Pulmonary Fibrosis…
It’s one of those “difficult to explain” diagnoses. Picking it up is quite “easy” as it presents with a long term history of worsening shortness of breath and manifests with characteristic fine inspiratory crepitations on auscultation. I recently followed up a case where the cause of the pulmonary fibrosis could actually be explained!
A long time ago, I saw a 67 year old lady in A&E who presented with shortness of breath and a dry cough. She complained of some inspiratory chest pain with intermittent fevers. Looking back, it turns out I requested a chest X ray which had some right sided basal consolidation (so I thought). I ended up discharging her with some antibiotics with the impression she had a small lower respiratory tract infection.
I ended up seeing the same patient last week. It’s been about 18 months since I saw the patient and we both recognised eachother. Sweet.
However, things were more serious this time. The same patient, now 69 was so much more frail. It was as if she had aged 10 years! She presented with shortness of breath and cough, this time saturating to 79% on air. Having spoken to her it seems she was diagnosed with pulmonary fibrosis. Now I’m usually used to seeing the word “idiopathic” associated with it but instead saw “environmental”. I was curious…
You can never ask too many questions..
Having looked through her letters it turns out that she was eventually referred to her GP for repeated “lower respiratory tract infections.” After having a high resolution CT chest, it was found that her entire lung architecture was fibrosed (apparently this isn’t a word but it is in my (medical) dictionary!).
The respiratory team dug very deep to find out exactly why such changes had occurred and concluded that it was due to her living conditions. You see, the patient had lived in a council flat for the best part of 40 years. I asked her about this and she said that the amount of mould was unimaginable. From the bathroom to the kitchen and the sitting room to the bedrooms, the entirety of the house was covered with mould.
The GPs noted her living conditions and so did the council. Despite the patient complaining about this, it was left ignored and now the patient has to suffer with the repercussions. Tough story. I grew up in a council estate but was fortunate enough that my father would really try his best to maintain our old home. However, not everyone does this and there some serious complications.
It’s ironic I came across this case as only a few days ago, the findings of the death of 8 year old, Awaab Ishak were released. It is postulated that he passed away from respiratory complications secondary to excessive mould. In the enquiry, there were a few useful points that we should note that can really transform our own practice:
There was a lack of follow up from the primary care physicians for the health visitors report. The health visitor did in fact raise her concerns about the mould.
District nurse referral to primary care services was made but was only followed up many months later as it was initially triaged as a “social/housing matter.”
Awaab was taken to an urgent care centre with a respiratory illness on a number of occasions and despite safeguarding (housing related) referrals being made, he was discharged home. This occurred a few times.
What are some of the lessons we can take from this? Here are some things I took away from my experience and I hope they can benefit you too.
There was a severe breakdown in communication between health services. Integrating services and respecting the professional opinions of others is key.
Do not be afraid to refer to safeguarding if you are in clinic, hospital or on a home visit. Patients identify clinicians as a “safe space” so it is important to listen to the concerns of patients. Safeguarding is everyone’s responsibility.
Social history is absolutely key. Ask about work, living conditions and home environment. There is so much we can do as clinicians in any setting. A good, clean home will undoubtedly lift everyone’s spirits.
I’m glad that prime minister Rishi Sunak has promised an overhaul with regards to social housing. We are upset of the sad death of Awaab Ishak, but there must be many in the community with similar issues.
Unfortunately, my patient is not doing too well. She remains in hospital - happy and cheerful when lying still but incredibly short of breath on exertion. She does remain in good spirits so that’s important!
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That’s all from us this week,
Have an awesome week and don’t forget that social history!
Caio
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