Post Long Case Exam (Int. Med)

My patient for the long case was an elderly Malay man in his 80's, having a massive right-sided pleural effusion (that's water in the lung) due to lung cancer. I had more than ample time to clerk him and perform a complete physical examination before Dr. J came in.

Dr. J seated me at the nurses counter and I started to present my history and clinical findings. I did ok I guess, although it was interrupted by phone calls for Dr. J. Clinical specialist mah! And here comes the first blunder of the day...

Dr. J: So what's your diagnosis?
Me: (damn confident) Lung cancer!
Dr. J: *frown* You can diagnose lung cancer clinically meh?
Me: ... ... ... (confidence decreasing at a rapid rate)
Dr. J: Ok, nemind, come let's examine the patient.

And then Dr. J greeted the patient and asked whether I had examine him justnow. And I proceeded to examine him. And here comes the second blunder/stupid mistake... I auscultated his chest before doing a percussion. I was silently hoping he didn't see that as he was busy flipping the case notes. Well... he did...

When I was done with my physical exam...
Dr. J: Shouldn't auscultation come after percussion?...
Me: (damn, he saw it...)
Dr. J: Ok, nemind, come...
We went back to the nurses' counter to look at some chest radiographs.


Dr. J: So tell me, what do you see on the chest x-rays?
Me: There's an air-fluid level on the right lung signifying a pleural effusion, and the left lung is hyperinflated.
Dr. J: Meniscus sign! Air-fluid level suggests lung abscess. What else do you see?
Me: Err... err... upper lobe diversions here and there, a patch of heterogenous opacification here, err... no cardiomegaly (dunno what else to say edy)...
Dr. J: Ya ok, why do you think the left lung is hyperinflated?
Me: It may be due to lung collapse due to pleural effusion (simply shoot).
Dr. J: You mean it's a compensatory hyperinflation (trying to help me with the answer he wants).
Me: Yes yes, compensatory...
Dr. J: If it's not compensatory, what else could it be due to, the hyperinflated left lung?
Me: COPD (chronic obstructive pulmonary disease) due to him being a chronic smoker?
Dr. J: Yeeeeessss... that's right... he smokes like nobody's business. Now tell me, what do you think has caused the pleural effusion?
Me: Lung cancer... lung carcinoma... (gulp!)
Dr. J: Can you be more specific on the lung cancer?
Me: Bronchogenic carcinoma (gulped again!).
Dr. J: Which type of lung cancer do you think he has?
Me: Small cell carcinoma, coz he presented acutely 2 months ago and has progressively worsen ever since.
Dr. J: But I thought his cough started last year?
Me: (Ugghh!) Ermm, in that case, I would say it's a non-small cell ca.
Dr. J: Yesssss... it's a non-small cell ca. What type of histology would you expect in the biopsy?
Me: Adenocarcinoma.
Dr. J: Why?
Me: Coz it's commoner in smokers.
Dr. J: Other than that?
Me: ... ...
Dr. J: Adenocarcinoma affects glands, and where are glands foung in the lung? In the alveoli. Right... and thus adenocarcinoma affects lung periphery. As opposed to squamous cell carcinoma. It affects bronchus more, thus more centrally located or known as bronchogenic carcinoma...
Me: (wah, he sibeh good! If I examiner I sure pass him.)
Dr. J: Ok, this patient has multiple admissions for the last 2 months for pleural effusion. What is your first line management?
Me: To drain his pleural fluid by doing a thoracocentesis.
Dr. J: Ok, if the patient kept coming back for the same problem, what's your long term management?
Me: Put an indwelling drainage tube...
Dr. J: You mean to put a chest tube lah...
Me: Yeh yeh, chest tube... chest tube...
Dr. J: Other than chest tube?
Me: .............................................
Dr. J: Have you heard of chemical pleurodesis?
Me: (Shake head...)
Dr. J: It is done to fuse the parietal and visceral pleura so that no fluid can accumulate inside the pleural space.
Dr. J: Ok, you did OK, although there's some blunders here and there.

This is how Dr. J looked like after taking me for my long case exam:

Sigh... "A" is out of question (Dr. J: muahaha! "A"? HAHAHA!). Hope the result won't turn out too bad... gotta buck up! Gambateh!!!

p/s: Read Dr. J's take on IMU exam bloopers here. Do read it! Got comment by Dr. LKY on ethical issues! Haha! On more IMU bloopers by Dr. J, click here and here.