Thursday and Friday were re-cap days for Christine and I, so it is probably appropriate to combine these into one post. For Thursday morning, we met up with Dr. Huang again in the ICU and was presented with a current case of a 66-year old male with a chief complaint of dyspnea, yellow sputum cough, and sinusitis with no relevant PMH. The chest x-ray on admission was patchy bilateral infiltrate and a normal WBC count with a low percentage of neutrophils. Even though the working diagnosis was bacterial pneumonia, the lab data did not match up with the x-ray and clinical signs. A typical presentation would include a high WBC count with a high neutrophil percentage, but in severe cases, WBC count could fall. As a result, other differential diagnoses included Wegner's Granulomatosis, Goodpasture's Syndrome, TB pneumonia, and post-viral pneumonia. Note that the first two differentials were immune-related; immune causes could not be ruled out due to the interesting CBC. In addition, even though he was tested for H. influenza and the result was negative, the sensitivity is ~30%. This meant that there is a good amount of false negatives. Dr. Huang ordered ANCA and Anti-GBM tests to try to exclude them, but the results were pending. However, since there was no hemoptysis, he believed that these were not as likely. A couple days after admission, he had severe sepsis, so he was treated with ceftazidime. The following chest x-ray showed more infiltrate, so a chest CT with no contrast (due to his acute renal failure) was indicated. An air bronchiogram was noted with consolidation, ground glass appearance, and pleural effusion in the middle and lower lung fields. A ground glass appearance is a hazy increase in lung opacity, but vessels can be seen in contrast to consolidation which obscures the vessels. There are many non-specific causes, but alveolar filling (due to fluid, pus, and cells) or fibrosis are the most common pathophysiology. In addition, there can be overlap in which both states can be seen and would us to suspect a chronic disease or broncho-alveolar carcinoma. TB pneumonia was less likely since on the CT, there was not the characteristic tree-in-bud appearance or nodules. This appearance represents bronchiolar luminal impaction by mucus, pus, or fluid from inadequate breathing and insufficient mucus expulsion. Depicted below is a picture of tree-in-bud denoted by the arrows (courtesy of: http://pubs.rsna.org/doi/pdf/10.1148/radiol.2223991980):
Also, acid fast stain results came back and it was also negative, allowing us to exclude TB pneumonia. As his condition deteriorated, his WBC count became elevated and he was intubated in order to suction out excess sputum. Percussion therapy was indicated and his new symptom of bronchospasm was treated with IV methylprednisolone (a corticosteroid). His disease started to resolve and sputum cultures finally came back with P. aeruginosa, K. pneumoniae, alpha-Streptococcus, and yeast-like growth. They have sensitivity to piperacillin/tazobactam combo and levofloxacin, so Dr. Huang switched to these antibiotics. We saw the patient afterwards and we were glad to see that he was improving!
On Friday, we had Dr. Kan to ourselves for the whole day. Again, we rounded on his patients and he explained their disease progression, various treatment strategies, and insights into their chest x-rays/ultrasound. Many of his patients were not new; we saw them before on Monday. For some, their complaints resolved while others had more unfortunate outcomes (i.e. treated initially for bacterial pneumonia, but replaced with XDRAB/ORSA infections). Nevertheless, it was fascinating to end the week by "going full circle." I feel as though my knowledge in internal medicine has vastly improved since the beginning of the week. Things that I was initially hesitant with have become less worrisome. Material that I had learned during my first year of medical school have only been reinforced and expanded upon. I am grateful.
Personal note: These two sites were extremely helpful in interpreting chest x-rays. I would suggest going through the tutorial. Practice makes perfect and it is easy to miss the big picture when everything looks the same.
1. http://radiologymasterclass.co.uk/tutorials/chest/chest_home_anatomy/chest_anatomy_start.html
2. http://www.radiologyassistant.nl/en/p42d94cd0c326b/lung-hrct-basic-interpretation.html
Personal note 2: We also shadowed Dr. Lin, a thoracic surgeon, Thursday afternoon and he invited us to scrub in and watch a VATS bullae resection the following Monday. The video of him performing a prior one was fascinating, but he was done with surgeries for the day. This is a personal reminder to try to shadow him one day when I have "freedom of movement" (internal group joke). Haha.
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