2ICS & PTB

1. What is the correct way to identify the second intercostal space? (Hint: sternal angle)

2. What are the criteria to diagnosis PTB (pulmonary tuberculosis)? (Hint: 2/3 criteria)

3. What is TB intensive and maintenance/continuation phase? (hint: type of medication and duration)

1. Second intercostal space:

• The angle of Louis / sternal angle is a useful place to start counting ribs, which helps localize a respiratory finding horizontally. If you find the sternal notch, walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge. This is the sternal angle. The 2nd rib is continuous with the sternal angle, slide your finger down to localize the 2nd intercostal space.
• The angle of Louis also marks the site of bifurcation of the trachea into the right and left main bronchi and corresponds with the upper border of the atria of the heart.

2. Diagnosis criteria of PTB (2/3):

1. Clinical picture of PTB: cough >2-3/52, fever, LOW, +/- hemoptysis
2. CXR signs of PTB: Upper lobes consolidation / cavitation
3. Sputum AFB (+): 3 x early morning sputum is collected on first day, subsequent 1 x early morning sputum for another 3/7.

However, before diagnosis can be put as PTB, we can consider whether to give anti-TB drugs after collecting the sputum. Signs that suggest PTB (but not enough to diagnose it):

• Clinical picture of PTB
• CXR signs of PTB
• FBC changes: ↑ Monocyte, ↑ Platete, ↑ ESR

If the above signs are fulfilled, it is highly suggestive for PTB, and anti-TB drugs can be given after sputum is collected. Remember to check for serum Na+ to exclude SIADH. 

3. TB treatment:

• Intensive phase of refer to the initial phase of TB treatment, 2/12 duration, on 4 anti-TB drugs. Aims: Eliminate clinical picture of TB, eliminate MTB in sputum, and prevent development of drug resistance.
  
  e.g. 2HRZE or 2HRZS
  
  
• Maintenance/continuation phase refer to the second phase of TB treatment, 4-7/12 duration, on 2 anti-TB drugs. Aims: Suppress MTB in host, and prevent relapse of TB.
  
  e.g. 4HR or 4(HR)3

--- UPDATE ---

 

Answers:

1. The sternal angle is between the manubrium and sternum. Once you identify the location by palpation, the left second rib is just beside it. Your finger moves along the second rib and move down below it. There the second intercostal space is localized. The importance of localization of second intercostal space is to do pleurocentesis, chest tube insertion and etc.

2. The criteria of PTB diagnosis:
a. Clinical symptoms
b. CXR findings
c. Sputum AFB(acid fast bacilli)

• Clinical symptoms: in your clerking, you must ask duration of cough, hemoptysis, evening rising temperature, night sweat, LOA/LOW (loss of appetite and loss of weight), h/o (history of) contact with PTB patients, h/o PTB in the past, risk factor (e.g DM, IVDU/Intravenous drug user, RVD+ve/retroviral disease +ve, so on). The symptoms must be more than 2 weeks duration.
  
• CXR findings: cavitation/haziness over upper zone/apical region of lung field.
  
• Sputum AFB: collection must be done x OD x 3/7

REMEMBER: to diagnose PTB, we need 2 out of 3 criteria.
TB is divided into PTB and EPTB (extrapulmonary PTB). PTB can be smear positive and smear negative.
Even sputum AFB is negative, with 2 other criteria, evidence is enough to label a patient with smear negative PTB. Smear positive PTB is PTB with sputum AFB +ve.
Note: sputum AFB is not sputum MTB.

3. TB intensive phase usually requires 2 months or 56 doses. The initial phase can be extended up to maximum, 84 doses, depending on the patient's condition. During this phase, the standard TB medication would be EHRZ / Ethambuthol + Isoniazid + Rifampicin + Pyrazinamide.
Then the latter phase would be continuation/maintenance phase. During this phase, the standard anti-TB medication would be H (Isoniazid) and R (Rifampicin). It is given at least 6 months.

You must know the common side effect of PTB medication.

• E - 15-25mg/kg/day; max 1200mg
  common SE- optic neuritis
  contraindicated for the patient with advanced age > 70 years old and age < 15 years old, poor vision, renal impairment.
  
• H - 5mg/kg/day; max 300mg
  common SE- liver impairment, skin rash.
  
• R - 10mg/kg/day; max 600mg
  common SE- liver impairment, acute renal failure, thrombocytopenia, drug-induced jaundice
  
• Z - 25mg/kg/day; max 1500mg
  common SE- liver impairment, hyperuricemia

S(Streptomycin)- used when it is indicated. Usually it is given for TAI (treatment after interruption), relapsed TB, reactivation of TB. Common SE- renal impairment, ototoxicity. It is contraindicated in age > 60 and in children, pregnancy.

Another way of TB prescription according to weight. It is used by chest physician in Kedah.

• S - Streptomycin
  0.75mg OD if BW > 30kg;
  0.5mg OD if BW < 30kg
  
• H - Isoniazid
  300mg OD
  
• R - Rifampicin
  600mg OD if BW > 50kg;
  450mg OD if BW 30-50kg and
  300mg OD if BW < 30kg
  
• Z - Pyrazinamide
  1500mg OD if BW >40-50kg;
  1250mg OD if BW 30-40kg and
  1000mg OD if BW < 30kg
  
• E - Ethambutol
  by practise 1400mg OD up to maximum 2600mg OD and we calculate 25mg/kg/day for E

TB medication is mainly prescribed by chest MO; however we need to know the usual dosage.

TB is the second main infectious disease after Dengue fever.

Additional Question:

What are signs of TB of CNS on neuroimaging? (There should be 5)

1. Tuberculoma: non-enhancing and enhancing.
2. Infarct: caused by vasculitis after being insulted by TB granulation tissue
3. Hydrocephalus: communicating and non-communicating
4. Meningeal enhancement, especially basal enhancement

Not sure about the last sign, but might be the following:

1. Cerebral abscess: rare complication
2. Cerebritis with enhancement at cerebral parenchyma
3. Granulation tissue in basal cistern, superficial sulcal spaces, Sylvian fissure
    → Isodense or mildly hyperdense exudate obliterates the basal cistern.
4. Cerebral oedema

Cardiomegaly, OHA, Hypoglycemia

1. What is the criteria to say a patient to have cardiomegaly based on CXR? (clue: cardiothoracic ratio)
2. If you are working in district hospital as a MO, would you give OHA to a pregnant woman? Why not?
3. A patient came to you with hypoglycemia. His DXT was 2.0mmol/L. For the past 5/7, he c/o (complaint of) dysuria and increased frequency of micturination, vomiting and low grade fever x 5/7. He noted his urine was cloudy. He claimed that daily he took 2 types of OHA - one was round-shaped,(roughly) 1cm sized white tablet and another one is small, oval shaped white tablet.
Q:
a. What would be your complete diagnosis then?
b. Let us guess what OHA he was taking, based on his description of the OHA tablets.
c. What would be your first step when the patient's DXT 2.0mmol/L and he is unconscious.

1. Cardiomegaly's criteria on CXR: When Cardiothoracic ratio > 0.5, i.e. the maximal transverse diametre of heart is >50% of the maximal transverse diametre of the thoracic cavity.

2. OHA shouldn't be given to pregnant woman as there are no data regarding safety of OHA usage in pregnant women. If the DXT is uncontrolled by diet and exercise then insulin is considered to control DM during pregnancy.

3. Hypoglycemia

a. Diagnosis: Hypoglycemic attack secondary to UTI. 

Although infection is the usually cause for hyperglycemia due to increased requirement of insulin, but infection can cause hypoglycemia by the following causes:

• Infection causes loss of appetite (LOA) and cause patient reduces food intake.
• Infection causes decrease of DXT by increased metabolism.

These result in relative insulin overdose if the patient still take the same dose of OHAs.

b. Possible OHA is metformin and glicazide or glibenclamide, as these drugs are white tablets, available in either round or oval shape, and the combination of metformin + sulfonylurea is a common treatment.

c. Immediate action to restore back the DXT to normal is needed. Dextrose 50% 25-50ml IV till recovering of consciousness, followed by D5 infusion or glucose drink PO. If IV access not possible, can consider glucagon 1mg IM / SC. 

--- UPDATE ---

 

Answer.

1. Cardiothoracic ratio will determine whether a patient to have cardiomegaly. Normal CTR should be less than 0.5. In the CXR, we take the length of heart and length of whole thorax in longitudinal direction. Then we divide the cardiac length with thoracic one. If the value exceeds 0.5, then it is cardiomegaly. Do remember that we can only measure CTR from CXR in PA erect. CXR in supine PA or AP can give you wrong view of heart position.

2. OHA is recommended for pregnant women. Firstly blood sugar must be controlled well during pregnancy to prevent hyperglycemic complications. (You shall find out about it-> polyamnio, congenital defects, macrosomia, post-partum fetal hypoglycemia etc. You also must know how post-delivery fetal hypoglycemia can develop and how to prevent it post-partumly.) Secondly, OHA may have teratogenic effect but it is not completely proven.

3. (hint: DXT means dextrostick. )

a. Diagnosis would be Hypoglycemic attack secondary to UTI(urinary tract infection).

b. White rough big tablet is metformin; usually small round tablet is gliclazide. Sometimes, gliclazide is small oval-shaped. Most of the time, glibenclamide is small oval shaped. All of them are white in colour.

c. If a patient develops hypoglycemic attack and is unconscious, we must give intravenous(IV) bolus Dextrose 50%(D50%) 50cc. IV D50% is given till the patient regains consciousness. Then we must maintain the blood sugar level with IV drip D10%/D5% (depending on the DXT). IM glucagon can be given if there is no IV access.

(You shall find out what is neuroglucopenia)

Cavity, OHA, Metformin

1. If you see a cavity in the CXR, what are the differential diagnosis? Please list out at least 5 diff diagnosis.

2. What does "OHA" mean? (clue: OHA is a short-formed.)

3. What is Metformin and its maximum dosage?

Differential diagnosis for cavity on CXR:

1. Primary lung cancer
2. Pulmonary tuberculosis (PTB)
3. Abscess formation in pneumonia
4. Lung infarction due to pulmonary embolism
5. Fungal disease: e.g. Aspergillosis
6. Lung cyst

OHA = Oral Hypoglycemic Agent, drug for type 2 diabetes mellitus.

Metformin is an biguanide OHA, maximum dose is 1g per dose 8 hourly. 

--- UPDATE ---

The answer would be:

1. Cavity in the CXR:

- Bronchial CA(carcinoma); most likely SCC (squamous cell carcinoma- one type of non small cell CA)

(Extra: Lung CA is divided into small cell CA and non-small cell CA; non small cell CA is further subdivided into 3 types-> SCC, adenocarcinoma and undifferentiated lung CA)

- Lung abscess

- Pneumonia caused by microorganisms mainly of Klebsiella pneumonia and Staphylococcus aerus.

- Fungal lung disease, eg aspergilloma

- PTB (pulmonary tuberculosis)

- Wegener's granulomatosis

2. OHA is oral hypoglycemic agent

3. Metformin is biguanide for DM type II.
Maximum dosage would 1g tds(8 hourly)

- Contraindicated in liver and kidney impairment and congestive heart failure(CCF), lactic acidosis.

- Usually in practise, if creatine reaches 150 mcgmol/L, then it must be discontinued. 

- Usage starting dosage would be 250mg BD up to 1g tds

Meniscus Sign & Fluid in Abdomen

Note: This post is in respond to some questions that someone asked me.

1. What is meniscus sign and its importance?

2. How to do fluid thrill, shifting dullness, splashing sound?

Regarding the first question, meniscus sign. It can refer to 2 things, which I don't know which one is your specialist referred to.

Firstly, it can be referring to the curve that we saw on CXR of a patient with pleural effusion.

• In initial phase of pleural effusion we can only see blunting of the costo-pleural angles.
• In later phase we can see the fluid increase, but the fluid level is not flat, but a upward concave curve, which raise up at the lateral of the chest wall
• In severe pleural effusion we see the whole lung field become white.
• So regarding why is it important. My surgery teacher like to emphasized the shape of the fluid level.
• If curve (meniscus sign), this is a pleural effusion, i.e. only fluid in pleural cavity.
• If flat fluid level, this is a pyopneumothorax, i.e. there are both fluid and air in the pleural cavity, hence different management.

Secondly, it can also refer to the crescent moon-shaped air space in the cavity, which is partial filled by something.

• E.g. in mycetoma, aspergillosis of lung.
• Try imagine a round spherical cavity, and a ball of smaller diameter is place in that cavity.
• The remaining air space in that cavity will appear like a crescent moon on CXR. Hence also known as crescent sign.

Second question is regarding the physical examination of fluid in the peritoneal cavity.

• In Russia the therapy teacher taught a different way of examine, but same principle.
• The principle is that the ascitic fluid will move around (shifting) when the patient change position.
• Imagine turning around a bottle which is half-filled with water.
• So in Russia, what the teacher does is when patient lies down supine on the bed, she percuss the abdomen from top to bottom to find the fluid level.
• Then she ask the patient to change position, either sits up, or lies on the side. Then she do the same thing again to find the fluid level.
• If the fluid level (or the position of the dullness caused by the fluid) is different, it means there is fluid in peritoneal cavity.

So the same principle apply for shifting dullness, only different method.

• Patient is lying supine on the bed, examiner do percussion from the top, or the umbilicus, down to the one side, e.g. down to the right side, to find the fluid level (the place when the percussion note change from resonant to dull).
• Without removing the middle finger of your left hand away from the abdomen, ask the patient to turn to the opposite side, which is the left side.
• Then percuss at the finger which you didn't remove just now, if the percussion note is resonant instead of dull, there is presence of shifting dullness, i.e. the dullness of the fluid has shifted to other place because the patient change position. And this indicate the presence of ascitic fluid in the abdomen.
• However shifting dullness can only be elicit when the fluid is not to much.
• If there is too much fluid, the dullness caused by the fluid is still at the same place.
• Imagine again, turning around two bottles, one is half-filled with water, and the other one is completely filled with water.

So in order to check for the presence of massive ascitic fluid, the fluid thrill is done.

• Ask an assistant or the patient himself to put the edge of the hand in the midline of the abdomen (like a karate person chopping wood with his hand).
• Put both hands on the the lateral sides of the abdomen, one on left, one on right.
• One of the hand, e.g. left hand lightly tap or press on the side of the abdomen (another method is to use middle finger to flick on the side of the abdomen).
• If the right hand on the opposite side of the abdomen can feel the vibration (the thrill from the fluid), this indicate the presence of abundant fluid in the abdominal cavity.
• The principle is that as you tab / press / flick the abdomen, the fluid vibrates, and the vibration travels to the opposite side.
• However fluid thrill cannot only be elicit when the fluid is too little, because large amount of fluid is needed to cause the vibration or thrill.
• By the way, the hand in the midline is used to prevent the vibration of the skin of abdomen to travel to the opposite side.

Source: http://www.profizham.medicineukm.com/

I am not quite sure about splashing sound. But I remember in Russia got learn something like this.

• Left hand fix at the xiphoid, right hand with 4 flexed fingers palpate the epigastrium, and try to hear for splashing sound.
• Splashing sound (succussion) is a sign that presence in patient with pyloric stenosis.
• But I don't know is this what the specialist wants.
• In the internet I found a different method. "Succusion splash is a splashing heard when rocking a patient with a fluid collection in the pleural space, abdominal cavity, stomach or elsewhere."

*  *  *

For more information about physical examination, you can refer this site:
http://www.profizham.medicineukm.com/shortcase.html

http://cme-vsmu.blogspot.com/

Recommended books for physical examinations:

• Clinical Examination, a systematic guide to physical diagnosis by Talley & Connor
• X'press Revision in Short Case by Chew Nee Kong, published by Universiti Malaya

These 2 books can get from Kamal bookstore.

• The Medical Short Case: An Examination Guide published by Penang Medical Practitioners' Society
• Pacing the PACES by Eow Gaik Bee

These 2 books are not available at Kamal, but can get from Penang hospital, or you can order online through this site below
http://internalmedicinemrcp.blogspot.com/2011/07/mrcp-paces-reader.html

I hope these information can help you.

Last but least, remember what the Lord says,

He said to me, "My grace is sufficient for you, 

for my power is made perfect in weakness."
Therefore I will boast all the more gladly about my weaknesses, 

so that Christ's power may rest on me.
That is why, for Christ's sake, I delight in weaknesses, 

in insults, in hardships, in persecutions, in difficulties.
For when I am weak, then I am strong. 

2 Corinthians 12:9-10

曾经擦肩而过的人

一个不打不相识，
好学但怪癖，
聪明但暴力，
性趋向不明，
很明显不信主的人。

一个曾经同房，
勤奋但好玩，
节俭但狂野，
有远见但爱流浪，
曾经但不再寻求主的人。

一个在天海之间遇见，
被抛弃而迷失，
寻求但不肯委托，
能自立但选择依赖，
好像但却没有也不想信主的人。

一个雪中送炭，
有借有还，
不寻求但询问，
好学但方式不对，
宁愿信偶像也不信主的人。

....

...

..

.

一次是不成熟，
一次是错觉，
一次是错误，
一次是试探。

____________________

这本是火焚烧，直到毁灭，

必拔除我所有的家产。

約伯記 31:12

For it is a fire that consumeth to destruction,

and would root out all mine increase.

Job 31:12 KJV