I trailed her on o2 via our portable concentrator , to no avail or Improvement in sats or symptoms . Soooooo... In classic doctor rob uganda style fashion, I planned on sending her home on hi dose steroids. I theorized that she likely had right heart failure from chronic ILD  as evidenced by her compensated hypoxia and lung exam . Now with my history and exam, the patients daughter told me her brother was coming with some recent imaging. I get these results an hour later annnnddddd wait for it...

High res ct shows diffuse reticulonodular changes and honeycombing c/w interstitial lung disease . 

Take that ct scan.....diagnosis purely based on history and physical . 

No hilariously, or just classic Joy Hospice style. My lady wanted to go home . So despite her sats of 80-85 and no way of doing home o2 plus her malaria, we sent her home on azithro/pred 60/ malaria treatment with follow up in a week with a goal of tapering her steroids based on her clinical appearance and functional status. 

....and so ends another day at Joy Hospice .