Session 9: Group Work

Question 1

What features of this history and examination cause you concern, and warrant hospital admission?

Answer 1

Severe left sided chest pain

Green sputum

Fever

RR

Question 2

What do you think you might hear on auscultation of Yvonne’s chest?

Answer 2

Pulmonary crackles

Question 3

Her arterial O2 is 87%. What is normal arterial O2 sat?

Answer 3

94-98%

Question 4

CXR is done. The report indicates that this shows consolidation of the left lower lobe, with increased shadowing in the left lower lobe and loss of cardiac outline. Explain how these changes might have occured.

Answer 4

Exudate/fluid in the alveoli where the fluid obstructs the view of the heart.

Question 5

What other tests would you order to help in the management of Yvonne’s condition?

Answer 5

Cough sputum test

Gram stain

Blood culture

U & E

CRP

ABGs

Question 6

What is the most likely organism causing her illness?

Answer 6

S. pneumoniae

Question 7

Answer 7

Yes looks like S. pneumoniae

Gram positive and diplococci that is sometimes in chains.

Question 8

Which antibiotics would you choose to treat Yvonne?

Why these in particular?

Answer 8

This should be treated as severe pneumonia.

Treat with co-amoxiclav and doxycyclin

Treat with meropenem if penicillin allergy

Question 9

What features in this history supports the diagnosis of pulmonary tuberculosis?

Answer 9

Tiredness

Weight loss

Fever

Cough

Haemoptysis

Diabetes

Left upper zone

Question 10

Suggest one important condition to exclude in this patient?

Answer 10

Lung cancer

Question 11

Answer 11

Consolidation/shadowing in left upper zone

Question 12

This patient is likely to have post-primary TB due to reactivation of latent TB. What factor is most likely to have caused reactivation of TB in this patient?

Answer 12

Poorly controlled diabetes.

Question 13

What other conditions can result in reactivation of latent TB?

Answer 13

HIV

Drug abuse

Long standing corticosteroids

Organ transplant

Blood transfusion

Severe kidney disease

Chemo

Question 14

How can the diagnosis of active pulmonary TB be established.

Answer 14

TB Culture (golden standard)

Direct smear

CXR

NAAT

Question 15

Would and IGRA assay or a Tuberculin skin test be useful in the diagnosis of pulmonary TB in this patient?

Explain your answer.

Answer 15

Not really. The tests can’t distinguish between latent or active TB.

There are other means of which you can test for active TB.

Question 16

Anti TB treatment is commenced with 4 drugs. Name the four drugs commonly used in TB treatment.

Answer 16

Rifampicin

Isoniazid

Pyrazinamide

Ethambutol

Question 17

Why are 4 drugs used in the treatment of TB?

Answer 17

Mycobacterium tuberculosis have random resistant strains to antibiotics. If you only give one, one of the strains might emerge and promote resistance.

In the case of giving 4 antibiotics it is very unlikely for the bacilli to be resistant to all 4.

All in all it is done to prevent resistance.

Question 18

The GP warns him that his urine may turn orange. What is the explanation for this colour change?

Answer 18

Rifampicin rasies transaminases and induces cytochrome P450

Question 19

The GP arranges for all members of the family to have a chest radiograph and IGRA test. Why?

Answer 19

To see if they have latent TB.

Question 20

What condition does this patient have, as suggested by the clinical history, chest radiograph and CT findings?

Answer 20

Bronchiectasis

Sinusitis, pneumonia and cough

Visible bronchioles

Bronchioles larger than arteries

Question 21

What is the pathological definition of this condition?

Answer 21

Chronic dilation of one or more bronchi with poor mucous clearance.

Question 22

What underlying diseases may cause this condition?

Answer 22

Cystic fibrosis

Whooping cough

TB

Hypogammaglobulinaemia

Question 23

What underlying disease most likely explains this patient’s symptoms?

Answer 23

Late onset CF

Question 24

What further testing could this patient undergo to help diagnose her underlying disease?

Answer 24

Sweat test to check for Cl- levels. (They should be high)

Genetic test should be done after this.