prep4step2
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Can anyone tell me the major difference of Q1 vs. Q2? I got confused because these 2 questions have different answers.
Q1.
A 64-year-old man presents to the physican's office complaining of fevers for the past 2 days. Over the past 24 hours, he has developed a productive cough. He also reports that he has frequent chills, and has been waking for the past 2 nights with drenching sweats. His past medical history is remarkable only for mild exertional angina. On physical examination, he does not appear chronically ill but appears moderately dyspneic. His temperature is 38.6 C (101.4 F), blood pressure is 136/94 mm Hg, and respirations are 26/min. There is no jugular venous distention. The lungs have coarse rhonchi at the right lung base with increased fremitus in the same area. He has a regular heart rhythm, with a 1/6 systolic murmur at the left sternal border. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?
A. Chest x-ray film
B. Sputum Gram's stain
C. Chest CT scan
D. Pulmonary function test
E. Peak expiratory flow rate measurement
Q2.
A 59-year-old man presents to his primary care physician with fever and chills. His past medical history is significant for osteoarthritis for many years. He has a long smoking history of greater than 150 pack-years. He routinely takes only a non-steroidal anti-inflammatory agent for pain. He presents with 5 days of fever and chills associated with a productive cough. He has not been hospitalized recently and lives at home with his wife and has no sick contacts. On physical examination he is comfortable, his temperature is 38.9 C (102 F) and has bibasilar crackles heard best at the left base. Which of the following is the most appropriate next step in diagnosis?
A. Arterial blood gas
B. Chest radiograph
C. Complete blood count
D. Oxygen saturation check
E. Sputum gram stain
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| asmi
Forum Hero
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1. gram stain first.
2.CXR
:idea: Can you name the source of these Q's ?
I think iam wrong in both answers :cry: , i got to workhard.
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| daira
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For Case 1: I think the first test should be chest Xray. Chest Xray is always the first test in diagnosis of Pneumonia, to know the nature of pneumonia, if it involves a single lobe or its interstitial disease.
For Case 2: I think it should be Chest radiograph again.
If we try to look for the management and not diagnosis, then we might need ABGs or oxygen saturation, to decide if he needs admission or not. But that is a management issue, not a diagnosis issue.
I think that CXR should be answer for both. As you already said that the answer is different for these qs, so I am sure I am wrong.
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| prep4step2
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Hi ASMI:
You're right for both questions. Can you tell you why you chose sputum gram stain for q1 while CXR for q2? Basically the 2 cases look so similar to me.
Many thanks in advance...
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| asmi
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Hi prep4step2,
I was thinking in terms of duration of fever and productive cough ,in first case its 24 hrs duration...simple gram stain can lead to diagnosis.
In second case ..5 days duration...so CXR might help .
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| BellKicker
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Impressive, asmi
I would have picked x-ray in both, too. In fact, I have never seen anyone start out with a gram stain in real life.
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| prep4step2
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Here is "official" answer to the two questions.
Q1:
The correct answer is B. This patient has a classic
presentation of an acute community acquired bacterial
pneumonia, as demonstrated by the findings of acute
onset of fevers, rigors, and a productive sputum. His
physical examination is consistent with a right lower
lobe pneumonia and consolidation in this region. A
sputum Gram's stain may demonstrate the organism
responsible for this patient's pneumonia. The next
step would then be a chest x-ray to confirm the
presence of a pneumonia and identify its size and any
associated parapneumonic effusions.
A chest x-ray film (choice A) is also indicated, but
may take an hour or more to actually be obtained. For
this reason, collecting sputum for a Gram's stain,
before the x-ray, may shorten the time to definitive
therapy.
Chest CT scan (choice C) is usually reserved for
evaluation of suspected masses.
Pulmonary function tests (choice D) and peak
expiratory flow rate measurement (choice E) are
usually reserved for evaluation of chronic lung
diseases, such as emphysema, chronic bronchitis,
pulmonary fibrosis, and asthma.
Q2.
The correct answer is B. The suspicion, based upon the
clinical examination, is that this patient has
pneumonia. The only way to definitively diagnose
pneumonia is with an infiltrate present on chest
radiograph. All further decision making about this
patient will depend on whether the suspicion of a
pulmonary infection is confirmed.
An arterial blood gas (choice A) is not necessary in
this situation. These tests are routinely performed on
asthmatic and COPD patients when the results are
already known empirically. For example, a COPD patient
who has a room air saturation of 80% and is tachypneic
with labored breathing will almost certainly be
hypoxic and hypercarbic. Even if this patient did have
a pneumonia, the arterial blood gas will reveal no
useful information that an oxygen saturation and
thorough history would not.
A complete blood count (choice C) is important, but
not before you determine whether this patient has a
pneumonia. An elevated leukocyte count can only be
interpreted after such information is obtained. This
concept is a general one in clinical medicine, never
order laboratory tests unless there is specific
information sought that may help to confirm or negate
a diagnosis.
An oxygen saturation check (choice D) is not
appropriate at this point given that the patient's
appearance is benign. Hypoxemia would be evident in
the patient's respiratory rate, appearance, or his
inspiratory effort.
A sputum sample (choice E) is often obtained when a
bacterial pneumonia is suspected and selective
antibiotic therapy is desired, but the presence of an
infiltrate on radiograph would dictate antibiotic
therapy based on his age and place of residence (home,
hospital, ICU bed). These empiric guidelines are
adequate for most therapy and can be tailored to
selective therapy based on evolving clinical findings.
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| prep4step2
Forum Newbie
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Honestly, the answers don't convince me.
What asmi says may be right, assuming not enough changes to show up on x-ray in 24 hours?
Or is it because case 1 shows clearer signs of consolidation such as "coarse rhonchi at the right lung base with increased fremitus in the same area" while case 2 has only "bibasilar crackles heard best at the left base?"
I'm still quite confused. If there is no established protocols for diagnostic processures here, I guess I would have to try my luck in the exam.
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| asmi
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Hi prep4step2 ,
Yes ,a simple procedure like gram stain can lead to diagnosis .I can assure you that ,its a simple procedure but with great place.
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| Ouli Maty
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I would have gone for CXR for both. When you think that radiologic changes come often late even after treatmt. It does make sense.
Asmi, thank you for your insight.
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| docdoc
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Interesting questions.
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| usmledoctor1
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in exam mark x ray for both. even if the x ray takes 1 hour or so that will not really matter much. patient is not in so much emergency and also gram stain will too take atleast more than an hour. further if we r in real hurry we can see wet film of xray. i disagree with the logic that we ordered sputum stain coz we thought chest xray is gona take so much time. i totally disagree with the following statement - A chest x-ray film (choice A) is also indicated, but
may take an hour or more to actually be obtained. For
this reason, collecting sputum for a Gram's stain,
before the x-ray, may shorten the time to definitive
therapy.
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| merrk
Forum Elite
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CXR for Q2 is convincing b/c the man is a heavy smoker and you have to rule out a mass which may present for the first time as pnemonia.
In CAP you generally do not do CXR, but the man is 64 yrs old with multiple comorbids... HTN, angina, I would go for CXR!!
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| tuesday
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answer for both is CXR(chest radiograph)
The question stem for both asks " WHAT IS THE MOST APPROPRIATE NEXT STEP IN DX?
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