General lethargy in patient with history of esophagal constriction

    
      Re: General lethargy in patient with history of esophagal constriction
    


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Posted by HFHSM.D.-rf on March 01, 1998 at 10:45:17:

In Reply to: General lethargy in patient with history of esophagal constriction posted by Conor Heneghan on February 15, 1998 at 11:51:47:

: Dear MedHelp:
  I am writing on behalf of a family member who has has a very unfortunate medical history (as detailed below), and who is currently feeling incredibly drained of energy and disheartened by her general state of health. I belive she has getting excellent care from the doctors she is seeing, but noone has pinpinted any causes yet, so I am interested to see if any of your physicians have general comments to make. In particular, if they could suggest questions that shw should be asking her physicians that would be helpful.
  Thanks very much for this service you offer.
  Conor Heneghan, PhD

  Patient Details:  68 year old woman, Caucasian
  Current Symptoms: Very low energy levels, frequent minor upper respiratory infections, mild depression.
  Previous Surgical and Medical History:
  The patient's general medical history can be divided approximately into four time periods as follows:
  (1) Pre 1989
  (2) January 1989-February 1990
  (3) March 1990-March 1997
  (4) March 1997- present
  Pre 1989
  Up to 1989, the patient's general health was very good. About 1987/88, she was having some difficulty in swallowing. Her G.P., XX, referred her to XX at the XX Clinic. XX in turn referred her to a general surgeon. He indicated that she had a restriction in her oesophagus and that this could be improved by surgery.
  January 1989-February 1990
  The patient entered the XX hospital in January 1989 for surgery to improve the oesophagus restriction. Her gall bladder was also removed during this initial surgery. About 5/7 days after surgery and shortly before discharge, she developed what was described variously as septicaemia or peritonitis. She was moved immediately to the ICU, where she remained for approximately 10 weeks. During this period she had two further major operations, one to correct the septicaemia,  and one to correct the oesophagus.
   It is the patient's understanding that the septicaemia was caused as a result of the oesophagus not being fully healed before she was placed on solid food, allowing food to pass out through a small unhealed hole.
   In the course of the operation to deal with the septicaemia, it was necessary to break her rib cage in much the same manner as is done in heart bypass surgery. The vagus nerve was also severed at this time, she believes. Further surgery was necessary to correct the oesophagus, during which a portion of the oesophagus was removed and her stomach was brought up and attached to the shortened oesophagus. During the period from the onset of the septicaemia until a few days before discharge, she was fed intravenously.
   She was discharged from the XX hospital in early April 1989 and moved to a convalescent home for a number of weeks. Her weight at discharge was 5 stone, as compared to a typical weight of 7.5 stone prior to 1989. During her stay at the convalescent home, she developed severe diarrhoea and an area of her rib cage just above the waistline became inflamed and begin to exude pus, and was extremely painful. The attending doctor referred her back to her G.P. and to the XX Hospital.
   On discharge from the convalescent home, she went back to the Adelaide and XX instructed her to attend the outpatient clinic on a  daily basis to have the infection dressed. XX undertook day-care surgery in late May 1989, and following this he told her that the infection was due to a stitch  which had not been removed from previous surgery. However the infection did not improve, and she continued to attend at the outpatient clinic until late June 1989. During this period her weight fell considerably due to diarrhoea.
   Towards the end of June 1989, XX indicated that he could do no more for the ribcage infection and said he would refer the patient to a surgeon specialising in this field. One of the surgeons recommended, Ms. YY, was a cardiothoracic surgeon who practised on the south side of the city. The patient entered the XX Clinic under the care of YY in July 1989, and underwent surgery to correct the ribcage infection. The surgery was not successful and the patient underwent further debridement on an outpatient basis in September, October and November of 1989.
   In late November 1989, after discussion with YY, the patient was referred to ZZ at the XX Hospital. She entered the XX in December 1989 for a radical excision of a chest wall infection. Following this operation she suffered from severe pain in her shoulder and back, and Mr. ZZ referred her to Dr. UU who carried out a number of nerve blocks for pain control in January and February 1990.
  March 1990-March 1997
  During 1989 and in the period following the series of operations, the patient continued to attend  her G.P.'s clinic for her general medical care. Her health remained very poor for some considerable time. Over this entire period, she continued to experience pain in her rib cage and needed to take a considerable number of pain killers. The diarrhoea was kept reasonably in control by codeine phosphate, but any change in diet would trigger off further bouts. Her weight moved up to 6 stone after about a year and remained close to this figure for most of this period. She continued to have swallowing difficulties for all of the period and  this got considerably worse towards the end of 1996 and early 1997. Her G.P. considers her weight loss to be due to malabsorption and has been giving her B12 injections on a monthly basis for a number of years.
   During 1996, she developed severe back pain on a number of occasions. Her G.P. referred her for physiotherapy, which improved the condition generally after a few weeks.
   While the patient's health was not good at any stage during this period, it was possible for her to engage in light housework and make trips to the shops. She did attempt to travel on holidays three times, but on one occasion was forced to curtail her trip due to ill health.
  March 1997-Present
  In the latter part of 1996, and early 1997, her general condition disimproved. She suffered from colds and eating became more difficult. Following a blood test, her G.P. referred her to XX. She entered UU Hospital in around 1997 and underwent a number of tests. During that period, she was also referred to XX. None of the tests undertaken by YY showed any abnormalities, other than the barium swallow.
   Following discharge from UU's, her weight improved over a period of a few months reaching a peak of about 6.5 stone. However, she did not feel well at any stage, and her level of activity was reduced further. She also continued to have many colds.
   About November 1997, her G.P. discovered a suspected heart murmur and referred her to WW who arranged for her to have an ultrasound test. WW indicated that he thought her heart was slightly displaced probably from previous surgery. He recommended that she should return for a further examination after about 6 months (May 1998). WW also thought the pain in her back was due to the heart condition.
   Since about November 1997, the patient has been coughing up a considerable amount of phlegm. She has discussed this with her G.P. who feels it is most likely associated with sinus problems, rather than any underlying infection.
   A further blood test in late December 1997 showed a higher level of platelets than normal. The patient feels that her general health is at its worst since 1989, and is unable to undertake any activity without quickly becoming fatigued.
  
  Current Medications
  Codeine phosphate  -  2xDAY
  Distalgesic, -  approx. 4 per day
  Tranzene (sedative)  -  one tablet per night
  Halcyon  -