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40-year old woman with a productive cough for 3 months.

Discussion in 'Case Studies' started by J.P.C. Peper, May 9, 2012.

  1. J.P.C. Peper

    J.P.C. Peper Bronze Member

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    Summary.

    A 40-year old woman presented with a productive cough for 3 months that was worsening with yellow and sometimes blood-stained sputum; there was also shortness of breath on exertion and weight loss of 3 kilograms. She had fever on and off and night sweats for 1 month. There was no chest pain or ankle swelling.

    On examination she looks wasted; slightly breathless, blood pressure 110/70 mm Hg, pulse rate 100/min (regular), temperature 38,5° C, respiratory rate 20/min. JVP is not raised. The mouth showed oral thrush; no KS. In the lungs there was reduced chest expansion, with dullness on percussion and on auscultation reduced breath sounds with reduced VR and VF on the right hemithorax. The trachea and apex beat were both displaced to the left. On abdominal examination the liver was enlarged by 3 cm; no palpable spleen, no masses, no shifting dullness. No oedema.

    Questions.

    1. What’s your differential diagnosis?

    2. What investigations should be done?
     

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    anshu likes this.

  2. Rocket Queen

    Rocket Queen Super Moderator

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    1. I think about lung cancer with metastases in liver.

    2. Lungs X-ray, blood analyses, liver CT, bronchoscopy...
     

    Last edited: May 10, 2012

  3. J.P.C. Peper

    J.P.C. Peper Bronze Member

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    Answers:

    1.

    - pleural effusion: mycobacterial (TB), bacterial (parapneumonic)
    - empyema: bacterial, mycobacterial
    - malignancy: bronchial carcinoma, lymphoma

    2.

    - HIV test
    - FBC
    - sputum for acid fast bacilli (AFB)
    - pleural tap: diagnostic (appearance, cells, differential, glucose, protein, ZN and gram stain) and therapeutic
    - chest X-ray
    - O2 saturation (pulse oximeter)

    Comments.

    Because cough and shortness of breath are commonly caused by respiratory or cardiac problems, detailed history from both tracts should be taken. In this case the absence of oedema, extra heart sounds and raised JVP are all important negative findings. The finding of oral thrush is significant as this points to HIV infection; the absence of KS in the mouth is an important negative finding as the presence thereof may suggest that the pleural effusion could be due to KS. In addition, the findings of KS would mean advanced HIV disease. The enlarged cardiac dullness on percussion and displaced apex beat may point to heart failure, but in this case are explained by mediastinal shift because of the large pleural effusion. The enlarged liver in this case, in the absence of evidence for heart failure, may be the result of disseminated TB or may be due to another, thus far undetected process.

    Literature:

    A book I had when I did a minor Tropical Medicine in Zambia. I copied this case in my notes, so unfortunately I don't know the title or author.
     


  4. Rocket Queen

    Rocket Queen Super Moderator

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    Thank you for answer.
    KS is shortcut for what? Sorry, but my english is not so good.
     


  5. J.P.C. Peper

    J.P.C. Peper Bronze Member

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    It's short for Kaposi sarcoma. I'm sorry for the confusion.
     


  6. Rocket Queen

    Rocket Queen Super Moderator

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    Ok. Thank you for the explanation!
     


  7. hmsila

    hmsila Well-Known Member

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    I suppose this is pulmonary tuberculosis..

    investigations include sputum for AFBs..sputum for Culture..Wbcs..Esr..
     


  8. Nyarpolo

    Nyarpolo KINO

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    PTB??

    sputum afb i think
     


  9. anshu

    anshu Active member

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    thanks dr.peper for teh Q&A ,why not pneumonic empyema?..why PTB?(pulm tuberculosis)..
     


  10. ishu90

    ishu90 Young Member

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    looking at the productive cough of 3 months duration with weight loss and sputum being yellow with hemoptysis....first differential is tuberculosis.depending on the endemic region she belongs to other differential diagnosis of an intracellular organism can be made.but such wasting is generally noted in tuberculosis.
    on further examination of the patient, the findings suggest pleural effusion on the right side...however since it should hv been an exudative pleural effusion according to her symtoms she would hv complained of pain during cough and post inspiration and since breath sounds and VF VR r reduced and not absnt suggests pleural fibrosis....however differential diagnosis of an atypical bacteria causing pneumonia and lung carcinoma should also be kept in mind.
    therefore investigations preferred would be-
    1.chest xray PA view
    2.sputum acid fast staining.
    3.montoux test/newer modalities such as MGIT for culture.
    4.HIV may be done but other symptoms and no history of sexual or blood transfusion exposure is mentioned.
    5.a poosible pleural tap with pleural fluid examination should be done...in case b needed pleurodesis may be done...if results r negative and findings are inconclusive she should be started on anti tubercular drugs and wait for any improvement.if yes continue according to regimen otherwise investigate of other possibilities.
     


  11. Sandra Dunggio

    Sandra Dunggio Active member

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    The diagnosis are Pulmonary Tuberculose with right pleural effusion.

    Investigations are :
    - Hematology examination
    - Sputum for Acid Fast Bacilli
    - Chest X-Ray
     


  12. Naldisy

    Naldisy Active member

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    my differential diagnosis : 1. Pulmonary Tuberculosis
    2. Neoplasma
    3. Pleural effusion

    Investigations by :
    1. Hematology analysis
    2. Sputum for acid fast bacilli (AFB)
    3. Chest X-ray
    4. Liver Function Test
    5. O2 saturation
     

    Melissa likes this.

  13. Dr.M.Mahisha Vardhini

    Dr.M.Mahisha Vardhini Young Member

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    Tuberculosis , HIV
     


  14. trio wicaksono

    trio wicaksono Young Member

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    1. DD: malignancy in lungs, TB, Tb infection in patient with HIV,

    2. Rontgen thorak, sputum investigation, CT scan maybe. serology of HIV
     


  15. sinned

    sinned Well-Known Member

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    Lung Ca or TB Sputum culture, CT Scan.
     


  16. naz

    naz Well-Known Member

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    I think lung cancer but ddx can be TB,bronchiectasis,
    sputum culture,ct,cbc,esr,crp
     


  17. matacida

    matacida Young Member

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    Pulmonary tb, extra pulmonary tb (pleuritis tb w/pl effusion, hepatitis tb), oral candidiadis, HIV/AIDS Stage 4......sputum AFB, CXR, Abd Usg, VCT for HIV testing, ALP (increase in Mycobacterium avium complex...frequent in HIV/AIDS)
     


  18. Melina

    Melina Active member

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    1. Pulmonary Tuberculosis, and possible extrapulmonary tuberculosis ( hepatic focus)
    2. First: Where she lives? Theres a person with chronic cough in there?
    Laboratory: Three serial sputum bacilloscopies - Complete blood count- Chest X ray - HIV test



     


  19. Tariq khan jadoon

    Tariq khan jadoon Young Member

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    We'll I think it's brchogenic carcinoma with Mits in the liver or with pulmonary tuberclosis with effusion shifting the liver down
     


  20. Endris Mohammed

    Endris Mohammed Active member

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    1. kaposis sarcoma
    2. lymphoma
    3. Mediastinal LAP secondary to ? Tuberculosis
     


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