miky
Forum Senior
Topics: 16
Posts: 99
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70 yo male
History:
worked for 25 years on the yard, retired 12 yrs ago,
chronic stable angina,
smoked 20 cigs/day until 5 years ago,
progressive shortness of breath that began roughly 15 years after he had hired on the yard.
Come to you because of severe shortness of breath of recent onset (can't remember exactly the moment), severe dizziness, chest pain worse with breathing in deep air, and a chronic, productive cough (yellow - green sputum) occasionally blood-streaked.
The pt. lost 10 kilos over the last 6 weeks.
Physical:
BP = 145 / 95
HR = 150
RR = 30
Temp: 39.7 C
Chest exam: rales and crackles on the right hemithorax, dulnness on percussion of the left hemithorax, trachea shifted on the right side, parasternal heave, right sided S3& S4, sysolic murmur heard best on the LSB
ankle edema
blue color of his lips and nose
moderate clubbing
Lab:
SaO2 = 89&
CXR - small nodular oppacities distributed diffusely on the right lung; the left lung field is totally white;enlarged right hilar lymph nodes; trachea pushed on the right side.
Blood - negative GS
The next most logical investigation is:
The most probable dx is:
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always happy and ready to serve and help my friends and patients as well.
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| sanz
Forum Elite
Topics: 14
Posts: 154
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Logical Ix: CT chest, then bronch & biopsy
Probable Dx: left lung Ca producing a mass effect, causing trachea deviation and right sided heart failure.
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| miky
Forum Senior
Topics: 16
Posts: 99
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Sanz, read very carefully every word of the case. It's a nice case, although a bit more difficult than those usually given in step 2CK. Your dx & management plan are wrong.
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| deea
Forum Newbie
Topics: 5
Posts: 32
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I think it's COPD - bronchitis type, with severe fluid accumulation on the left side
The next investigation is pleural tap.
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| deea
Forum Newbie
Topics: 5
Posts: 32
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Miky, after I saw ur profile I realised why it was so easy for me to answer ur question - classical Semiology case!!!
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| miky
Forum Senior
Topics: 16
Posts: 99
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Deea, here you are wrong :cry:
Yes, it's classical, but you should pay more attention to it.
Correct dx: Silicosis and Pulmonary Tuberculosis (the MCC of fever in a pt. with silicosis). Can you tell me why?
Next: PPD test
Next: Pleural tap - AFB stain, LY culture
Also ABGs (can you tell me why?)
Tx: O2 supplement, ETI & MV (can you tell me why?), start anti-TB drugs (four drug regimen - can you tell me why?)
Wait for your answer.
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always happy and ready to serve and help my friends and patients as well.
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| deea
Forum Newbie
Topics: 5
Posts: 32
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!The enlarged hilar lymph nodes on the right -that maybe caused by TB
The thing that made me think of COPD with severe bronchitis was this:
"a chronic, productive cough (yellow - green sputum) occasionally blood-streaked", in a heavy smoker, with decrease SaO2.
Although i don't deny that "small nodular oppacities distributed diffusely on the right lung" is a specific sign of silicosis - I thought that this is of second importance - and COPD is superimposed on it.
And "dullness on percussion of the left hemithorax, trachea shifted on the right side, parasternal heave, right sided S3& S4, sysolic murmur heard best on the LSB " are signs of hydrothorax on the left. The cause of this may be TB but it can also be bacterial pneumonia on a lung with COPD,with subsequent hydrothorax.
But i admit only now i saw the lost in weight!!!
 I'm not trying to contradict ur diagnosis - just diminish my blame and prove there was easy to get it wrong
As for the next step - maybe a pleural tap AND a bronchial lavage with an acidfast stain and a gram stain ( :wink: maybe he has some other bacteria besides Tb)
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| miky
Forum Senior
Topics: 16
Posts: 99
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Dear Deea,
Have you seen the "SCRUBS"? .
It's a nice series and very instructive too. There is a guy there who says: "if you hear neighing, think of a horse not a zebra" :idea:
Yes, you have some point there when you say that the pt. might have COPD. But COPD is not accompanied by diffuse opacities and hilar LAP :wink: . It's expectable that you find mixed obstructive and restrictive pattern in this pt, but the clinical picture is very much suggestive for Silicosis 8) . And if you find fever in a pt. with silicosis and a pneumonia like picture, always rule out TB, since it's the most frequent complication in such pts :idea: .
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always happy and ready to serve and help my friends and patients as well.
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