Lets start doing the CSA: Cough Productive of sputum

[Hanson]

Okay, lets start studying for the CSA. Lets do the common diseases first because common things occur commonly. How do you approach a patient with cough productive of yellowish sputum?

[Hanson]

Originally Posted by Hanson

Okay, lets start studying for the CSA. Lets do the common diseases first because common things occur commonly. How do you approach a patient with cough productive of yellowish sputum?

A typical scenerio for a patient with cough productive of yellowish sputum:

Ms. P. is a 38 year-old female. She comes in with a complain of cough productive of yellowish sputum. Her vitals are: RR=20 P=80 Temp=100.2 BP: 130/80

You have 15 minutes to do a complete H&P. You will have 10 minutes to write up your findings:

Here is how I would approach a patient with cough productive of yellowish sputum. I will divide it into four acts (just like a play).

Act I- Prelude to the Encounter:

The first thing I do is try to come up with 3 or 4 differential diagnosis. In this case 1. pneumonia, 2. Viral URTI, 3. Cancer 4. TB. I learn this technique from the OSCE book and I think it is excellent. Now with this in mind I can come in.

Act II- The Encounter

>> Knock knock knock--> this is a polite way to let the patient know that you are coming.

[Ms. P] Who's there?

[Me] This is Dr. Nguyen.

[Ms. P]Coming doctor.

[Me] Hello Ms. P, my name is Dr. Nguyen. It's a pleasure to meet you. I will clean my hands then I will talk to you okay Ms. P. (remember to ). If you have nice teeth open them up wide so Ms. P can see those teeth. She will have good impression of you. If your teeth is not so nice, try not to smile openly but smile gingerly. Also, try to use Crest and Listerine to freshen those breath. You don't want your patient to die on you. [I walk to the sink and clean my hands]. No cheating here. You really need to use soap to clean those hands. Standardized patients are trained to look to see if you are pretending to clean your hands.

While cleaning my hands, I want to fill up the dead air with not so serious conversation.

[Me]It's a nice day outside, Ms. P.
[Ms. P]Oh yeah. I know

Now I am done with my hand cleaning. There will be a stool for me to sit down.

Remember that I have come up with 4 differential diagnosis in Act I. The next step is to think of questions to ask for each of them. It is best to start up with an open ended question.

[Me] What bring you here Ms. P?

[Ms. P] Oh, I cough so much and I don't feel good.

[Me] Oh Ms. P. I am so sorry to hear that. I know it is terrible to cough like that. Ms. P. how long have you been coughing?

[Ms. P] For 2 days already

[Me] Did you cough up anything, for example blood.

[Ms. P]Yes, some yellowish phlegm. It looks nasty.

Now I will come up with questions for each of my broad differentials:

For Pneumonia:

I will ask:
1. Any fever?
-if yes: how did you take your temp and how high was your fever
-if no: continue on to the next question

2. Any chills?
- if yes: uhm, it must be very uncomfortable for you. I understand how it feels. (This is to show empathy--> good browny points)

3. Any sick contacts in the family?
- if yes: who and for how long had that person been sick?

4. Any pain when you cough?

5. Any shortness of breath?


For viral URTI. The questions are the same as pneumonia so you don't have to ask anything here.

For TB:

6. Do you excessively sweat at night?

7. Have you noticed any weight loss?

8. Have you ever been tested for TB?
- if yes: what was the results?

9. Have you travelled to a third world country?

For Cancer:

10. Do you smoke?
-if yes: how much do you smoke a day

11. Do you work in a shipyard or roofing company (looking for mesiothelioma).

12. Do you have contact with pigeons, chicken or other birds? (for hypersensitivity pneumonitis)

12. Any loss of apetite?

Once I have over 11 questions, I can feel comfortable. Now I will do Kaplan's PAM HUG FOSS mnemonic to cover my tail.

P- Do you have any PAST MEDICAL HISTORY of CA, Pneumonia, TB?
A- ALLERGY: Are you allergic to any medications or anything?
M- Are you taking any MEDICATIONS?

H- Do you have any history of HOSPITALIZATIONS?
U- URINARY SYMPTOMS: Do you have dysuria, hematuria, incontinence, or urgency?
G- GASTRO. Do you have black stool, red stool, nausea/vomiting, constipation or diarrhea.

F- FAMILY HISTORY: Any FH of CA, Heart Attack?
O- I forgot what this stands for.
S- Sexual history. Multiple partners? Do you use protection?
S- Social History- Do you drink? I already asked about smoking and occupation.

As you can see, the PAM HUG FOSS mnemonic gave you 9 additonal pieces of question. I would always use PAM HUG FOSS.

Okay, we need to do a physical exam. I think I will do it tomorrow? Feel free to ask Ms. P. some more questions.

[Hanson]

[Me] Okay Ms. P, next I would like to do a physical exam on you. I would like to drape you up for privacy, okay?
[Ms. P] Ok, whatever.
[Me] I draped her up to make her feel comfortable.

Okay here are the things I will check for:

I have to check her ENT to make sure she does not have pharyngeal exudates, bulging tympanic membrane, clotted up nose.

I have to feel her lymphnodes. Her occipital, post auricular, submandibular, sublingual, submantle nodes are all important. I also check for the left supraclavicular node or Virchow's node which indicates gastric metastasis. You can also feel some supraclavicular fullness in Pancoast's tumor.

For lungs:
1. percuss all lobes. As long as you go through the motion of tapping on her back, she won't know the differences between poking her with your fingers and actually percussing.
2. auscultate both sides of lung fields

Next I have to close the encounter:
Thank you Ms. P. for being so patient. The tentative diagnosis is that you most likely have viral infection since your physical exams are all normal. You don't smoke, you do not have family history of cancer, and you don't have risk factors for getting TB. So I am not worrying about you catching the nasty stuff. However, I need to order some tests. The vampire will come in and get some blood from you okay. Thank you.

Next, we will talk about how to write up the note.

[Hanson]

After 15 minutes you will have to leave the room and you will have 10 minutes to write your notes. The paper that you have to write on is the same as the one in your Candidate Orientation Manual that ECFMG sent to you. It is on page 15.

As you can see on that form, there is not much room to write. So it is highly recommended that you write in bullet style. You want to group all your perinent negatives and positives together. The form starts with a History part.


History - Include significant positives and negatives from history of present illness, past medical history, review of systems, social history and family history.

Ms. P is a 38 year-old WF with a complaint of cough productive of sputum for 2 days.

+ yellowish phlegm (-) fever, chills,
+ sore throat (-) pain on coughing
+ short of breath (-) night sweat
+ sick contact at home (2 year-old daughter with viral infection 3 days ago.
+ loss of appetite (-) weight loss
+ nausea (-) vomitting, diarrhea, constipation

PMH- no known allergy or asthma, no known CA, TB or pneumonia
FH- no family history of stroke or diabetes
SH- work as a bank teller. No EtOH/Cigarette/drugs, no risk factors for TB
Sexual History- not sexually active, use condoms


The next part is a physical exam:
HEENT- NCAT, no bulging tympanic membrane, no pharyngeal exudates, no foreign body in nasal septum, no cervical adenopathy.
CV- S1,S2 present; no S3/S4. RRR no M/G/R
Res- good air movement on inspiration and expiration. No wheezing rales or rhonchi.

The next part is Differential Diagnosis: you don't have to list all 5. Listing 4 is okay according to the manual.

DIFFERENTIAL DIAGNOSIS: DIAGNOSTIC WORKUP
1. Viral URTI 1. CBC with diff
2. Allergic rhinitis 2. CXR
3. Pneumonia 3. Na/K/Cl/CO2/Cr/BUN/Glucose
4. TB 4. Pulse Oximeter
5. lung CA 5. PPD placement

[FLK]

Originally Posted by Hanson

. How do you approach a patient with cough productive of yellowish sputum?

with caution, he might cough on you

sorry, couldn't resist

Something I remember from rotating through the UK...they are the kings of history:

INDIAN MINTS P

Infectious
Neoplasm
Degenerative
Iatrogenic
Autoimmune/Allergic
Nutrition

Metabolic
Iatrogenic
Neurogenic
Trauma
Syphilis

Pregnancy


Anyway, I used to run through this when I was a student and intern, each time I did a history and physical, just so I wouldn't forget something.

It's also a fun game to play.

Microcytic anemia...run through the list and come up with a cause for each

hypocalcemia

chest pain.


etc etc.

each sign or symptom, you run the list. it's a nice way to review.

[Hanson]

Thank you very much for replying! I was so lonely in this forum. Just me writing questions and answering to myself. Wow, somebody finally answered!

People please participate because it is very boring to talk to myself all the time.

Thank you very much!

[Doc]

Hanson, you might be talking to yourself, but alot of people are listening. This is great thing that you're doing with these cases and I think that it's helping alot of people. Does anyone else agree? Keep it up!

[FLK]

Originally Posted by Hanson

A typical scenerio for a patient with cough productive of yellowish sputum:

Ms. P. is a 38 year-old female. She comes in with a complain of cough productive of yellowish sputum. Her vitals are: RR=20 P=80 Temp=100.2 BP: 130/80

You have 15 minutes to do a complete H&P. You will have 10 minutes to write up your findings:

Is this how long they give you for the exam and write up?
25 minutes?
Wow!

I would imagine in your office where you have 8 patients scheduled per hour, you would see the last patient in your waiting room in about 3 weeks.

I am not poking fun, just trying to remember what it was like back in the day, when I was learning. It brings back a lot of good ( and bad ) memories going through your case, and looking at words like Pancoast tumor!

I will give you the 3 minute rushed managed care approach to this patient ( don't do this at home )

Why are you here today
I have a cough productive of yellow sputum ( only in fantasy exam land do patients give you this history) I have this cough.

How long have you had it.
3 days

Are you coughing up anything ?
Yes, gross yellow stuff.

any other symptoms?
Yes

what are they
I have a runny nose, a sore throat, and my legs hurt

any fever
yes.

how high
99

any other symptoms?
sometimes It hurts to swallow

are you taking any meds
tylenol cold and flu

any health problems
just my liver transplant last year

smoker
only when I drink

how often do you drink?
just happy hour

anybody sick at home
just my boyfriend: he has PCP pneumonia

exam:
HEENT: red throat, sans exudate.
sinus percussion: nontender
nodes: scattered nodes. nothing special
TM's Normal

lungs: clear
( not percussed......shame on me)

Well, everybody in town has a viral syndrome, and so do you.
Keep taking fluids and your tylenol. should resolve in a week.
return if you have difficulty breathing , chest pain, or worsening symptons.

Write up:
viral prodrome
3 days.
PMH: nil
PE: HEENT pharyngeal erythema. no exudate. no sinus tenderness
Lungs CTA
no murmur

A: Viral syndrome
P Fluids, OTC cold meds, return new Sx

I am making a few jokes, ( about the alhoholic liver transplant patient with the boyfriend with AIDS ) but it's just a funny reminder of the super duper detailed way we learn medicine, and then they cram an office full of patients and expect you to do a thorough job in 3 minutes ( and document everything of course, for billing )

[FLK]

Originally Posted by Hanson

+ yellowish phlegm (-) fever, chills,
+ sore throat (-) pain on coughing
+ short of breath (-) night sweat
+ sick contact at home (2 year-old daughter with viral infection 3 days ago.
+ loss of appetite (-) weight loss
+ nausea (-) vomitting, diarrhea, constipation


Res- good air movement on inspiration and expiration. No wheezing rales or rhonchi.

: DIAGNOSTIC WORKUP
1. Viral URTI 1. CBC with diff
2. Allergic rhinitis 2. CXR
3. Pneumonia 3. Na/K/Cl/CO2/Cr/BUN/Glucose
4. TB 4. Pulse Oximeter
5. lung CA 5. PPD placement

Why order all those tests?
Your patient has a viral syndrome, atypical pneumonia at worst.

Supportive care and at worst, a script for some zithromax.

The shortness of breath could be due to nasal congestion, fatigue or some adults have reactive airways ( asthma ) with atypical presentation ( cough variant asthma )


Now the questions:
CBC with diff: do you expect a left shift? No, because your patient isn't ill appearing. I can tell you what it is: WBC 8,000 with possibly a mild lymphocytosis. Can't justify the 100 bucks and the hour she'll have to wait at the lab...not to mention that you will haev to track that down, and then OF COURSE, the lab reports some spurious value ( thrombocytopenia ) that you are now forced to deal with.....you didn't even want a freaking platelet count, and now you have to deal with an abnormal one that is lab error.

CXR: your exam was normal. the history is not typical for chronic illness ( TB ) She has no risk factors for TB. History Exam does not favor bacterial pneumonia. Do a peak flow if you are worried about asthma ( due to shortness of breath )...can't justify the hour she'll spend in radiology, can't justify the 100 dollar radiology charge and the 100 dollar radiologist charge. Then the over cautious radiologist will call it " cannot R/O viral pneumonia" Clinical correlation recommended....thanks

Chem7: What are you looking for??????????


Pulse oximeter : OK, that's a good choice. can do it in the office, and it reassures your Clinical suspicion, not Discovers something.

PPD: well she doesn't have any risk factors, but if you want to place it as part of a general annual health exam thing, go ahead.
Now she'll haev to return in 72 hrs for a test she probably doesn't need, and take time off work, etc.
Bet she won't show up if it's negative, and you'll lose sleep wondering if she has TB.

All I am trying to do is to get you into the frame of mind that you ought to have your diagnosis with a good history and physical.
Remember, you will have to justify labs and tests you order to your examiner ( and later to your patients and their insurance companies! )

Order a test to CONFIRM what you already suspect ONLY if it will aid in your management ( or is necessary to document your treatment )
We live in a malpractice world, so for example, if you suspect that a petient has a viral pneumonia, you can use a normal WBC count and diff to justify NOT treating with antibiotics.

Don't order expensive tests if they are not going to change your plan of action.
Whatever you do, be prepared to justify it.

If I am your CSA examiner, I will commend you on your thorough presentation and differential. Remind you not to forget asthma, and ask you to justify the 500 dollars you spent on this patient's viral syndrome...and then I'll pass you.

good job

[Hanson]

Alright, I passed!!

Yes, I should not have forgotten asthma and peak flow.

Thank you Dr. FLK for the real world patient encounter.

Hanson