Case 26 - 54 yo F with cough

Question 1

Physical examination

Answer 1

If the patient has a tissue, always ask to see it!

Offer the patient a glass of water or tissue if they have a coughing fit.

Question 2

Physical examination

Answer 2

Head and neck exam (inspected mouth, throat and lymph nodes)
CV exam
Pulmonary exam (breath sounds, rhonchi, rales, wheezing, tactile fremitus)
Abdominal exam
Extremities (check for clubbing, cyanosis or edema)

If the patient has a tissue, always ask to see it!
Offer the patient a glass of water or tissue if they have a coughing fit.

Question 3

Closure

Answer 3

We will need to obtain some blood and sputum tests as well as a CXR

Working at a nursing home puts you at risk for TB, so we will test you for that. I would recommend that you adhere to standard respiratory precautions while working with patients who have TB

Quitting smoking could improve your chronic cough and decrease your risk of cancer

Do you have any questions for me?

Question 4

Differential diagnosis

Answer 4

Pulmonary tuberculosis (fever, night sweats, blood-tinged sputum, decreased appetite)
Lung cancer (fever, night sweats, blood-tinged sputum, decreased appetite, smoking)
Pneumonia (fever, sputum production, heavy smoking, h/o chronic bronchitis)

Question 5

Diagnostic work-up

Answer 5

PPD or QuantiFERON Gold
CXR - PA and lateral
CT - chest
Sputum culture, Gram stain, AFB smear, cytology, routine and mycobacterial sputum cultures
Blood cultures
CBC with differential
Bronchoscopy
Lung biopsy