Thread by @theliverdoc

#crazy Useless #patient

1/n
Middle-aged man, loves his #family, #farming, drives a cab, #happy. Son & wife at #home. Father-son relationship strong as rock. One #morning, son finds father mumbling to self. Mother says he hardly slept
Mumbling becomes angry ramblings. #Clinical

2/n
Has very little #breakfast. Walks excessively. Goes and lies down, only to get up and walk again. Family interactions little. Sleeps well for 2 hours from 12 to 2PM. Lunchtime. Groggy #father gets on the lunch table and defecates near plates and food. Son and mother aghast.

3/n
Father has gone mad. Calls the friendly neighbor, brings his car, rushes to #Medical specialty #clinic nearby. Father disoriented. Son gets the Fword from his own father multiple times, he is shocked! Then comes hurling of abuses after which they restrain him in the car.

4/n
In the clinic, #young duty-doc LOOKS at the patient, diagnoses #psychosis, advises observation and sedatives. After 2mg lorazepam, patient knocked out, later wakes up confused. Starts gibberish talk again. In between he identifies the wife, not son. This is devastating.

5/n
The young #Doctor is called again. He says this needs advanced #treatment. Psychosis is ‘refractory’ - he tells the #nurse – like a bloody crazy useless mad person (son overhears). Saddened by the fact that his father is driven to crazy for what reason?

6/n
So, they rush him in an ambulance to a bigger General #hospital nearby where an elderly #emergencymedicine doc sees the confused, groggy, occasionally abusive patient in restraints. He LOOKS attentively, but also #touch and #EXAMINE the patient.

7/n
Lesson 1: don’t #practice visual medicine. CLINICALLY EXAMINE the patient. The patient and family are gladdened by this. They get a sense that there is #care and #comfort is on the way if a doctor places her/his hands on the patient. Don’t be shy. #MedicalStudents

8/n
He finds a firm liver, enlarged spleen and spider angioma signs of cirrhosis. Son says father used alcohol heavily, stopped a year ago after #Blood vomiting after binge&retching. Doc says looks like he has cirrhosis and issues – needs gastro/liver doc. #Medical #examination

9/n
Our evaluation confirms #cirrhosis and portal hypertension (PHT; increase in liver pressure when liver shrinks). PHT is like a block in the highway. Cars get to take service roads and bypasses. These service roads/bypasses for #Portal venous blood are called #collaterals

10/n
Some collaterals are huge – called shunts, drawing blood away from liver, increasing #ammonia waste, resulting in brain failure – hepatic encephalopathy. In patient, blood ammonia levels were >300 and patient diagnosed with hepatic encephalopathy. #CT #Scans show large shunt

11/n
What was done? Lower ammonia. Look if patient candidate for liver #Transplant (using #MELD score and if not a transplant candidate, then block the shunts. How? Simple non-surgical #interventional #radiology procedure – shunt embolization by @SRajesh_IR
#irad #GITwitter

12/n
See what happens in the image below. Large shunts are taken care of. Ammonia reduction brings patient back to senses. Discharged a week later; CT scan done 3 months later showed shunts are gone. #Sedatives and #hypnotics worsen #encephalopathy in cirrhosis.

13/End
Do not forget to examine. Examine. Examine.
‘A good physician treats the disease but a great physician treats the patient who has the disease’
Not every cirrhosis patient is a goner at diagnosis.
“Diagnosis is not the end, but the beginning of practice”

#livertwitter
@drcheruvarun @drdeepakmadhu @Sanchit30497977 @juanpabloarab

#MedTwitter #tweetorial