Director Chien began the rounds by briefly summarizing the conditions of his patients on the wards. He explained that contracting TB is rare: 30% of active TB cases are due to living with someone with TB for a long time. Of the 30%, 90% will be healthy their entire life. Of the 10% who will have symptoms, 5% will suffer from TB due to immunocompromised situations such as steroid use or complications of diabetes. Other countries have used BCG vaccination, usually administered within 24 hours after birth since that is the most at risk population for extrapulmonary TB such as TB meningitis and miliary TB.
Patients presented the following diseases: COPD, bronchopneumonia, lobar pneumonia, aspiration pneumonia, tuberculosis, acute respiratory failure, restrictive lung disease and many comorbidities. From the wards here are some clinical pearls:
- Augmentin (amoxicillin and clavulanic acid: remember the B-lactamase inhibitor) is the standard treatment for CAP.
- Cravit (levofloxacin) was prescribed for discharge to be taken orally.
- Patients presenting with pneumonia were usually put on antibiotics for 14 days before discharged.
- ENT consulted if vocal cord palsy is suspected.
One interesting case was a 56 yo male with kyphoscoliosis who presented with restrictive lung disease. Kyphoscoliosis is a structural issue that can cause restrictive lung disease in the way that structure can affect function (whoaa sound familiar?!). It's in Dr. Kahn's lecture about sleep apnea. At the time of blocks I was just remember seeing that picture of kyphoscoliosis and feeling very badly for the patient and memorizing it as "impairing ventilatory function". Whatever that means.
Later in the afternoon, Dr. Huang walked us through his thought process on diagnostic algorithms and how to read a chest x-ray. I found this extremely rewarding since he had all the CXRs and lab values all pulled up on a patient he had. He also walked us through certain scenarios that we might encounter as physicians. During this session I found that a CT scan can really go a long way. Through a CT scan he was able to locate the level of occlusion in the right middle bronchus. He was able to find a tumor that was showing signs of necrosis. From there he could determine that the consolidation evident on the CXR was RML syndrome. The CXR plus the CT were strong diagnostic tools.
Other modalities he used to find the etiology of pleural effusion:
- thoracocentesis - determine if exudative or transudative using light's criteria
(1. Ratio of pleural fluid protein to serum protein is >0.5
2. Ratio of pleural fluid LDH concentration to serum LDH concentration is >0.6
3. Pleural fluid LDH concentration is greater than 2/3 of the upper limit for the serum LDH concentration. ) . Determined to be exudative.
- biopsy, medical or surgical. Medical being the "blind biopsy" in which an endoscopic tube is stuck down the airway and samples are taken from abnormal areas. This needs to be done 3 times before endobronchial lesions can be ruled out. Surgical is through thoracoscopy and is much more invasive.
Scenarios that Dr. Huang put us through:
- What if bleeding occurs while performing a bronchoscopy? Apply local pressure, epinephrine, and if all else fails, grab a radiologist and surgeon to fix it.
- How can you distinguish an AP, PA, and supine view if radiologist didn't label it? AP vs PA= scapula should be more lateral in a PA view since the pt will be hugging the device while the PA view is being taken. AP vs supine- can't see gas bubbles in supine. These are more indirect and less accurate ways to quickly orient yourself to a CXR.
All in all, pulmonology is exciting and covers such a wide spectrum of issues. TB is an especially interesting disease that occurs in certain countries and it would be interesting to investigate further into the history of the BCG vaccine and why it is not applied in the US. It has been rewarding to see the clinical and the pathological aspects of my studies converge during rotations.
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