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Date posted: May 5, 2012

Dr Beenadas

Presenting complaints

Cough 6 days, coughs continually for a long time.
Productive, white sputum. Throat irritation precedes coughing.
Nausea + + +.
Headache, chest pain and pain around umbilicus with cough.
Cough < by slightest exertion, talking tight clothing,
< by cold damp weather etc.
Difficulty in breathing – 1 week. < by coughing.
Hoarseness – since 3 days. 

History of presenting complaints
Presenting complaints started 12 days after an exposure to cold damp climate during his travel to Palghat, Coimbatore etc. Then he took some Ayurvedic Medicine, single dose on the first day itself. thereafter cough becomes productive and associated with weakness of body. Increased cough, fever and dyspnoea  occurred two days after medicine intake. Vomited mucus once and nausea still remains. Four days back noticed edema of both legs which lasted for one  day, during his travel. Patient feels irritable and tendency to run out of  bed if hears voice and prefers to lye still in bed as movement brings cough.

History of previous complaints

  1. History of anterior wall myocardial infarction 2 years back with dyslipidemia.
  2. History of hemorrhoids 4 years back.
  3. History of angina 6 months back, admitted here and got relief.
  4. No history of asthma or bronchitis.

Family history

  • Father – died of heart failure.
  • Mother – died.
  • Has one sister and 2elder brothers. Sister died of renal & cardiac complaint and one brother suicided.
  • No family history of asthma and allergic disease. 

Personal history

  • Place of birth – Karaparamba.
  • Educational status – SSLC
  • Religion – Hindu.
  • Occupational status – Musician.
  • Marital status – not married.
  • Habit and Hobbies –
  • Non-vegit, addicted to tea, had smoking habit – stopped 2years back,
  • Was alcoholic, now stopped 2 years back.
  • Domestic relations – poor. 

Physical features

(a) Generals

Functionals :-

  • Appetite – decreased, prefers cold.
  • Thirst – normal, prefers hot tea.
  • Sleep – reduced, due to cough.
  • Dreams of horrible animals – dragon- attacking him. Frightful dreams.

Eliminations :-

  • Stool – constipated.
  • Urine – normal
  • Sweat – normal

(b) Response to

  • < – Night;            can’t tolerate air or fanning;
  • Chilly patient;     desires covering
  • < cold climate;     complaints < by bathing.

 Psychic features
Wants to be quiet. Tendency to run out of bed. Imagines he is semiconscious and talks to imaginary person. Horrible dreams make him frightful and then praying.

Regionals

  • Head :- Headache only during coughing.
  • Vertigo :- while standing.
  • Teeth :- sore feeling in teeth.
  • Throat:- irritation in throat leading to cough.
  • Stomach :- pain around umbilicus during cough.
  • Expectoration :-whitish or yellowish.
  • Skin:- blackish discoloration on the back with pealing of skin after bathing. 

Physical examination

Generals:- 

  • Built :- poor ;         Complexion :- dark
  • Wasting of muscles present.
  • Pulse rate :- 113\mt ;     R.R – 36\mt
  • Temperature :- 104F;     B.P :- 110\78 mm of Mg.
  • Not anemic, no pallor, no clubbing, no edema
  • No lymphadenopathy, not icteric. 

Systemic:- 

Respiratory system

  • Inspection:-
  • Upper respiratory tract – NAD.
  • No movement of accessory muscles of respiration.
  • Shape of chest :- bilaterally symmetrical
  • No chest deformities like pigeon chest, Harrison’s sulci, rickety rosary.
  • No congenital disorders of vertebral coloumn like kyphoscoliosis, pectus excavatum.
  • No drooping of shoulders; no dilated veins on chest.
  • Apex beat:- visible at left 5th intercostals 1\2” medial to midclavicular line.
  • Type of breathing :- abdominal.
  • No marks of puncture, incision or scars over chest wall. 

Palpation:-

  • Trachea :- central in position.
  • Apex beat felt at left IC space 1\2” medial to midclavicular line.
  • Tenderness of right side of chest –present.
  • Chest expansion-Decreased.(2-3cm)
  • Vocal fremitus – increased on right side. 

Percussion:-

  • Left lobe – resonant.
  • Right lobe – dull 

Auscultation:-

  • Breath sounds – bronchial.
  • Added sounds – b\l crepitation, more on right side.
  • Vocal fremitus – increased on right side.
  • Brobchophony and whispering pectoriloquy – noted over right side. 

Investigations:-

13-7-07.

  • Blood – ESR :- 22mm of Hg
  • Hb    :-13.3g%
  • WBC :- 4.8×10 /dl
  • DC – L36: N52; mixed – 11.1%
  • CXR –  Opacity noted on upper lobe of right lung. 

Provisional diagnosis : Pneumonia.

Diagnosis of patient

Totality of symptoms  :-

Disease

  • Cough With White Sputum
  • Chest Pain With Cough
  • Cough < Physical Exertion, Cold Weather
  • Dyspnoea < Coughing
  • Hoarseness And Irritation In Throat

Patient

  • Prefers Hot Drinks
  • Chilly Patient+ + + ,Cannot Tolerate Fanning.
  • Complaints < By Bathing
  • Tendency To Run Out.
  • Horrible and frightful dreams.

Miasmatic Expressions

Psora:-

  • Chest pain and pain around umbilicus with cough.
  • Cough < cold warm weather.
  •  Hoarseness of voice.
  • Imagines as semiconscious and tendency to run out.
  • Horrible frightful dreams.

Sycotic.

  • Pneumonia with consolidation of lungs.
  • Sycotic pneumonia and bronchitis, cough and cold < in humid moist atmosphere.
  • Tachycardiya.
  • Syphilitic-
  • Feels worse at night.
  • Cough paroxysmal
  • Dyspnoea < lying down. 

Evaluation of symptoms

  • Stomach – desire tea
  • Generality – cold in general – <
  • Generality – heat vital, lack of
  • Respiration – difficult, cough with.
  • Respiration – difficult exertion after.

Medicines given

  • 11-7-07    – Ipecac 3x /2d
  • 12-7-07    – Ipecac30/2d
  • 13-7-07    – Bell200/1d 

PNEUMONIA
Pneumonia is the infection of alveoli, distal airways and inerstitium of lung that is manifested by  increased weight of the lungs, replacement of normal lung’s sponginess by consolidation and alveoli filled with WBC , RBC and fibrin.

Definition :- (clinician)
Pneumonia is  constellation of symptoms and signs – fever, chill, cough, pleuritic chest pain, sputum production, hyper or hyperthermia, increased respiratory rate, dullness to percussion, bronchial breathing, egophony, crackles, wheezes, pleural friction rub with at least one opacity on chest X-Ray. 

Host defenses protecting lungs
Nasal turbinate and sharp angular turn from the naso and anterior oropharynx into posterior pharynx acts as baffles where inhaled particulate matter can impact. Ciliated cells overlying mucus layer  of trachea, bronchi and terminal bronchioles move a mucus layer which float. Mucus consists of complex glycoproteins called mucins that trap micro-organisms.

The entry into lower respiratory tract is protected by glottis and is cleared by coughing defense include macrophages, fibronectin, lysozymes  lactoferrin, Ig G, defensins, cathelicidins, collectins and complement. Surfactant is bactericidal to certain pathogens and along with Ig G and fibrinectin, can oponise bacteria.

FACTORS IN PATHOGENISIS
Routes of infection :- gross aspiration, micro aspiration, haematogenous spread from a distal infected site and direct spread from a contiguous infected site.

Microbial factors :- Micro organism develop a verity of mechanism to counteract host defense.

Eg:- Chlamydia pneumonia produce – ciliostatic factor;

Mycoplasma pneumonia      -      shear off cilia;

S.pneumonia& N.meningitidis – proteases.

Host factors:-Hypogammaglobulinemia, defects in phagocytosis or ciliary function, neutropaenia, functional or anatomical asplenia or a reduction in CD4 & T lymphocytes count are all host defense deficits.

Anatomical defects:- obstructed bronchus, bronchiectasis or sequestration of pulmonary segment etc lead to recurrent pneumonia or failure of pneumonia to resolve.

Pathophysiology
Vital capacity, lung compliance, functional residual capacity and total lung capacity  are below normal.

Pathology
This is manifested as 4 general patterns – 1) Lobar Pneumonia 2) Broncho Pneumonia 3) Interstitial Pneumonia 4) Miliary Pneumonia.

1.Lobar pneumonia
Classically involves an entire lung lobe relatively homogeneously, although in some patient a small portion of the lobe may be unaffected or at an earlier stage of involvement. Four  stage of lobar pneumonia may exists simultaneously in the  same lung.

1) First stage – Stage of Congestion :-occurs during the first 24 hours and is characterized grossly  by redness and a doughy consistency  and microscopically by vascular congestion and alveolar edema. Many bacteria are present and are swept by the rapid expansion of edema fluid throughout the lobe via the Pores of Kohn. Only a few neutrophils are seen at this stage.

2) 2nd stage – Stage of Red Hepatization.:- This term is because of the color of the lung and the similarity of its airless, noncrepitant firmness to the consistency of liver – is characterized microscopically by the presence of many erythrocytes, neutrophills, desquamated epithelial cells and fibrin in the alveolar spaces.

3) 3rd stage – Stage of Grey Hepatization :- The ling is dry, friable and grey-brown to yellow as a consequence of a persistent fibrinopurulent exudates, a progressive disintegration of RBC and the variable presence of hemosiderin. The exudates contains macrophages, neutrophills and seldom bacteria.

 2nd & 3rd stage lasts for 2-3 days each, with a 2-6 day duration of maximal consolidation.

4) 4th stage – Stage of Resolution :- characterized by erythocytic digestion of alveolar exudates, resorptin, phagositosis or coughing  op of residual debris and restoration of the pulmonary architecture. Fibrinous inflammation may extent to  and across the plural space, causing a rub heard by auscultation, and may lead to resolution or to organization and plural adhesions.

11.Bronchopnumonia
A  patchy consolidation involving  one or several lobes, usually involves the dependent lower and posterior portions of the lung – a pattern attributable to the distribution of aspirated oropharyngeal contents by gravity. The consolidated area are poorly demarcated; in some cases there is an abrupt delimitation of the pneumonia at interlobular septa. The neutrophilic exudates is centered in bronchi and bronchioles with centrifugal spread to adjacent alveoli and diminishing cellular exudates. Often there is pulmonary edema in the periphery of the lesion.

111. Interstitial pneumonia.
Is defined by histopathologic identification of an inflammatory process predominantly involving the interstitium, including the alveolar walls and the connective tissues around the bronchovascular tree. The inflammation may be patchy or diffuse. The alveolar septa contain an inflammation of lymphocytes, macrophages and plasma cells. The alveoli contains protein rich hyaline membrane similar to that found in ARDS may line the alveolar space. Bacterial super infection of viral pneumonia also produce a mixed patter of interstitial and alveolar air space inflammation.

1V. Miliary Pnumonia.
Numerous discrete lesions resulting from the spread  of the pathogen to the lungs via the bloodstream. The varying degree of immunocompramise manifests as variation in the tissue reaction.

Pulmonary complications in pneumonia
Necrotizing pneumonia, formation of abscess, vascular invasion with infarction, cavitations and extension to the pleura  with empyema or bronchopleural fistula. 

Community accured pneumonia.(cap) 

  • Risk factors of CAP – alcoholism, asthma, immunosuppresion.
  • Risk factors for Pneumococcal Pneumonia – Dementia seizures CCF, CVA, tobacco smoking, alcoholism,COPD.
  • Risk factors for invasive invasive pneumococcal disease include – male gender, black race, chronic illness, current tobacco smoking and passive exposure to  tobacco smoke, HIV infection.
  • Risk factor for Legionnaire’s disease include – male gender, current tobacco smoking, Diabetes mellitus, hematological malignancy, cancer, ESRD and HIV infection.
  • Risk factor for Gram negative bacteria :- aspiration, previous hospital administration, previous antimicrobial treatment and broncetasis.
  • Etiology :- Organism causing pneumonia may be identified from culture of blood, sputum, plural fluid, pulmonary tissues or endobronchial secretion.
  • CAP include bacteria, fungi, viruses and parasite.
  • Pathogens – S.pneumoniae, H.influenza, S.aureus, M.pneumonia, C. pneumonia, Moraxella catarrhalis, Leginella,aerobic Gram negative bacteria, influenza virus, adenovirus and respiratory syncytial virus.S.pneumonia account for 50% of CAP. 

Clinical features.
Vary from mild to fulminent and fatal. Onset may be sudden, dramatic and insidious. Fever, cough (nonproductive  or productive of purulent or rust colored sputum), pleuritic chest pain, chills or rigors, and shortness of breath are typical. Headache, nausea, vomiting, diarrhea, myalgia, arthralgia, fatigue, etc may also be present. Confusion may be important manifestation in elderly persons.

Physical signs :-  tachypnoea, dullness  to percussion, increased tactile and vocal fremitus, egophony, whispering pectoriloquy, crackles and pleural friction rub.

Single most useful clinical sign of severity of pneumonia is respiratory rate > 30/mt. mortality rate is highest for pneumonia due to P. aeruginora, them for klebsiella, E.coli, S.aureus and Acinetobacter.

Worsening of co morbid conditions – DM, CCF, IHD and asthma.

Complication.

  • Respiratory failure, CCF, shock, atrial dysarrhythmias, MI, GI bleeding and renal insufficiency.
  • Most common  immediate cause of death in pneumonia patient – respiratory failure, heart disease and infection.
  • Associated with pneumonia related  mortality include – dementia immunosuppression, active cancer, systolic hypotension, male gender, multilobar pulmonary infiltration.

Diagnosis

1)Chest X-Ray

2) CT – detects pulmonary opacities in patient when chest X-Ray not show pneumonia or again chest X-Ray is repeated after 24-48 hours.

3) Etiological Diagnosis :- blood culture, sputum strains and culture

Detection of antigens of pulmonary pathogens in urine:-

eg :- L.pneumophilia serogroup 1 antigen _ Legionnaire’s disease.

Bacterimic pneumococcal pneumonia – S.pneumonia.

Serology – detection of IgM antibody or demonstration of a fourfold rise in titer of antibody.

Eg:- serologic tests are complement fixation, indirect immunoflouresence, ELISA.

Agent diagnosed are – M.pneumonias, C.pneumonias, Chlamydia psittaci, legionella, C.burnettii

Polymer Chain Reaction :- detection of DNA (Legionella, M.pneumonia & C.pneumonia) or RNA of microorganisms.

Complication:- Pleural effusion, Lung abscess, recurrent pneumonia.

Aspiration pneumonia
It is due to introduction of foreign substance or objects into the lower respiratory tract. Areas involved are those that are most dependent in the supine position – posterior segment of upper lobe and superior segment of lower lobe.

Etiology :- cause in elderly – Enterobacteriaceae, S.aureus, S.pneumoniae and H.influenza.

Epidemiology:-
Gastric contents are aspirated into lungs with a consequent inflammatory response – due to aspiration of oropharyngeal flora into the lungs with consequent bacterial infection.

Risk Factors :- altered level of consciousness , incompetent gastro esophageal junction, elevated intragastric pressure or volume and neuromuscular disease(glottis closures)

Clinical Feature :-
Chemical pneumonitis which is severe, require assisted ventilation. PH of <2.5 & a gastric aspirate volume of >0.3ml/kg(20-25ml in adults) is need to develop aspiration pneumonia.

Diagnosis:-

  • History of aspiration.
  • Location of pneumonia – depends on position of patient when aspiration
  • Ocurs. Eg – in recumbent position, opacity in posterior segment of right upper lobe.

Prevention :- oral hygiene. 

Hospital acquired (nosocomical) pneumonia.
It is the pneumonia occurring at least 48 hours after hospital admission.

Common in medical and surgical wards, in ICU patient undergoing  mechanical ventilation. Tubes serves direct bacterial introduction into lower respiratory tract, prevents effective coughing to clear lower respiratory secretions, damage he tracheal epithelium and allows the accumulation of oropharyngeal secretions.

Presence of nasotrachial or nasogastric tube increase risk of nosocomial sinusitis.

Etiology:-Common cause – S.aureus (64%) then, enterobacteriaceae.

Clinical features:-presence of a new or progressive infiltrate on CXR + at least 2 of the following – 1) fever >37.8*C 2) Leukocytosis >10,000WBC/L 3) purulent sputum.

Other symptoms _ dyspnoea, hypoxemia & chest pain.

Diagnosis :- endotrachial aspiration or bronchoalveolar lavage.

PSB( protected specimen brush) +ive if at least (10)3CFU(colony forming units) of bacteria /ml

Pneumonia Rubric – 

Kent-

(1) Chest-hepatizaton of lungs-

      3 – phos,    2 – Br, Cactus, Camph, Chel,Iod, Kali.carb, Kali.clor, Kali.iod, Lache,  Lob, Lyco, Nux.vom, Sangu, Tubercu.

(2) Chest – Inflammation – Lungs

      3 – Aco, Ant.tart, Ars, Bry, Car.veg, Chel, Hep, Lob, Lyco, Mer, Phos,   Puls, Rhus.tox, Senega, Sepia, Sul, Ver.vir

Boerick

(1) Resp. system- Inflammation- 1) Bronchopneumonia

2- Acon, Ant.tart, Ars.iod, Bry, Chel, Ipecac, Phos, Puls, Tub.

1- Am.iod, Ant.ars, Ars, Bell, Bry, Iod, Kali.carb, Puls.

(2) Croupous pneumonia-

2- Acon, Ant.tart, Bell, Brom, Bry, Chel, Iod, Kali.carb, Lyco, Phos,  Sangu, Sul, Ver.vir.

1-  Am.iod, Ars.iod, Arn, Campher, Car.veg, Gels, Hp.sul, Ip, Lache,  Nat.sulph, Nit.ac, Op, Rtus.tox,Tub.

(3) Stages of pneumonia- Congestive-

 2 -Acon, Fer.p, Iod, Sang, Ver.vir

(4) Stage of Consolidation-

2-Bry, Iod, Phos.

(5) Stage of resolution-

 2-ant.tart, Hepar, Kali.iod, Phos, Sang, Sulp.

THERAPEUTICS 

ACONITE- In pulmonary congestions, 1st stage of pneumonia. Symptoms are high fever, distinct chill, pulse- small, full, hard & tense. History of exposure to cold winds. Skin hot, dry; hard teasing and painful dry cough. Expectoration is watery, serous and  frothy, may blood tinged. Restless tossing about ,anxiety and fear of death.

VER.VIR- Full, hard and rapid pulse, red streak through the centre of tongue. Indicated at commencement of pneumonia – violent congestion about chest preceding pneumonia. Great arterial excitement, dyspnoea, chest oppression and stomach symptoms of nausea and vomiting. High fever.

FER.PHOS- 1st stage of inflammation before exudation takes place. Expectoration is thin watery and blood streaked. Violent congestion of lungs- whether at onset of disease or during its course. Thus it corresponds to secondary pneumonia in the aged and debilitated. High fever oppressed and hurried breathing and bloody expectoration. Little thirst.

IODINE- 1st & 2nd stage of pneumonia,croupous form. High fever and thirst less. Rapid tendency for hepatization. Cough and dyspnoea as if chest would not expand. Sputum blood streaked.Iod 1x-3x arrests process of hepatization if given.

BRYONIA- Fever present ;sharp, stitching  pleuritic pains. Cough is hard and dry. Sputum is scanty and rust colored. Tongue is dry. Patient wants to keep perfectly quiet. Right sided remedy. Pain in chest worse by motion, breathing and relieved by lying on right or painful side.  For pneumonia complicated by pleurisy.

PHOS-Follows Bry and is complimentary. Lungs are hepatized. Cough with pain under sternum; mucus rales, sputa is yellowish mucus with blood streaks or rust colored.

HEPAR SULPH- After phos. as the exudates begins to soften. Cough after exposure to dry cold wind, rattling of mucus,<by cold air or drinks. Cough when any part of body is uncovered. Patient has to sit up and bend back in asthma.

TUBERCULINUM- In lobular pneumonia rising as intercurrent from 6x-30x is important.

SANGUNARIA- Fever, burning and fullness in the upper chest. Sharp, stitching pains on right side. Dry cough, dyspnoea  and expectoration of rust color sputum. Circumscribed redness and burning heat of the cheeks esp. afternoon. Engorgement and congestion of lungs.

CHELIDONIUM- Bilious pneumonia is indication. Stitching pain under right scapula. Cough is loose, rattling and difficult expectoration.

ANT.TART- Indicated at stage of resolution. Fine moist rales heard all over the hepatized portion of lungs. Oppression of breathing compels to sit. No expectoration. More suited in aged and in children.

KALI.CARB- Sharp stitching pain in chest, worse by motion. Affect lower part of right lung. Dyspnoea and great mucus in chest. Indicated when Ant.tart & Ip fails to raise the expectoration.

SULPHUR- In any stage of pneumonia. Slow speech, dry tongue, weakness and faintness are characteristic.Dyspnoea <12 &2 at midnight causing patient to sit-up in bed. Psoric constitutions with tendency to develop into tuberculosis.

LYCOPODIUM-Useful in delayed or partial resolution. Tightness across the chest, aching over lungs, great weakness. Threatens to run into acute phthisis.

IPECAC- Cough incessant and violent with every breath. Chest seems full of phlegm. Bubbling rales. Constriction in chest with nausea. Hoarseness. cough dry and asthmatic. Rattling cough. Fever with nausea, thirst,

CAL.C chilliness and shivering.

CUPRUM.MET- Spasm and constriction of chest. Spasmodic asthma alternating with spasmodic vomiting. Cough better  by drinking cold water. ARB- Chest very sensitive to touch, percussion or pressure. Suffocating spells. Painless hoarseness. cough exited by tickling in the throat and accompanied by vomiting.

ARS.ALB- Respiration anxious, stertorous and wheezing. Oppression of chest on coughing, walking and on going upstairs. great anxiety. chest, shivering or great heat  and burning in chest..

CARBO.VEG- Cough < in evening, going from a warm to cold place, in bed. Chilliness or coldness in Expectoration of green mucus or yellow pus or spitting of blood and burning pain in the chest.

CAUSTICUM- Aphonia from weakness of muscles of larynx. Hawking up of abundant mucus. Cough excited by speech and cold. Cough relieved by swallow of cold water. Cough with involuntary passage of urine.

NAT.SULPH- Sycotic pneumonia, lower lobe of right lung affected , with great soreness of chest. During cough patient has to sit up in bed and hold the chest with both hands.

Dr.Beenadas
Lecturer, Department of MM
Govt. Homeopathic Medical College. Calicut

Comments

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