Today marks the 1st day of my
pulmonology rotation with student doctor Megan Lung. We started the day with
attending a daily internal medicine meeting and today R1 Dr Lo presented on JNC
8 guidelines. We then met our director Dr Chien, who began by giving us a brief
summary of all the patients that we will be seeing during patient rounds. There
were a total of 18 patients but I will only be talking about a couple of cases
that stands out:
Case 1: 77 y/o with
old CVA, normally stay at a nursing home. Hx DM2, Htn, paralytic ileus. Dx with
suspected aspiration pneumonia and was put on Augmentin. Dr Chien found
increased stridor upon auscultation at the R neck area. He later then told us
that patient has hx of vocal cord palsy/paralysis on one side so ENT
consultation was ordered. ENT physicians generally can perform fibroscopy to
confirm vocal cord palsy.
Case 2: 70 y/o male
w/ hx COPD. Patient was admitted for COPD w/ AE. Although patient has extremely
poor lung function, he only presents w/ dyspnea on exertion (~10m), and therefore
was only put on Advair (LAB2 agonist salmeterol + fluticasone). Patient’s
family tried to request for application for a caregiver but Dr Chien refused.
Dr Chien explained that it’s extremely difficult for patients that are under 80
y/o to obtain approval (government use a point system to evaluate the need of
caretaker here in Taiwan and >80 vs <80 y/o has a 30 pt difference). It
is a rather sticky situation but the family would have to bear with it for a
few more months until the patient turns 80 by November.
Case 3: 58 y/o male
admitted for fever and dyspnea at the ER w/ hx CAD and old MI (w/ stent).
Patient is diagnosed w/ pneumonia at middle and lower of the right lung. Since
patient has severe underlying disease, he was put on Levofloxacin to cover both
typical and atypical pneumonia. Otherwise, patients w/ pneumonia here are
generally put on macrolide/Augmentin. Patient was on IV Levo for 8 days and
will be discharged today with oral antibiotics. Patient can be switched to oral
antibiotics if afebrile for 24 hours.
Before the patient rounds, I asked Dr Chien on
the clinical practice on Tb patients here in Taiwan. He said that most
countries outside of the States receive BCG at birth. In Taiwan, people were
receiving 2 doses before 1985, and only 1 dose after 1985 since prevalence of
Tb decreased. I was surprised at the probability of contracting Tb from active
Tb patient: 30% only if live w/ Tb patients long enough according to Dr Chien,
and 90% patient will be healthy their whole life! Additionally, patients here
are allowed to be discharged for work after being treated for 14 days in most
cases (unless complications occur) since 99% of the infection will be
controlled by that time.
In the afternoon, we went through one patient
case in detail with Dr Huang at ICU. He guided us through the approach of a
patient diagnostically and how to narrow down differentials. Case presented was
a 91 y/o male with underlying arrthymia (on pacemaker). His CC at the ER was
severe cough w/ hemoptysis.
CXR AP view showed cardiomegaly, pleural
effusion at CV angle, air accumulation of the R lung and edema.
Step 1: Obtain pleural fluid to determine if:
transudate vs exudate, w/ Light’s criteria as guideline
（note: lymphcytosis often is indication of Tb/malignant cancer）
è DC segament 87%, exudate
Step 2: CEA, culture, cytology, cell growth
à (-) cytology,
cell growth, (+) CEA; difficult to determine whether fluid is caused by
malignant cancer
based on these results
(-) cytology is not conclusive since it
might be malignant cells not reaching the fluid area yet
à (-) Acid fast; negative
result does not exclude TB
Step 3: If results are non-conclusive/all
negative, the next step is pleural biopsy. There are 2 ways for biopsy
(surgical/medical). 3 samples (blind
biopsy – sonar) should be obtained. If still inconclusive, thoracoscopy by
surgeons
Step 4: Check renal fxn. If renal fx is okay à both w/
contrast and w/o contrast CT
In our case, CT of the patient showed near total
occlusion of IMB (intermediate middle bronchus) caused by centralized tumor w/
signs of necrosis
Step 5： Tissue proof via biopsy. The risk for biopsy for our patient is
very high since tumor is close to major blood vessel and therefore upon
discussion with the family, biopsy was not performed. Dr Huang mentioned that
if bleeding did occur when biopsy is performed, physician will generally apply
localized compression + epinephrine injection, and then inform
radiologist/surgeon in case previous method fails.
The prognosis for our patient is poor and Dr
Huang predicts that he is most likely going to be staying at the RCW.
Dr Huang said that standard approach to patient
with suspected pneumonia (signs of collapse) is to treat for pneumonia for 2
weeks first. If the patient is not improved after 2 weeks, then will have CT
scan and check for endobronchial lesion.
Other tips from Dr Huang:
There are 2 major causes for unilateral opaqueness
of the lungs:
1. Effusion
2. Collapse – due to infection, tumor etc (lung collapse mainly due
to obstruction)
If there is effusion, it may shift the heart away from the lesion;
If it’s a collapse, it will pull the heart towards side of lesion. Often times
however, you may find the combination of both situations in cases such as
pneumonia
Collapse – intercostal space will be narrower; look for J-P
sign of the diaphragm for collapse of RUL
If patient has Tb on RUL, trachea will
shift towards the right side
CXR silhouette sign:
·
If we can’t see the Right heart boarder: most
likely lesion at RML
·
If you can still see the R heart boarder: most
likely lesion at RLL
·
RML syndrome: appears like “combination” of RML and RLL lesion, indication of
lesion at RIMB
Overall, there are 2 general ways to
systematically approach a CXR:
1. ABCDE method (many of my previous classmates have discussed in
their blogs)
2. Soft tissue in the peripheral area, including bones as well à diaphragm à mediastinum à lungs
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