13 Aug 2008 at 9:51pm Can we ordain ourselves in the majesty of God in who's to live or die?LuisLomeliMD
9 min - Aug 14, 2008The data in this video is complex and the interested reader must pause video in order to read the tex. The 56-year-old patient with hospital acquired Mycobacterium chelonae complex was first diagnosed as having Idiopathic (unknown) Pulmonary Fibrosis (IPF) by an academic pulmonologist that worked out of a renowned medical school in California. Prior to his hernia surgery, this patient was doing relatively well working as a butcher. He was morbidly obese and had hypertension. I recommended that he'd not undergo the elective surgery that had been recommended by a local surgeon. A few weeks after his upper abdominal hernia surgery, he developed dyspnea (shortness of breath) and clubbing. A chest film revealed what you see in this video. The academic pulmonologist (lung specialist) felt certain that patient had idiopathic (unknown) pulmonary fibrosis based on "classic CT findings" and recommended that he be put on Cyclophosphamide (Cytoxan®) and high dose Prednisone. Cyclophosphamide is an alkylating chemotherapeutic agent. Because of his hypertension, I felt that an equivalent dose of Dexamethasone (non-salt retaining) should be prescribed instead of salt retaining Prednisone. The pulmonologist was adamant that this patient should take Prednisone. I suspected that this case was not idiopathic, but I had a difficult time proving my clinical impression. Several tests through the public health department were reported as negative for any TB pathogen. Because he was privately insured, I was able to send him to a reference laboratory where the final diagnosis of Mycobacterium chelonae complex was made through culturing of especially collected sputum. This patient was put on clarithromycin and felt much better being off the corticosteroids. His radiograph also shows evidence of emphysema. A few weeks later after his diagnosis of Mycobacterium chelonae complex, he developed acute and severe gastrointestinal (GI) bleeding. Because of patient's religious convictions, he refused any blood though his hemoglobin dropped below 1 g/dL. He suffered severe anoxic brain damage after his gastrointestinal bleeding and was in a vegetative coma until he died 10 months later. This patient had an unfortunate and tragic end. In acute blood loss, it may take up to 24 hours for the hemoglobin or hematocrit to reflect the actual blood loss. In acute blood loss, to assess the actual blood loss, clinicians must rely on the clinical picture and vital signs that should include, when possible, blood pressure changes appropriately taken when the patient is supine and upright. Otherwise healthy adults can frequently tolerate chronic hemoglobin levels as low as 7 g/dL. For your information, the hematocrit is three times the hemoglobin level. The video also shows an old Boutonniere injury with fracture. These fractures or injuries commonly have a poor outcome irrespective of how qualified the treating provider may be. Because of such poor outcome, I send my patients to an orthopedist for consultation and further treatment. In the video you'll see a patient with anorexia nervosa and tuberculosis. She later died of tuberculosis compounded by her poor nutritional status. It is often necessary to provide patients with directly observed therapy (DOT) in order to promote compliance and reduce the emergence of drug resistance. The conductor in the video with wheezing due to active tuberculosis had first been treated elsewhere as having bronchial asthma. The first-line drugs used to treat tuberculosis include Isoniazid (INH), Rifampin (Rifadin®; Rimactane®), Rifabutin (Mycobutin®), Pyrazinamide and Ethambutol (Myambutol). Rifapentine (Priftin®) is similar to generic Rifampin and may be much more expensive. For further information, health care readers should access the CDC at www.cdc.org. Pyridoxine is vitamin B6 and the adult dose is 25 to 50 mg/day. It is given in order to reduce the peripheral neuropathy that is rarely associated with Isoniazid (INH). This video has been reduced from its original DVD format (1720 MB) to a mere 19 MB via QuickTime so that it could be shown via the Internet. Though this video is only 19 MB, it is unfortunately only accessible through high speed Internet or DSL, not dial up. Therefore, many countries in the world have a difficult time accessing my work via the Internet. I hope to correct the latter problem through private efforts. I will be posting two more Radiology works, and I will change the format in order to make the text more readable at such low resolution. Luis Lomeli, M.D./Beta "In nature there is no right or wrong, there are only consequences." 'Can we ordain ourselves in the majesty of God in deciding who is to live or die? Can we tame the savageness of Man and stand united for a just cause: Universal Health Care?' By RBK, A Greek Writing, and Luis Lomeli, M.D.
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