Pulmonology, Week 1, Day 1

6/9/2014

Day 1 of our internship with the Taiwan International Healthcare Training Center at the Taipei Hospital!

This morning we did rounds with Dr. Chieng. Before seeing his patients, Dr. Chieng reviewed the chest x-rays and medications of the 17 patients with us. Then he said, "Let's test your memory!" and off we went rounding. Most of the patients were diagnosed with pneumonia, and some had tuberculosis or COPD. Some patients included:

- 85 year old male with acute exacerbation of COPD. This patient had chronic hypoxemia, some lung fibrosis, bronchiectasis, cor pulmonale, SpO2 89-90%, and oral candidiasis. He was given amoxicilllin-clavulanic acid+ clarithromycin.

-50 year old male with tuberculosis. The patient was a college teacher and contact tracing was done to determine that he was exposed to a student who had TB.

-50 year old female with pneumonia. This patient had bloody sputum, hemoptysis, and anxiety. She was given moxifloxacin. 

Something to note is that in Taiwan, trade name drugs are used, Ambicyn= amoxicillin-clavulanic acid, Uricin=clarithromycin, and Avelox=moxifloxacin. I wonder how it is possible to use non-generic drugs here?

Upon entering the patient rooms, I could see that family members were sleeping in the patients’ rooms as well, which made me think about the effect a family can have on the care of the patient. Families can advocate for their patients or they can hinder a patient’s care. Also, because there were so many patients, it was difficult for the doctor to spend more than a few minutes with each patient and it seemed as if some family members wanted to speak with the doctor a bit longer. Thus, the amount of time spent with each patient seems to be an issue here in this community hospital in Taiwan, as well as in the United States.

This afternoon we went into the ICU with Dr. Huang. We discussed the case of a 61 year old male who presented with fever and dyspnea of 2 days with a PMH of CVA and subdural hemorrhage. Dr. Huang showed us how to interpret a chest x-ray. He stressed that while we should find a method that works for us, it is very important to interpret in a step-by-step manner. The first 3 things to check are 1) Right and Left side, 2) quality of the chest x-ray, and 3) the position of the patient. Then, one way to read a chest x-ray is to check in order of ABCDEFG:

           

Airway

            Bone/Breast

            Cardiac

            Diaphragm

            Esophagus/Extrapulmonary

            Foreign body

            Gastric bubble

Also, it is important to check the regions that are easy to miss: apex of the lung, sub-diaphragm, and retrocardiac regions. We used the above patient’s chest x-ray to practice interpretation of chest x-rays. The diagnosis was pneumonia. Then we watched Dr. Huang perform an ultrasound on the patient to determine if there was any pleural effusion.

Today, I learned how important chest x-ray is in the diagnosis of pulmonary diseases. It can be used to guide which other tests need to be performed, and which therapies to initiate. Being able to read a chest x-ray is a skill that physicians must possess; and today’s lesson from Dr. Huang has inspired me to hone my ability to interpret chest x-ray.