September 29, 2009

progressive shortness of breath for one week duration

A 55 years old Malay man presented to the clinic with the chief complaint of progressive shortness of breath for one week duration. he is a smoker and smoke for about 20 cigarettes per days for 20 years.

he also complained of cough since three years ago with yellowish sputum.

1) What other question you would like to ask and why?
2) What investigation you would like to perform?
3) what is the most probable diagnosis in this patient?

Good luck

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  1. 1)-any chest pain.
    -any contact with pulmonary TB
    -musical sound during expiration

    2)-sputum culture and sensitivity (to confirm bacteria)
    -full blood count(any infection)
    -chest x-ray(any consolidation in pneumonia)
    -sputum staining(zeihl nelsen staing for Tb)


  2. 1) Have he had any feaver before? - infection
    chest pain? -
    any trauma on the chest?- pneumothorax, pneumonia..
    is there any contact with anyone with tuberculosis?-TB
    how much sputum he coughed each day?
    what makes his difficulty in breathing become worst? onset and so on.

    2)blood test fot total WBC? to indicate if he has any infection.
    chest X-ray.
    Sputum culture and sensitivity to indicate what type of organism causes infection in this patient.

    Because the sputum was yellow, maybe it indicate infection rather than just clear sputum.

    3) It can be COPD from history of smoking with minor infection.

    ~_~, again.. just from my 2nd year knowledge..

  3. to be specific COPD,
    Chronic bronchitis because the production of cough should be in two consecutive years.

    dunno- =p

  4. in order to answer this kind of question, we have to read the answer carefully. for example, the first question require you to justify why you ask certain question for examples. plus, your question must be directed towards your diagnosis or to exclude other diagnosis which resembles the presentation

    for examples, when patient come with SOB as the most prominent complaint. your assesment should be more on resp system and followed by cardiology problem.

    in second phase md in USM, usually we have to ask 3 important question.

    both of you have answer it well but it just not complete in term of explaination.

    for example musical expiration during expiration. you have to reason that you would like to exclude the dignosis of asthma. there will be mark for u even though asthma is not really suggestive based on the onset of the symptom.

    contact with tb patient is important and necessary to elicit in any history taking of respi system. just when u answer it, try to correlate with history.

    respiratory chest pain is more sharp or pleurisy in nature and not confined to left retrosternal area.

    amount of sputum is a good question. certain disease especially bronchiectasis will have more sputum. asthma or copd would rather present with dry cough unless there is underlying infection.

    this patient is more likely to have COPD base on the onset of the cough which is in the middle to late age plus with the history of smoking.

    differentiating between emphysema or chronic bronchitis base in this question statement alone is difficult. but there are severel hint. most of it will present when you do the physical investigation and other investigation like cxr, anti-trypsin level.

    for more explaination, click on the link provided in the article..

    feel free to correct my answer if there is any mistake.. thank you

  5. i see, so emphysema and chronic bronchitis is difficult to differentiate.

    thank you very much..

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