NO.1 RULE : Talk about everything you know. Don't be scared to impress your examiner, but only say things that you sure you know how to answer.
No.2 RULE : Try to answer in a way that you can "drag" the examiner into your world. Lead them to ask the questions that you know how to answer ! Impress them !
Source : Dr. Siva & Dr. Paras
Situation :
- Chinese Male
- Middle age
- Presents with chronic cough for 2 months
- Initially cough with sputum, which is whitish in colour
- For recent 2 weeks, associated with blood streaks
- a/w SOB & fever these 2 weeks
- Went to GP before for treatment
Random Fact 1 : Pleuritic chest pain includes CHEST PAIN ONLY DURING COUGHING. Thus, pleuritic chest pain means chest pain during inspiration or coughing. (Source : Dr Siva from A&E)
Question : Tell me how would you investigate this patient ?
Answer :
I would like to divide my approach to investigation in 2 ways, which are blood biochemical investigation, radiological investigations, and lastly, special tests.
Blood :
- FBC
- Hb - Chronic cough -> Poor oral intake -> malnutrition -> anemic
- Hb - Sputum with blood streaks
- Hb - Anemia in mycoplasma pneumonia (atypical)
- White Cell count - Infections ?
- Neutrophils high - Bacteria
- Lymphocyte high - Virus
- Eosinophil high - allergy, parasire
- Monocyte high - Chemotherapy (Dr say will give distinction for anyway who answer this correctly xD)
- Lymphocyte low - suspect Legionella atypical Pneumonia
- Signs of dehydration (Hypo Na, Hyper K)
- Hyponatraemia -> Legionella
- Signs of renal failure (Urea and cretinine high) - can happen in aypical pneumonia (Legionella)
3. LFT
- albumin - chronic illness -> albumin low
- ALT & AST - atypical pneumonia (Legionella) -> liver enzymes high
ABG
- assess oxygenation status
4.ESR
- Sensitive but not specific indicator for presence of disease
- Raised ESR -> any inflammation, age, anaemia (esp sickle cell anemia), polycythaemia
-> Therefore, when ESR is raised in sickle cell anemia, polycythaemia -> beware
- Very high ESR (>100mm/h) -> 90% predictive value for disease
- Used as indicator for chronic disease
5.CRP
- Same with ESR, but changes more rapidly
- Increase in hours, and falls within 2-3 days
- Usage : Monitor response of therapy and disease activity
6. Blood C&S
- Both aerobic & anaerobic
- Atypical serology
7. Sputum AFB, C&S 3 times, early morning sample (Why early morning ? I x tau. Please post here if you know why, thanks ! ^.^)
8. Blood Culture
8. Mycobacterium PCR
9. Urine UFEME, C&S (x tahu kenapa, lupa dah, masa tu oncall, letih xD)
10. Serum Tumour Marker
- Not routinely done, but result might be positive -> (Chronic disease give elevated tumour marker)
- Lung Ca doesn't have any tumour marker
Radiological :
1. CXR
- Signs of pneumonia ?
- Signs of malignancy ? - well defined circumscribed lesion, cannonball appearance,
if have, go for CT thorax
- TRO Pneumothorax, pleural effusion
2. ECG
- TRO CVS causes
Special tests:
1. LN Biopsy
- If any palpalble LN
2. Mantoux Test
3. Pleural Tap if any evidence of pleural effusion
Source : Dr. Siva & oxford
Random Fact 2 :
Elderly patient was hospitalized before for a long time due to infection. Discharged well. Came back with diarrhoea after 1 week, why ?
Answer : Pseudomembranous Colitis
Because of old age, and prolong antibiotic (esp if IV), normal flora of the guts are killed. Then, obergrowth of Clostridum Difficile, cause pseudomembranous colitis.
Tx : Metronidazole, or, Oral Vancomycin
Patient can also come back with SOB -> Hospital acquired Pneumonia
Source : Dr Ilyaas
By alvis
1 comments:
Sputum production is a lot and 'pure' in the morning in sense of it contain bacteria that we want to culture.
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