Doctor asks : "This patient present with chronic cough. Investigations ?"

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 :

1. 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
  

2. RP
- 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