High
Respiratory System
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F1.jpg"}},{"insert":"\n\nFollowing a truly brutal stretch in the ER, you\u0027ve decided to take some time off to trek in the mountain range nearby. You\u0027re accompanied by a group of people you met on a website dedicated to exploring locations off the beaten path.\n\nA few hours of driving brings you from almost sea-level to the foot of the mountains. As you draw into the small town which acts as a de-facto base camp for climbers, you notice a dilapidated sign saying \u0022ALTITUDE: 8,000 FEET\u0022.\n\nThe single European member of your group asks, \u0022That\u0027s around two and a half thousand meters, right?\u0022 Another member replies in the affirmative.\n"}]}
1
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F2.jpg"}},{"insert":"\n\nThe following morning, you and the rest of the party gather your gear and start the trek. While the trail is steep and quite tricky in certain places, you find yourself more than up to the challenge. After a short break for lunch, the trek continues, and you are soon close to the waystation where you plan to spend the night. \n\nAs you stop for a moment to take in the scenery, you notice that one person looks rather distressed. A few moments later, he suddenly starts to vomit.\n\n\u0022Doctor! Please help him!!\u0022 a young woman in your group starts to shout. Asking everyone to calm down, you proceed to take a look at the man.\n"}]}
2
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F3.jpg"}},{"insert":"\n\nFifty-two year old Gerard complains of a generalized headache that started around 3 hours ago, and which has gradually increased in intensity over time. He also feels nauseous and fatigued. His medical history is only significant for allergic rhinitis. He is not on any medications currently.\n\nYou realize that, just like you, Gerard has skipped acclimatization, because he was unable to take leave from work until the very last minute. A quick examination reveals a pulse of 88 bpm and respiratory rate of 20\/min. There is no wheezing or cough. Nor are there neurological or visual deficits.\n\nAs you complete the evaluation you thank your foresight in packing a few important medications into your bag beforehand. Sometimes, there are definite advantages to being a doctor.\n"}]}
3
{"ops":[{"insert":"What will you tell Gerard?\n"}]}
1. "Take this Ibuprofen tablet, and make sure you are well hydrated. Once you've taken a short rest, we can continue the climb"
2. "You seem to have acute mountain sickness. You'll need to stop the climb and slowly descend back to town"
3. "This is the first sign of acute mountain sickness. Rest here, while we contact emergency services and arrange a medevac"
4
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F5.jpg"}},{"insert":"\n\n\u0022I\u0027m afraid that you have acute mountain sickness, and we\u0027ll need to get you out of here as soon as possible,\u0022 you start off, only to be interrupted by the young woman who shouted earlier.\n\n\u0022Are you sure, Doctor?\u0022 she asks. \u0022I read about mountain sickness on WebMD, and it says that all you need to do is to stay hydrated, take painkillers, and rest a bit!\u0022\n\nOut of the corner of your eye, you notice Gerard giving you a \u0022Are you a real doctor?\u0022 look.\n\nRather embarrassed, you realize that the young woman and WebMD are quite correct.\n"}]}
5
{"ops":[{"insert":"\u0022Please, doctor! I\u0027ve been planning this trip for months!\u0022, Gerard says. \u0022Isn\u0027t there any other option?\u0022 he continues, looking at you pleadingly.\n\nYou attempt to recall what you know about acute mountain sickness, and realize that while descent will definitely cure him, resting for a while and continuing the climb should not result in any major adverse effects either.\n"}]}
6
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F7.jpg"}},{"insert":"\n\nYou advise Gerard to stay well hydrated, and to rest for a while before continuing the trek. You also give him some Ibuprofen to help with the headache.\n\nAs the way-station is less than an hour away, you ask the rest of the group to proceed onwards, while you and a couple of seasoned hikers stay back with Gerard. After about an hour, he starts to feel better, and you continue the climb.\n"}]}
7
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F8.jpg"}},{"insert":"\n\nOnce you reach the way station, you accompany Gerard to his room, where the \u0022in-house\u0022 doctor at the station takes over. He concurs with your assessment, and recommends that Gerard spend a day resting, so that he is better acclimatized. As the doctor takes his leave, you ask what the altitude of the way station is, to be told that it is 9,800 feet (approximately 3000 meters).\n\nThe following morning, the majority of the group agrees to wait until Gerard has rested, barring a couple of climbers who are pressed for time, and decide to continue on their own. The rest of you set out on the following day, and after another strenuous hike, you reach the summit in the early afternoon.\n\nAfter numerous high-fives and panoramic photos, you triumphantly descend back to the way station, where you plan to spend the night before descending back to the foot of the mountain tomorrow.\n"}]}
8
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F19.jpg"}},{"insert":"\n\nAfter a quick dinner, you retire to your room, only to be woken up by a frantic hammering at your door. As you get up from bed, the handle turns, and the excitable young lady springs in, looking rather agitated.\n\n\u0022Doctor! Gerard started vomiting again a few minutes ago and can\u0027t breathe now!\u0022 she almost screams. \n\nAs you throw on a dressing gown and hasten over to Gerard\u0027s cabin, a corner of your mind ponders how this vacation has turned out to be quite different from what you envisioned.\n"}]}
9
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F9.jpg"}},{"insert":"\n\nAs you rush into Gerard\u0027s room, you notice that he is noticeably dyspneic, and clutching his chest while sitting up in bed. He coughs repeatedly, bringing up thin and clear sputum.\n\nOne of the cabin staff members hurriedly hands you a bag and says: \u0022here is the emergency medical kit, doctor. Our own doctor is out in the wild attending to another emergency, and we can\u0027t raise him on the radio. We\u0027ve already called for a medevac, but it might take another hour for them to arrive\u0022.\n\nYou sigh in relief when you look inside and find (among other items) a neatly coiled stethoscope. \n\nA quick examination shows Gerard\u0027s pulse rate to be 126 bpm, with a blood pressure of 138\/92 mmHg, respiratory rate of 38 cycles\/min, and temperature of 37.7 C. He is not cyanotic, but you do hear diffuse wheezes over both lung bases.\n"}]}
10
{"ops":[{"insert":"You decide to start oxygen via face mask.\n\nWhat else will you do?\n"}]}
1. Start oxygen and administer acetazolamide
2. Start oxygen, nebulize him with salbutamol, and administer furosemide
3. Start oxygen and administer nifedipine
11
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F11.jpg"}},{"insert":"\n\nYou start high-flow oxygen and administer acetazolamide, while keeping a close watch on Gerard\u0027s vital parameters. However, despite your best efforts, Gerard continues to deteriorate. \n\nYou are told that the medevac team will arrive in just a matter of minutes, but with a sinking feeling, you realize that they will be just a bit too late.\n"}]}
12
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F9.jpg"}},{"insert":"\n\nYou consider nebulizing Gerard with salbutamol, given the presence of bilateral wheezes. Fortunately, you then realize that his symptoms are not due to bronchoconstriction per se.\n\nThinking quickly, you decide that Nifedipine might be a better option.\n"}]}
13
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F12.jpg"}},{"insert":"\n\nThanks to your timely treatment, Gerard starts to stabilize. Soon afterwards, the medevac team arrives and rushes him off to the hospital. \n\nSubsequently, the \u0022camp\u0022 doctor arrives back at the way-station and thanks you for your help. He confirms your clinical suspicion by stating that Gerard was diagnosed with high-altitude pulmonary edema (HAPE) following admission.\n"}]}
14
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F13.jpg"}},{"insert":"\n\nThe following day, you and the rest of the group descend back to the town. Before proceeding home, you decide to visit Gerard at the hospital.\n\nAs you enter the ward, Gerard sees you and waves a warm welcome. You also notice a group of medical students standing by his bed, holding up an x-ray to the light and arguing about it.\n\nGerard says that he feels much better now, and hopes that he will be discharged soon. As you chat with him, you notice a beside chart plotting his vital signs over time. According to this, his vitals are essentially back to normal.\n\nThe attending physician arrives in the middle of the conversation, and you give him room by withdrawing a short distance. After few questions and a quick examination, he looks at the x-ray and then asks the medical students what they would like to do next, considering the radiographic findings.\n\nThe students all look lost. As they continue squinting at the x-ray, your experienced eye discerns mild patchy opacities in the right mid-zone. Remembering many similar experiences while you too were in medical college, you cannot help but root for them.\n"}]}
15
{"ops":[{"insert":"What do you hope that they will say?\n"}]}
1. Order a CT thorax to further evaluate both lungs
2. Start him on antibiotics
3. Discharge him
16
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F15.jpg"}},{"insert":"\n\nThe attending physician suddenly speaks: \u0022since no-one seems to have a clue about what to do with this patient, let me tell you.\u0022 He proceeds to explain that the changes in the chest x-ray are what one would expect after HAPE, and that Gerard is fit to go home.\n\nYou slip out of the room discreetly, trying to figure out why you missed something so basic. You also feel relieved that you\u0027re no longer a medical student, and thus do not have to deal with the pressure of answering such questions.\n\nOh well, at least you did save Gerard\u0027s life.\n"}]}
17
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M12_F16.jpg"}},{"insert":"\n\n\u0022Oh, nothing really,\u0022 you picture yourself as a medical student once more, answering the attending\u0027s question. \u0022Some changes in the x-ray are to be expected, but they usually resolve within a few days, and require no further treatment.\u0022\n\nWhen the attending speaks and confirms your mental answer, you can\u0027t help but feel a little bit smug.\n\nWell done!\n"}]}
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