Fever with cough.

A 60 years old male presented to your clinic with the history of two weeks fever associated with cough producing blood stained sputum. On further questioning, he also complaint of malaise, and night sweat. He is an active smoker since 19 years old and smoke 20 cigarettes per days.

Questions

1) What is your provisional diagnosis (2m)

2) What signs you would like to elicit in physical examination (2m)

3) Give two investigations you would like to perform and give reasons (4 marks)

4) What is the most likely the causative agent (2m)

Diagnostic approach

Ok, when patient comes with fever + hemoptysis. Please think of either carcinoma or Tuberculosis (this two MOST COMMON). But, in this patient, TB is most likely. The key point here is NIGHT SWEAT. (TB not usually comes with chest pain except involve pleura.) Malaise is almost always present in all disease.

Ok! Next step is PHYSICAL EXAMINATION. The most important signs to be elicited are dull on percussion (remember APICAL or UPPER ZONE) and lymphadenopthy (supraclavicular@ anterior neck triangle).Rhonci or rales may present on auscultation.

To confirm the diagnosis, we usually perform CHEST X-RAY (patchy or nodular opacity in upper zones, loss of volume & fibrosis with/out cavitations), Sputum staining (Ziehl-Neelsen or acid Fast Bacilli) and culture (Lowenstein Jensen media). For sputum. Remember to take early morning sample (highest concentration of bacteria). Mantoux test can be perform but not specific as well as blood culture.

Culprit

-Always think of Mycobacterium tuberculosis in healthy patient and Mycobacterium avium in Immunocompromised pt. Others include M.bovis, M. intracellulare

- In Pursuit to Excel Professional II examination!! Good luck friends-