We would like to quote Carlos Pesce below "We
own our thoughts, but what we say or write enslaves us".
Please click on the links of the names to see their comments (names added according to their signatures).
Dr. Carlos Pesce (Argentina)
Dr Thuppil Venkatesh (India)
Joe Fisher M.D. FRCP(C) (Canada)
John West, M.D. (USA)
Tim Quigley Peterson, M.D. (USA)
Christina Jefferson, M.D.
(USA)
Michiro Nakashima, M.D. (Japan)
Prof.Dr.Franz Berghold (Austria)
Hernan Valencia (Ecuador)
Prof. Tim Reynolds (UK)
Muchas gracias por enviarme este case report. Es muy interesante y desde ya me gustaría seguir recibiéndolos.
Un cordial saludo para ambos desde Argentina.
Dr. Carlos Pesce.
Sociedad Argentina de Medicina de Montaña.
1) What is your diagnostic impression and what
should be done ?
Creo que este caso, a la luz de los antecedentes
de tabaquismo severo, del segundo R2 aumentado en área pulmonar
y de su
estudio funcional respiratorio podría
ser catalogado como un paciente con Obstrucción Crónica al
Flujo Aéreo, y dentro de esta entidad, creo
que por el predominio de la disminución
de la capacidad vital respecto del FV1 me inclinaría más
a pensar en un enfisematoso más que en bronquitis
crónica. Tres factores no son concordantes
con este diagnóstico en principio, la ausencia de poliglobulia,
el ECG, que si bien tiene R altas en V1-V2 no
muestra onda P pulmonar y la placa de tórax.
A pesar de que la radiografía de tórax muestra horizontalización
costal, los pulmones no se ven
hiperaereados sino congestivos con infiltrados
hiliofugales y arterias pulmonares ingurgitadas. Llama la atención
la disminución de las imagenes
vasculares en el campo medio e inferior derechos
con un final abrupto de la arteria pulmonar homolateral. Otro dato que
vuelve confuso el
diagnóstico es la ausencia de ruidos respiratorios
en la auscultación. Creo que la hipocapnia (PCO2 y etCO2 bajos)
aleja la posibilidad de
trastornos severos de la ventilación o
de ocupación del acino pulmonar.
Los síntomas neurológicos referidos
por el pacientes, tales como cefalea y nauseas pueden ser adjudicados a
la presencia de
Mal Agudo de Montaña, la ausencia de signos
neurológiocos como ataxia o alteraciones del estado de conciencia
en el examen físico descartan la
posibilidad de HACE.
Mi primer diagnóstico a descartar es Tromboembolismo
Pulmonar, por lo que el procedimiento de elección sería un
estudio
radioisotópico de ventilación perfusión
pulmonar. La taquicardia, la hipoxemia, la hipocapnia, el R2 aumentado,
la ausencia de datos en la semiología
respiratoria, la leucocitosis y el sobrepeso,
creo que obligan a descartar este diagnóstico en primera instancia.
2) Do you think this is a dangerous condition
? Creo que el cuadro es peligroso en tanto no se descarte la
posibilidad de
TEP. Mi segundo diagnóstico es HAPE, pero
creo que la ausencia de ruidos a la auscultación pulmonar alejan
mucho la
posibilidad de este diagnóstico.
3) Please express your comments and let us know
if you would like to receive more case reports on high altitude medicine.
Como mencioné al principio me agrada
mucho este tipo de ejercicio y me gustaría seguir recibiendo nuevos
casos para
analizar.
4) If you wish we can keep your opinion anonymous.
No tengo problemas con que se haga mención
de mi nombre. Somos dueños de lo que pensamos pero esclavos de lo
que
decimos o escribimos.
Dr. Carlos Pesce.
Sociedad Argentina de Medicina de Montaña.
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"Greetings from India". I am pleased to receive
your kind mail and I am sure that many such case reports shared amongst
high
altitude medical experts across the Globe will
do lot of good to all of us. I complement your efforts. In the forthe comming
World High
Altitude Congress we can have one session on
the Case reports only; I will request Re Li Ge to consider this option.
Thank you for
your communication. I could not access the links
in your mail and hence my comments with limitations.
Details provided about Mr S M. is interesting.
I have come across similar episodes on large number of people from low
altitude
who were chronic smokers and quit somoking long
time ago who arrived by flight to Leh at high altitude in Ladakh
part of
India. This is a different case of AMS but complicated
due to nutritional and exercise associated changes.
With mild hypoproteinemia this patient has the
tendency towards water retention resulting in discomfort described. Hb
being
normal has no problem in Oxygen saturation. With
mild diabetic has inability for the energy supply for various functions.
The situation is not dangerous and the symptoms such as headache and anorexia continues for some time.
I wish to get more case reports and my views can be circulated to others interested to make a comment.
With best wishes,
Dr Thuppil Venkatesh
High altitude Biomedical Center,
St John's National Academy of Health Sciences,
Bangalore India 560034
Phone 0091-80-5502341, 5532146, 206 5058, 206
5050, Fax 5520777.
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My Dear Dr Gustavo's,
I am pleased to receive your mails and thank your
for the additional information which is very interesting. I do see in the
X-ray
lot more to understand the situation. I will
send my comments.
I will also write to Prof. Ge Re Li to explore
the possibilities of having a joint meeting of "LaPaz and Tibet symposium".
Where
else on this earth we get these two similar altitudes
and altiplanoes across two opposite hemispheres and across the globe.
Where else we find such large number of Low landers
reaching high altitude places such as La Paz and Lhasa or Leh.
Problems are similar and care and concern will
be similar.
I think that the President of ISSM should make
some International organization to extend support to the developing country
(scientists and medical experts at High altitude)
to participate in the next ISMM meeting. I will explore the possibilities
from
other sources.
With best wishes,
Venkatesh
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I love the case and I love the format!!!
I think he has HAPE. I am surprised at his
maintaining his PFT's and I wonder whether this typical. His electrocardiogram
is
quite abnormal but non-specifically so.
He has no initial Q in I, AvL and the lateral leads which is suspicious
of previous
antero-septal MI or possibly, along with the
clockwise rotation of T axis in the precordial leads, may be indicative
of RV strain.
My diagnosis is HAPE with pulmonary hypertension and R heart failure.
I am sorry, I have forgotten the interpretation
of the breath-hold test. I look forward to getting a refresher when
you send us
your analysis.
Joe
On further reflection I also think that he may have some underlying infection and would perhaps treat him with some antibiotics.
Joe
Joe Fisher M.D. FRCP(C)
Staff Anesthesiologist University Health Network
Associate Professor, University of Toronto
The Toronto General Hospital
Department of Anesthesiology
200 Elizabeth St.
Toronto Canada 5MG 2C4
Tel: 416 340 4800 X 3071
Pager: 416 336 6827
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Thank you for sending me your interesting case
number 6081. The salient findings including non-specific symptoms related
to
high altitude (headache, nausea, anorexia) but
also a cough with white sputum. On examination an increased P2 suggests
pulmonary hypertension. Arterial blood gases
show an abnormally low arterial PO2 of 46 (you do not give the barometric
pressure but assuming this is 505 torr his A-a
difference is about 25) suggesting considerable lung disease and the arterial
PCO2 is also abnormally low at 25. The chest
X-ray does not reproduce well but shows bilateral shadowing suggestive
of
interstitial lung disease though some edema cannot
be ruled out. Spirometry is consistent with a restrictive pattern. My
impression is that this patient probably has
pre-existing lung disease, possibly interstitial fibrosis, and should go
back to
Washington (presumably D.C.) for further investigation.
His severe hypoxemia and other symptoms mean it would be unwise
for him to stay in La Paz. Thank you for sending
me this interesting report.
Best wishes as always,
John West
jwest@ucsd.edu
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I enjoyed looking this over.
I practice at 9,300 feet, which is high for
the USA, but not Bolivia.
My opinion is that this patient has HAPE.
He needs Oxygen to keep his sats
over 90%, Nifedipene 20 mg every 6 hrs and continuation
of Diamox.
Please add me to your email list,
Tim Quigley Peterson
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1) What is your diagnostic
impression and what should be done ?
[Dr. Christina
Jefferson] Looks like pulmonary edema probably triggered by altitude--Treatment--O2
and diuretics
2) Do you think this
is a dangerous condition ?
[Dr. Christina
Jefferson] Yes marked hypoxia
3) Please express your
comments and let us know if you would like to receive more case reports
on high altitude
medicine.
[Dr. Christina
Jefferson] This was fun--please send correct answers and what happened
to the pt.
Dr. Christima Jefferson
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Dear Gustavo Zubieta Sr. and Jr.;
Sorry for my delayed reply.
My comments are as follows.
1) What is your diagnostic impression and what
should be done ?
This case should be typical
AMS, not else. The results of amateur treatment could not be bases of diagnosis.
This man
should be predisposed to hypoxia- sensitive.
In case of like this, 100%
pure oxygen should be administered by means of "Demand Valve". Maybe, within
15minuits or so,
he might be well.
2) Do you think this is a dangerous condition
?
Yes, I think so. If
adminoistration of 100% pure oxygen failed, he should be transfered to
sea level immediately.
3) Please express your comments and let us know
if you would like to receive more case reports on high altitude medicine.
Yes, I would like to
know such cases more.
4) If you wish we can keep your opinion anonymous.
Not necessary to be anonymous.
michiro nakashima
nakashim@skyblue.ocn.ne.jp
takaori hospital
65,kamitakano-higashiyama,
sakyo, kyoto, 601-125
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nice to hear from you again hoping that everything is fine with you. My comments to the case No 6081:
The clinical aspect of this patient appears like
those numerous very common cases in similar situations when someone is
flown
up to high altitudes from the lowlands (Lhasa,
Leh etc.). As a practicioneer I would simply suggest without any lab results
and
further investigations: if someone improves his
symptoms by breathing oxygen it must be some sort of hypoxia-related problem.
Using
oxygen by mask during the night has been preventing
any appropriate acclimatization. Therefore it doesn`t surprise me too
much that the patient worsened after his third
night at 3510 m. Not to forget the BMI 33 of this quite fat man what
most likely
would impede any hypoxic hyperventilation. He
should have been brought down to lower altitudes. How did this patient
go on ? What
was the final diagnosis ?
Prof.Dr.Franz Berghold
Austrian Society for Mountain and Altitude Medicine
A-5710 Kaprun 130
Tel +43/6547/8227 Fax +43/6547/7772
Email: bergi@eunet.at
2) Do you think this is a dangerous condition ?
Yes, of course.
3) Please
express your comments and let us know if you would like to receive more
case reports on high altitude
medicine.
Yes, please.
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Recibimos -Medical Report-. Es de mucho interes en especial para Varinia e incluso para mi que soy un neofito en el tema. Asi
que esperamos seguir recibiendo tu informacion.
Tania, manana se gradua de Psicologa Clinica.
Saludos,
Hernan Valencia
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Please accept my apologies
for the delay in applying - and as I am not that much of an expert on high
altitude medicine I might
be totally wrong - so please don't quote me!
1) Impression:
Low PO2, Low PCO2 => overbreathing to get
more O2 -> blowing off CO2.
pH normal
Low Bicarb (& basedeficit) => compensation
for low PCO2, possibly also due to acetazolamide
FBC unremarkable
Urinalysis - may indicate further investigation
when he has finished his holiday.
Sounds a similar pattern to my wife when we have
been skiing in the high parts of Colorado... So I would just monitor.
[But as I say I'm not very confident here].
2) Not necessarily dangerous; hopefully self-limiting
but should be prepared to move to a lower altitude if problem persists
/
worsens.
3) Yes I would be interested in seeing more cases.
TIM
*************************************************************************************
Prof. Tim Reynolds,
Clinical Chemistry Department,
Queens Hospital,
Belvedere Rd.,
Burton-on-Trent,
STAFFORDSHIRE,
DE13 0RB,
UK.
tel: 01283 511511 ext. 4035
fax: 01283 593064
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