First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 26. 54-Year-Old Woman with Cough

DOORWAY INFORMATION

Opening Scenario

Marilyn McLean, a 54-year-old female, comes to the office complaining of persistent cough.

Vital Signs

BP: 120/80 mm Hg Temp: 99.5°F (37.5°C)

RR: 15/minute HR: 75/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 54 yo F

Notes for the SP

 Cough as the examinee enters the room.

 Continue coughing every 3-4 minutes during the encounter.

 Hold a red-stained tissue in your hand to simulate blood. Don’t show it to the examinee unless he/she asks you.

 During the encounter, pretend to have a severe attack of coughing. Note whether the examinee offers you a glass of water or a tissue.

Challenging Questions to Ask

“Will I get better if I stop smoking?”

Sample Examinee Response

“Well, we still have to sort out exactly what is causing your cough. If you stop smoking, your chronic cough should improve. But regardless of what is causing your cough, smoking cessation will significantly decrease your cancer risk in the long term.”

Examinee Checklist

Building the Doctor-Patient Relationship

Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

 Examinee offered the SP a glass of water or a tissue during the severe bout of coughing.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mrs. McLean, your cough may be due to a lung infection that can be treated with antibiotics, or it may result from something more serious, such as cancer. We will need to obtain some blood and sputum tests as well as a chest x-ray to identify the source of your cough. In addition, we may find it necessary to conduct more sophisticated tests in the future. The fact that you work in a nursing home puts you at risk for acquiring tuberculosis, so we are going to test you for that as well. I would also recommend that you adhere to standard respiratory precautions while working with patients who are infected with TB. Do you have any questions for me?

History

HPI: 54 yo F with PMH of chronic bronchitis c/o worsening cough x 1 month.

 Chronic cough for years.

 2 teaspoons of yellowish phlegm with streaks of blood.

 Dyspnea on exertion.

 Fever and sweats at night.

 Fatigue.

 Decreased appetite, 6-lb unintentional weight loss over 2 months.

 Exposure to TB as nurse's aide working in nursing home.

 Last PPD: 1 year ago and negative.

 No chest pain, chills, or wheezing.

 No recent travel.

ROS: Negative except as above.

Allergies: NKDA.

Medications: OTC cough syrup, multivitamins, albuterol inhaler.

PMH: Per HPI.

PSH: Tonsillectomy and adenoidectomy, age 11.

SH: 1-2 PPD for 35 years; stopped smoking 2 weeks ago. No EtOH. Sexually active with husband only.

FH: Noncontributory.

Physical Examination

Patient is in no acute distress.

VS: WNL.

HEENT: Mouth and pharynx WNL.

Neck: No JVD, no lymphadenopathy.

Chest: Clear breath sounds bilaterally; no rhonchi, rales, or wheezing; tactile fremitus normal.

Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nontender,BS, no hepatosplenomegaly Extremities: No clubbing, cyanosis, or edema.

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

 Pulmonary tuberculosis: Clinical suspicion is high for this diagnosis given the patient’s constitutional symptoms (fever and night sweats, unintentional weight loss) coupled with hemoptysis and recent exposure to active TB. The patient should be placed in respiratory isolation immediately. In those who have had recent contact with TB patients, a PPD is considered positive if it shows > 5 mm of induration.

 Lung cancer: As noted above, constitutional symptoms and hemoptysis in a long-time smoker are worrisome for cancer. Although not found on this patient’s physical exam, clubbing can be found in COPD patients with underlying lung malignancy.

 Typical pneumonia: Classic bacterial pneumonia begins with abrupt onset of fever, chills, pleuritic chest pain, and productive cough. Signs of pulmonary consolidation on physical exam are absent in up to two-thirds of documented cases. The more subacute time course seen here makes this diagnosis less likely.

Additional Differential Diagnoses

 Lung abscess: A lung abscess due to anaerobic bacteria is usually associated with gradual onset of fatigue, fever, night sweats, and cough producing a foul-smelling expectoration. Symptoms evolve over a period of weeks or months (the time course in this case favors abscess over uncomplicated pneumonia). Other bacterial causes of lung abscess typically present more acutely.

 Atypical pneumonia: Refers to infection by Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species. These can all present similarly with an insidious onset of fever, malaise, headache, myalgia, sore throat, hoarseness, chest pain, and nonproductive cough. Sputum may be blood-streaked. GI symptoms may be prominent in Legionella infection, and severe ear pain due to bullous myringitis may complicate up to 5% of Mycoplasma infections. The presence of weight loss, night sweats, and productive cough makes atypical pneumonia less likely in this case.

 COPD exacerbation: This patient’s baseline productive cough is due to COPD/chronic bronchitis secondary to tobacco exposure. Exacerbations of chronic bronchitis are more acute and involve increased sputum production and/or increased wheezing and dyspnea. Night sweats and weight loss are not typical features of this diagnosis.

 Other etiologies: Other common, benign causes of chronic cough include postnasal drip, GERD, asthma, and ACE inhibitors.

Diagnostic Workup

 PPD (tuberculin skin test) or QuantiFERON Gold: The PPD test is a screening tool for Mycobacterium tuberculosis infection. The QuantiFERON Gold test is a newer and more specific test for prior M tuberculosis infection, but its availability varies depending on the testing center.

 CBC: To identify leukocytosis in infection (nonspecific).

 Blood cultures: May be useful in severe pneumonia to identify causative pathogenic bacteria.

 Sputum Gram stain, AFB smear, routine and mycobacterial sputum cultures, and cytology: To identify a causative agent of infection or to help detect malignancy.

 CXR—PA and lateral: To look for apical cavitary disease in TB reactivation, noncalcified nodules in lung cancer, a cavity with an air-fluid level in lung abscess, a patchy infiltrative pattern in atypical pneumonia, and lobar consolidation in typical pneumonia.

 CT—chest: May demonstrate lesions unseen on CXR, and aids in characterizing the size, shape, and composition of lung and mediastinal pathology. Any nodules found on CT require comparison to a previous scan if available. A chest CT can also guide diagnostic procedures (eg, percutaneous transthoracic biopsies) and assist in staging.

 Bronchoscopy: Useful in diagnosing and staging lung cancer as well as in diagnosing infections.

 Lung biopsy: Can lead to definitive diagnosis. A range of techniques can be used depending on the location of the tumor.



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