Thank you Dr. Nikita and her team for sharing such an enriching acute case along with the video which enables us to experience the emergency situation exactly the way you did.
And the importance of time in whatever decisions we take in the case management with respect to investigations, diagnosis and treatment.
According to me Lower Respiratory Tract is the system involved due to the labored breathing, patient seems to be better lying on the right side. Very rapid onset of symptoms from Throat to lungs.
Would like to know about mental concomitants or rule out any event of anxiety/panic with the child which has led to hyperventilation, considering the mother also has an anxious temperament.
Investigations- CBC, ABG, CXR
Management- Nebulisation along with Acute Homeopathic remedy followed by I.C & C.R.
Dear learner, thank you for the response. Good thinking. Well done!
Please share your process of concluding that it is the respiratory system. Can such type of presentation be seen in other clinical conditions? How do we rule them out?
Can you elaborate on which findings in general and systemic examination will help you to make correlations and reach a probable clinical diagnosis?
Please also share your thoughts on how to perceive Homoeopathic acute totality in a very limited time in the emergency department.
According to me the respiratory system mainly involved in which the patient is using accessory muscles of Respiration with sternal notching so breathing is not normal and so we should examine her chest regarding respiratory sounds which kind of it is will help us in understanding which part of lung is involved since she has vomiting 2 episodes so one question arise is what if she aspirated it. There is fever so it can be due to infection so for this we have ordered some investigation like CBC and ABG and X -ray chest to see changes like any fluid buildup in chest.
Dear Learner, thank you for sharing your observations and line of thinking. Very well done!
You are on the right track but please do share how did you reach this conclusion. Is such a breathing pattern only seen in problems of the respiratory system? So, what is your differential diagnosis? Also, please share your management plan.
Do share your further thoughts so that we can take the discussion ahead.
Apr 13·edited Apr 13Liked by Integrated Homoeopathy Newsl.
This case stirred my mind reminded my pg pediatric residentship days 13 years back when i was pursuing my md in subject of pediatrics in mldmhi we were very much juniors those days in casualty one similar case came we were thinking of acute excerbation of hyperactive airways disease, Dr nikita mam was medical officer during those days handling pediatric ipd, she came in casualty and asked what do you all think? We said what we thought mam after looking at the case and after some question went near to patient (fruity odor) asked to do bsl which was quite high and urinary ketone positive a case of DKA.... We were just thinking superficially but mam was thinking on evolutionary aspect of disease on time timension which we call as SSFT and using deductive logic to arrive at conclusion
With respect to this case
1. A short history of illness worsening
2. Deep breathing pattern, labored breathing,looks like kossumaul breathing
3.a kidney tray kept at side patients has nausea or vomiting
4.lethargic as if given up
I would like to enquire from parents
1. Does this patient has excessive thirst appetite, urination (polyphagia, polydypsia, polyurea)
2.does this patient decreased sweating.
I would like to enquire
1. Past history of similar episode
Points towards hyperactive airway disease
2. Family history of IDM or Nidm
3. History of chocking during vomiting
Examination
Going near to mouth to see fruity odor of breath
T..
P... Volume of pulse
R..
SpO2 .... bp.. Hypotension may be in dka
RS... 1.Clear good air entry bilateral
Then i would think of disease isn't primarily respiratory its a metabolic acidosis in DKA leading to compensatory tachypnea
2. Wheezing, ronchi, decreased air entry then points towards hyper reactive airway disease
PA... CVS.. CNS
Investigation... bsl.. If high.. Urinary ketones... CXR in case of chest signs... ABG
Treatment...picu.. Oxygen fluid and electrolytes insulin as per DKA protocol
Meanwhile searching for totality to prescribe constitutional medicine and in such a emergency we definitely will have qualified mentals and physicals particulars concomitant which speaks about Constitution
Its a decade now in private practice that missed case opened new area of thinking about those disease which we least think
Thank you for this beautiful sharing. That powerful case had taught us all a lot.
You have made very precise observations in this case. The systematic and elaborative step-by-step approach to the case is very well thought out and presented. You have focused on the respiratory system and the endocrines. Can you please share if there can be other causes of such presentation which should be ruled out by thorough clinical assessment and how one confirms and reaches the final diagnosis?
Also, please share why you think a constitutional remedy will be helpful at this stage and state of disease.
Do post your thoughts on these so that I can get back to you.
Thank you for your response and for sharing your line of thinking. Good job!
Please share your differential diagnosis and the process of reaching the final diagnosis. Which data helped you to do so? How would you like to go ahead now and manage this case? Please let me know your further plan so that we can discuss this ahead.
Thank you for your response. Very clear and precise clinical thinking and management strategy. You are going in the right direction. Great job!
Just one question, why not homoeopathy too for the acute exacerbation? Can we handle such a case in a well-equipped Homoeopathic IPD set-up? Do we have the required armamentarium in Homoeopathy to manage this acute presentation? if yes, how to perceive the totality and reach the simillimum? What group of remedies can you think of?
Please do ponder upon this and reply. We can discuss this ahead once you share your thoughts.
Good job on the observation of the use of accessory muscles of respiration. In which conditions, are the accessory muscles of respiration required and what purpose do they serve? Can other systems be involved in such presentations that one might miss if a thorough clinical assessment is not done? how do we rule out other systems and confirm that it's the respiratory system?
you are right about the history from the mother and our observations. So, what steps will you take now to manage this child in distress? Please reply to these questions. I will get back to you once you reply.
It seems like patient has laboured breathing despite of giving plain neb. Kidney tray near her mouth shows that she is also experiencing nausea. We can calm down her mother and take her history such as modality, change in voice, F/H of any illness, P/H of asthma, allergies or GERD?
After coming to our provisional diagnosis confirmatory investigations can be ordered and keeping scope and limitations we start our treatment.
Dear learner, Thank you for your response. Good observations and strategy to move ahead. So, what diagnosis are you thinking of when you are talking about certain past histories? Please list down the investigations that you are thinking of ordering. What kind of management plan will you think of? which limitations are you anticipating? once you reply, we will discuss ahead on this.
There was laboured breathing pattern in the patient . It seems to be LRTI as the child is breathless. There are many causes for breathlessness and these type of breathing. Homoeopathic medicines with proper nebulization may help in this condition.
Dear learner, Thank you for your response. You are thinking of an infection of the lower respiratory tract as the probable diagnosis. Which type of infection could it be? Can you please elaborate on how did you reach this conclusion? Can there be non-infectious causes responsible for such a presentation? What are the symptoms, signs, clinical examination, and investigations that will help you rule out the many causes of breathlessness in this age group and reach the final diagnosis? What are the steps required to find the simillimum homoeopathic medicines which you think may help in this condition? Do think along these lines and reply so that I can help answer your further queries if any.
Thank you Dr. Nikita and her team for sharing such an enriching acute case along with the video which enables us to experience the emergency situation exactly the way you did.
And the importance of time in whatever decisions we take in the case management with respect to investigations, diagnosis and treatment.
According to me Lower Respiratory Tract is the system involved due to the labored breathing, patient seems to be better lying on the right side. Very rapid onset of symptoms from Throat to lungs.
Would like to know about mental concomitants or rule out any event of anxiety/panic with the child which has led to hyperventilation, considering the mother also has an anxious temperament.
Investigations- CBC, ABG, CXR
Management- Nebulisation along with Acute Homeopathic remedy followed by I.C & C.R.
Thank you, Dr. Swarda, from the entire team. Your kind words mean a lot to us!
Good line of thinking and management strategy. What are the possible part/tissues affected and the pathology? what do you think is the cause?
Please do elaborate on the steps to reach the acute Homoeopathic remedy in this case.
Do drop in your further comments. I will get back to you.
Respiratory system is mainly involved- resp. distress - use of accessory muscles.
First we have to assure mother and relax her so that proper history can be taken up about the complaints.
With that the general and systemic examination will help further.
Investigation - BSL, CBC, ABG, CXR can be thought of, and observe any PQRS symptoms,.
In such cases, acute homoeopathic medicine can be prescribed on the basis of acute totality.
Dear learner, thank you for the response. Good thinking. Well done!
Please share your process of concluding that it is the respiratory system. Can such type of presentation be seen in other clinical conditions? How do we rule them out?
Can you elaborate on which findings in general and systemic examination will help you to make correlations and reach a probable clinical diagnosis?
Please also share your thoughts on how to perceive Homoeopathic acute totality in a very limited time in the emergency department.
Do reply and I will get back to you on this.
According to me the respiratory system mainly involved in which the patient is using accessory muscles of Respiration with sternal notching so breathing is not normal and so we should examine her chest regarding respiratory sounds which kind of it is will help us in understanding which part of lung is involved since she has vomiting 2 episodes so one question arise is what if she aspirated it. There is fever so it can be due to infection so for this we have ordered some investigation like CBC and ABG and X -ray chest to see changes like any fluid buildup in chest.
Dear Learner, thank you for sharing your observations and line of thinking. Very well done!
You are on the right track but please do share how did you reach this conclusion. Is such a breathing pattern only seen in problems of the respiratory system? So, what is your differential diagnosis? Also, please share your management plan.
Do share your further thoughts so that we can take the discussion ahead.
This case stirred my mind reminded my pg pediatric residentship days 13 years back when i was pursuing my md in subject of pediatrics in mldmhi we were very much juniors those days in casualty one similar case came we were thinking of acute excerbation of hyperactive airways disease, Dr nikita mam was medical officer during those days handling pediatric ipd, she came in casualty and asked what do you all think? We said what we thought mam after looking at the case and after some question went near to patient (fruity odor) asked to do bsl which was quite high and urinary ketone positive a case of DKA.... We were just thinking superficially but mam was thinking on evolutionary aspect of disease on time timension which we call as SSFT and using deductive logic to arrive at conclusion
With respect to this case
1. A short history of illness worsening
2. Deep breathing pattern, labored breathing,looks like kossumaul breathing
3.a kidney tray kept at side patients has nausea or vomiting
4.lethargic as if given up
I would like to enquire from parents
1. Does this patient has excessive thirst appetite, urination (polyphagia, polydypsia, polyurea)
2.does this patient decreased sweating.
I would like to enquire
1. Past history of similar episode
Points towards hyperactive airway disease
2. Family history of IDM or Nidm
3. History of chocking during vomiting
Examination
Going near to mouth to see fruity odor of breath
T..
P... Volume of pulse
R..
SpO2 .... bp.. Hypotension may be in dka
RS... 1.Clear good air entry bilateral
Then i would think of disease isn't primarily respiratory its a metabolic acidosis in DKA leading to compensatory tachypnea
2. Wheezing, ronchi, decreased air entry then points towards hyper reactive airway disease
PA... CVS.. CNS
Investigation... bsl.. If high.. Urinary ketones... CXR in case of chest signs... ABG
Treatment...picu.. Oxygen fluid and electrolytes insulin as per DKA protocol
Meanwhile searching for totality to prescribe constitutional medicine and in such a emergency we definitely will have qualified mentals and physicals particulars concomitant which speaks about Constitution
Its a decade now in private practice that missed case opened new area of thinking about those disease which we least think
Thank you
Thank you for this beautiful sharing. That powerful case had taught us all a lot.
You have made very precise observations in this case. The systematic and elaborative step-by-step approach to the case is very well thought out and presented. You have focused on the respiratory system and the endocrines. Can you please share if there can be other causes of such presentation which should be ruled out by thorough clinical assessment and how one confirms and reaches the final diagnosis?
Also, please share why you think a constitutional remedy will be helpful at this stage and state of disease.
Do post your thoughts on these so that I can get back to you.
Acute excerbation asthma.. resirtory distress.. relived by one sided.. whezzing present
Thank you for your response and for sharing your line of thinking. Good job!
Please share your differential diagnosis and the process of reaching the final diagnosis. Which data helped you to do so? How would you like to go ahead now and manage this case? Please let me know your further plan so that we can discuss this ahead.
1. respiratory system - severe distress - movement of ale nasi - use of accessory muscles.
2. ? Asthma - due to thorat infection ? -
3. Auscultation, spo2, RBS, concious level assesment, heart rate, pulse rate, BP, CXR-PA View, CBP ESR, 2D ECHO.
4. h/o from mother
5. O2 supplimentation, slight head end elevation,
6. Treat the acute exacerbation with Allopathy.
7. Then go for Homoeopathy
Thank you for your response. Very clear and precise clinical thinking and management strategy. You are going in the right direction. Great job!
Just one question, why not homoeopathy too for the acute exacerbation? Can we handle such a case in a well-equipped Homoeopathic IPD set-up? Do we have the required armamentarium in Homoeopathy to manage this acute presentation? if yes, how to perceive the totality and reach the simillimum? What group of remedies can you think of?
Please do ponder upon this and reply. We can discuss this ahead once you share your thoughts.
The system involved is Respiratory, she is in distress, using accessory muscles for respiration, with Air hunger is present .
In such cases it is very difficult to take proper history, so we can rely on the history by mother + our own observations
Good job on the observation of the use of accessory muscles of respiration. In which conditions, are the accessory muscles of respiration required and what purpose do they serve? Can other systems be involved in such presentations that one might miss if a thorough clinical assessment is not done? how do we rule out other systems and confirm that it's the respiratory system?
you are right about the history from the mother and our observations. So, what steps will you take now to manage this child in distress? Please reply to these questions. I will get back to you once you reply.
It seems like patient has laboured breathing despite of giving plain neb. Kidney tray near her mouth shows that she is also experiencing nausea. We can calm down her mother and take her history such as modality, change in voice, F/H of any illness, P/H of asthma, allergies or GERD?
After coming to our provisional diagnosis confirmatory investigations can be ordered and keeping scope and limitations we start our treatment.
Dear learner, Thank you for your response. Good observations and strategy to move ahead. So, what diagnosis are you thinking of when you are talking about certain past histories? Please list down the investigations that you are thinking of ordering. What kind of management plan will you think of? which limitations are you anticipating? once you reply, we will discuss ahead on this.
There was laboured breathing pattern in the patient . It seems to be LRTI as the child is breathless. There are many causes for breathlessness and these type of breathing. Homoeopathic medicines with proper nebulization may help in this condition.
Dear learner, Thank you for your response. You are thinking of an infection of the lower respiratory tract as the probable diagnosis. Which type of infection could it be? Can you please elaborate on how did you reach this conclusion? Can there be non-infectious causes responsible for such a presentation? What are the symptoms, signs, clinical examination, and investigations that will help you rule out the many causes of breathlessness in this age group and reach the final diagnosis? What are the steps required to find the simillimum homoeopathic medicines which you think may help in this condition? Do think along these lines and reply so that I can help answer your further queries if any.