CLUBBING (with ABCDEF for lung diseases)
C yanotic heart disease
L ung diseases
U lcerative colitis + Crohn's (Inflammatory Bowel Diseases)
B iliary cirrhosis
B irth defect
I nfective endocarditis
N eoplasm (lung cancer, mesothelioma)
G I malabsorption syndromes (Coeliac disease)
Wassalam.
Pak Ali, a 60 years old man came to hospital. He complained of having shortness of breath during exercise and even during lying flat. He suddenly wakes up at night with thought of ‘feeling very breathless’.
30 years old male patient was hospitalized two weeks ago due to fracture of femur bone after involve in MVA. Currently, he complains of progressive right side chest pain which is sharp in nature and aggravated by inspiration. His body temperature is found to be 39.5⁰C. On Physical examination, the lower zone of right lung is dull on percussion and bronchial breath sound is heard on auscultation.
1) What is your provisional diagnosis (1m)
2) Name two causative agent that can cause the current problem (2m)
3) Portal of entry of (2) (1m)
4) List three investigation you want to perform and reason (6m)
Diagnostic approach
When hospitalized patient develop chest pain, think of either pulmonary embolism or hospital acquired pneumonia. Fat embolism is possible due to long bone fracture and prolongs immobilization. However, the nature of chest pain is usually sudden and onset. The physical examination also favor the diagnosis of Hospital acquired Pneumonia. (High grade fever, dull percussion, bronchial breath sound)
HAP usually caused by Pseudomonas aeroginosa and Staphylococcus aureus which enter the body via hematogenous spread from the site of IV line.
Pneumonia have four stages which is congestion, red hepatization, grey hepatization and resolution. This patient possibly in stage of red hepatization (fever, pleuritic chest pain). Chest X-ray may show opacity. Blood culture may yield a positive result. At this time, antibody to the infectious agent is not develop yet, hence immunoassay is not necessary. Full blood count may shows elevated neutrophils.
**Bersama mengembalikan kegemilangan tamadun ilmu Islam**
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-
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