Pulmonology, Week 1, Day 4

This morning in the ICU, Dr. Huang walked us through a patient case. The patient was a 60ish years old (I didn't catch the exact age) male who came into the ER for dyspnea and cough. Dr. Huang first showed us the chest x-ray and CT scans and then he guided our thought process towards the diagnosis. The x-ray appeared to be pneumonia, however the patient had no fever and the WBC count was normal. He explained his approach to us and told us his differentials included pneumonia, influenza, Wegener's granulomatosis, Goodpasture syndrome, and severe sepsis. His initial diagnosis was pneumonia and the initial treatment was a 3rd generation cephalosporin. Then, results of the sputum sample revealed infection with Pseudomonas aeruginosa, Klebsiella pneumoniae, and alpha-streptococcus. He explained that based on the sputum sample results, he changed his treatment to piperacillin-tazobactam and levofloxacin. Later chest x-rays showed that the patient was improving. Then we went to see the patient, who seemed to be doing well. Dr. Huang told us that they will try to extubate him in the following days.

It was so enlightening to be able to try to work out the diagnosis and hear Dr. Huang's approach to diagnosing and treating his patient. This case was not the classical presentation of community-acquired pneumonia, as we have learned. Thus, determining the diagnosis was not as straightforward as I had originally assumed. When we are in the classroom studying the clinical presentation of diseases, we forget to realize that ordering labs takes some time. Because this is a small community hospital, certain labs have to be sent to larger hospitals with more resources, thus increasing the time to receive the results, so treatments need to be initiated based on the the physicians do know. Also, when there are puzzling results, such as the diffuse CXR, but no fever and normal to low WBC cell count, more differentials need to be considered, such as Wegener's granulomatosis. When looking at the CXR, I could only think of pneumonia, influenza, and tuberculosis; I didn't even consider the other differentials. Only when prompted by Dr. Huang, did I even remember that we have learned about many other diseases. I cannot believe how much I have learned in one academic year and today's rotation reminds me of how much I have forgotten during the year. Also, I have come to realize that while we learn about classical presentations of diseases in the classroom, disease presentation in our clinical practice is not always going to be what we have learned. This is why the practice of medicine requires a high level of critical thinking ability and creativity.

This afternoon we spent some time with Dr. Lin, who is not only a thoracic surgeon, but also has a PhD in Biochemistry. He showed us the CXR of a patient who had a pneumothorax due to the rupturing of bullae and he explained some risk factors for pneumothorax: tall and slender, male, and smoking. Then he showed us the video from a Video-Assisted Thoracic Surgery (VATS), where he performed a bullae resection. It was awesome to watch! Before he continued with his patient visit, he invited us to watch 2 surgeries on Monday afternoon. I'm excited to be observing these surgeries next week!