A medical student is participating in her first clinical rotation of Internal Medicine and is asked to conduct a preliminary evaluation on a patient by her chief resident who is busy elsewhere. The floor nurse has just taken vital signs and notices the patient is coughing repeatedly. The nurse reports in passing to the student that the patient is a recent Asian immigrant who speaks no English but family members accompanying the patient had told the nurse that the patient had been coughing up blood for the last week. What should the medical student do at this time before walking into the patient's room?
a. Send the patient for an emergent chest radiograph.
b. Obtain a sputum sample from the patient.
c. Review this patient's previous medical records.
d. Request an N-95 mask for herself and other hospital staff members.
e. Send the patient to the state TB clinic.
The most correct answer is d, request N-95 masks.
A physician in training should have a high index of suspicion for tuberculosis especially in patients from regions with high endemic TB activity and who present with hemoptysis. Although other differential diagnoses may explain the patient's symptoms and imaging is required (answer a) to further differentiate the processes, it is imperative that preventive steps be taken to minimize transmission to other individuals at risk. Obtaining a sputum sample (answer b) will be important to diagnose smear-positive TB, or to help establish another diagnosis, but isolating the patient until three sputum smears are negative is recommended. While reviewing previous medical records is highly desirable in any patient encounter (answer c), a more immediate concern is the provision of an N-95 mask to reduce disease transmissibility and risk of infection (answer d). Once the diagnosis is established, the patient likely will need referral to the state TB program (answer e), as direct observed therapy (DOT) is the standard of care and clearly has contributed to decreased incidence of treatment failure because of improved adherence to therapy.
A 40-year-old woman who was born in India and emigrated to the United States at age 5 presents with a 10-day history of progressive shortness of breath with associated pleuritic chest discomfort, fevers, night sweats, and nonproductive cough. In the past year the patient has traveled to South Africa and India. Her current vital signs include radial pulse = 96 beats/min and respiratory f = 20 breaths/min. Decreased breath sounds are noted on the left posterior exam, as well as a dull note on percussion; a chest x-ray taken today is shown in Fig. 36.8.
Chest x-ray for the 40-year-old patient in Case 36.2.
What is the most appropriate next step in evaluating or treating this patient?
a. Conduct fiberoptic bronchoscopy.
b. Perform a thoracoscopic lung biopsy.
c. Order diagnostic thoracentesis.
d. Begin isoniazid (INH) treatment for latent tuberculosis.
e. Start antibiotics for community-acquired pneumonia and order another chest x-ray in 1 week.
The most correct answer is c, order thoracentesis.
The patient's radiograph demonstrates a homogenous opacity occupying one-half of the left hemithorax that is obscuring the diaphragm, signs that are most consistent with large pleural effusion. Therefore, the next step should be to perform diagnostic thoracentesis in which pleural fluid should be obtained. There is little reason to believe from the history that the patient aspirated a foreign body, and the radiograph does not demonstrate volume loss on the side of opacity, and therefore bronchoscopy is not indicated (answer a). The thoracoscopic lung biopsy (answer b) is a more invasive procedure and usually would be necessary if thoracentesis is non-diagnostic, specifically to obtain pleural and/or lung biopsies. All patients need to have diagnostic evaluation to exclude active tuberculosis prior to initiation of INH for latent tuberculosis (answer d). This is especially important since the monotherapy with INH to a patient with active tuberculosis can lead to the development of INH-resistant tuberculosis. Although antibiotic initiation should be prompt in patients suspected of pneumonia, that step does not preclude diagnostic evaluation of this very significant pleural effusion to exclude a complicated effusion or empyema and thus (answer e) is not correct.