He didn’t look well. The thin man in the corner of the ward was hooked up to an oxygen cylinder via nasal canulae, but was still breathing thirty times a minute – about twice the normal rate. I asked for some background history. Twelve years ago, aged 41, he had been diagnosed and treated for pulmonary tuberculosis. He initially did very well, was able to return to work on the land and felt fit. However, two years ago, his breathing became difficult and he was no longer able to work. He consulted a doctor at a Thai clinic as he thought the tuberculosis had returned. Apparently an X-ray of his chest showed some scattering, but no active TB.
A few days before I saw him on the ward, he was admitted with pneumonia and treated with antibiotics and oxygen. He said he felt better, and his blood oxygen saturation was 95%. However, when we had tried to wean him off the oxygen, his saturation fell to under 80%. Most people would be gasping for breath at this level, which is equivalent to being on the summit of Everest.
The nurses had checked for tuberculosis and other bacteria in his sputum with six samples, but all of these had been negative.
“Time for some teaching,” I said. “Let’s examine him. First of all, what do you see?”
“His trachea is not central, it’s deviated to the left,” said the observant senior nurse.
This isn’t a very common finding, but it is always significant. If you look at the centre of his throat, you can see the windpipe slanting down to the (his) left. The tubing you can see is the oxygen cannula.
There was a faint dotty red rash on his chest, which the nurses didn’t pick up. It looked as if it had been done deliberately, with straight lines in a triangle shape. I thought this was a sensitivity to a Buddhist medallion worn on a string around the neck. But it didn’t look right for contact dermatitis. What do you think?
This was dermatitis artefacta, caused by his wife needling his chest as a traditional medical practice to help his breathing.
The next step after observation is percussion, or tapping on the chest to “sound it out”. The lower front part of the chest was abnormally dull, but not at the back or side. Dullness means something solid or liquid is present instead of aerated lung.
The penny dropped. His tuberculosis had healed with so much scarring that the left lung had shrunk and pulled the trachea and the heart over to the left side. The next step in the examination process is auscultation, or listening with a stethoscope. On the left side I could hear bronchial breathing, suggesting that there was not much healthy lung tissue.
I stopped the nasal oxygen and his saturation level fell to 75% within a few minutes. The nurses were anxiously rechecking the pulse oximeter, as this is a dangerously low level indicating respiratory failure. But the patient was quite happily eating his breakfast without the encumbrance of tubes over his upper lip and into his nostrils.
He has just adapted to having slowly deteriorating lung function over the past two years, reducing his activity so he could cope without being acutely breathless all the time.
As we discharged him from the ward this morning, I spoke to his wife, explaining what had happened. I asked her if she had any questions and she said, “We haven’t had sex for two years. Is there anything you can do about that?”
In my defence, I asked the nurses to translate what exactly she meant, but they just giggled and said no sex. So I assumed that his exercise tolerance was so poor that he could not play an active part in coitus. I asked the wife about which sexual positions they used, but the nurses were laughing so much with embarrassment, that the message didn’t get through. “He just can’t do it,” the wife replied.
By this time, the other patients in the ward were getting interested, too. Some passers by even poked their heads into the ward to see what was the cause of so much hilarity. The wife was chatting away to the other patients and their relatives, and being quite open.
I don’t know very much about the sexual preferences of the Karen, but I realised that this man would need to be a passive partner. I talked about different sexual positions, demonstrating them on the raised bed area, as the nurses were in such fits of laughter that they couldn’t translate. The wife just looked me in the eye and shook her head. I turned to the husband and asked him if he could get an erection. “Not for the past two years,” he replied. Even he started to laugh, but he couldn’t.
I wonder if I still have any samples of Viagra, Cialis or Levitra that the pharmaceutical representatives gave me back in Leicester? They would be a better bet than the obviously fake dodgy imports of Vigra (sic) for sale on stalls at the local Rim Moei market.