Angela Shih Pulmonology W2D4

On the fourth day of Pulmonology rotation, we spent the entire morning in the ICU going over interesting cases with Dr. Huang. As busy as he is, Dr. Huang still found 4 interesting cases to show us. We went over more CXRs, CTs, diagnostic tools, and treatment options which was great practice for what we've learned so far.

Case 1
60 year old male with chief complaint of dyspnea upon exertion. He has a PMH of chronic sinusitis. Upon admission for the dyspnea, the lab work showed he had an elevated creatinine level of around 3mg/dL and also hematuria. The CXR revealed patchy infiltrates in the lower lobes while the CT showed consolidation bilaterally in the lower lobes. The patient's differential Dx were TB and pneumonia. Since TB was suspected, he was put in the isolation ward to test for TB and was treated with Tapimycin (piperacillin). Further CT scans revealed tree-in-bud signs, which are small clustered nodular opacities due to terminal airway mucus impaction and inflammation. After 2 weeks of treatment for the initial suspected infection with no resolution, more laboratory tests were performed. The patient turned out to be c-anca positive, and along with his other nasopharyngeal, lung, and kidney involvements the doctors diagnosed him with Wegener's Granuloma.

The new term I learned today was the tree-in-bud sign. It is a finding in CT scans which indicates some level of terminal airway obstruction which typically means a presence of an infection that has spread endobronchially and is usually associated with TB, bronchopneumonia, and cystic fibrosis. 

In addition to discussing cases, Dr. Huang also had a lot to say about the Taiwanese medical system. We learned that in Taiwan, because of high malpractice suits and difficult hours with low pay, many medical students are avoiding becoming OB-GYN, ER and family physicians. For instance, for every 10,000 medical students graduating each year, Dr. Huang said only about 10 become OB-Gyn physicians. As a result, in more rural areas in Taiwan there's an extreme shortage of these physicians and patients are suffering. From the discussion with Dr. Huang, it sounded like Taiwan is suffering from brain drain with most of the best physicians leaving the country to work elsewhere for better pay. It is a worrisome situation as this may begin to effect the overall quality of health care and the standard of medicine in Taiwan.