Tuberculosis Case History Format

1. Identification Data

• Name:
• Age / Sex:
• Address:
• Occupation:
• Date of admission:
• Date of examination:
• Informant and reliability:

2. Chief Complaints

• Cough with expectoration for 1 month
• Fever, mainly evening rise, for 3 weeks
• Loss of weight and appetite for 1 month
• Night sweats for 2 weeks
• Hemoptysis, if present, with duration and approximate quantity

3. History of Present Illness

• Onset, duration, progressive/static
• Dry or productive
• Quantity, color, odor of sputum
• Any blood in sputum
• Relation to posture, exertion, day or night

• Duration and pattern: low-grade, intermittent, evening rise
• Chills, rigors, sweating
• Response to antipyretics

• Loss of appetite
• Weight loss
• Fatigue, weakness
• Night sweats

• Breathlessness
• Chest pain, especially pleuritic pain
• Wheeze
• Hoarseness of voice

• Headache, vomiting, altered sensorium, seizures: CNS TB
• Neck swelling: tuberculous lymphadenitis
• Back pain or deformity: spinal TB
• Abdominal pain, distension, altered bowel habits: abdominal TB
• Joint pain/swelling
• Dysuria, hematuria, infertility: genitourinary TB

• No previous similar illness or anti-tubercular treatment, if applicable
• No known diabetes, HIV infection, chronic kidney or liver disease
• No history suggestive of malignancy or another chronic lung disease

4. History of Contact

• Contact with a known TB patient, especially at home
• Duration and closeness of contact
• History of cough among family members
• Overcrowding, poor ventilation
• Recent travel, hostel/prison/shelter residence
• Exposure to silica dust, mining, healthcare work

5. Past History

• Previous TB or anti-tubercular treatment
• Previous treatment completion, interruptions, or treatment failure
• Diabetes mellitus
• HIV status or recurrent infections
• Chronic liver disease, renal disease
• Previous hospitalizations or blood transfusions
• Any prior chest radiograph or sputum test results

6. Drug, Allergy, and Personal History

• Current medications, especially immunosuppressants or steroids
• Drug allergy
• Smoking: pack-years
• Alcohol use
• Injection drug use
• Nutrition and dietary history
• Bowel and bladder habits
• Sleep disturbance due to cough or fever

7. Family History

• Similar symptoms or diagnosed TB in household contacts
• Diabetes, HIV, or chronic respiratory disease in family members

8. Socioeconomic History

• Housing, ventilation, crowding
• Occupation and dust exposure
• Financial barriers to nutrition or treatment adherence
• Availability of family support and access to a TB program

Examination

General Physical Examination

• General condition, consciousness, nutritional status
• Temperature, pulse, blood pressure, respiratory rate, oxygen saturation
• Pallor, icterus, cyanosis, clubbing
• Lymphadenopathy, especially cervical and supraclavicular nodes
• Pedal edema
• Weight, height, BMI

Respiratory System Examination

• Chest shape, symmetry, movement
• Supraclavicular hollowing, intercostal retractions
• Prominent veins or scars

• Tracheal position
• Chest expansion
• Tactile vocal fremitus

• Dullness over consolidation, effusion, or collapse
• Hyperresonance if pneumothorax

• Bronchial breath sounds
• Crackles, especially upper-zone crepitations
• Increased vocal resonance
• Amphoric breath sounds or cavernous breathing in cavitary disease
• Pleural rub if pleurisy

Systemic Examination

• CNS: signs of meningitis or focal deficit
• Abdomen: hepatosplenomegaly, ascites, abdominal mass
• Spine and joints: tenderness, deformity, restricted movement
• Genitourinary examination if symptoms indicate

Investigations

1. Sputum examination
   • Acid-fast bacilli smear microscopy
   • Nucleic acid amplification test, such as Xpert MTB/RIF or another WHO-recommended rapid molecular test
   • Mycobacterial culture and drug-susceptibility testing when indicated
2. Chest radiograph
   • Upper-lobe infiltrates or cavities are typical of reactivation TB.
   • Primary disease can show consolidation and lymphadenopathy.
   • A normal chest radiograph does not exclude TB, particularly in people with HIV. Textbook of Family Medicine, 9e, p. 298.
3. Baseline tests before treatment
   • Complete blood count
   • ESR or CRP
   • Liver and renal function tests
   • HIV test, with consent and counseling
   • Blood glucose
   • Pregnancy test where relevant
   • Visual acuity and color vision assessment if ethambutol is planned
4. If extrapulmonary TB is suspected
   • FNAC/biopsy of lymph node
   • Pleural fluid analysis and biopsy
   • CSF examination and neuroimaging
   • Ultrasound or CT abdomen
   • MRI spine
   • Site-specific biopsy for histology, AFB testing, molecular testing, culture, and drug susceptibility

Example Case Summary

Important Clinical Notes

• A positive tuberculin skin test or interferon-gamma release assay supports TB infection but does not diagnose active TB by itself.
• Assess for drug resistance, HIV, diabetes, liver disease, pregnancy, and prior TB treatment before finalizing therapy.
• Suspected infectious pulmonary TB needs prompt infection-control measures and notification/referral according to local public-health requirements.
• Treatment regimen and duration must follow the current national TB program or specialist advice, especially for rifampicin-resistant or multidrug-resistant TB.

Treatment of Tuberculosis

1. Drug-susceptible pulmonary TB

Standard 6-month regimen

• Intensive phase, first 2 months:
  H + R + Z + E
  Isoniazid + Rifampicin + Pyrazinamide + Ethambutol
• Continuation phase, next 4 months:
  H + R
  Isoniazid + Rifampicin

2. Alternative shorter regimen

• Rifapentine
• Isoniazid
• Pyrazinamide
• Moxifloxacin

3. Pyridoxine supplementation

• Malnourished
• Pregnant or breastfeeding
• Diabetic
• Living with HIV
• Alcohol-dependent
• Having renal failure
• At risk of peripheral neuropathy

4. Monitoring during treatment

• Fever, cough, hemoptysis, appetite, weight, and adherence
• Adverse drug effects
• Sputum smear/culture or molecular follow-up according to local protocol
• Drug-susceptibility results
• HIV status and diabetes control

5. Infection control and supportive care

• Advise cough etiquette, good ventilation, and mask use while infectious.
• Evaluate household and close contacts for TB disease and TB infection.
• Notify and coordinate treatment with the local tuberculosis program.
• Provide nutrition support, smoking cessation, and management of diabetes, HIV, or other comorbidities.
• A patient with smear-positive pulmonary TB is generally much less infectious after effective therapy, but isolation decisions should follow local public-health guidance and clinical response. Textbook of Family Medicine, 9e, p. 298.

6. Drug-resistant TB

• Do not continue a routine first-line regimen without expert review.
• Obtain full drug-susceptibility testing.
• Refer to a TB specialist/national drug-resistant TB program.
• Use an all-oral, WHO-recommended regimen selected according to resistance pattern, previous drugs, disease severity, and drug availability.

7. Latent TB infection

• 3 months once-weekly isoniazid plus rifapentine
• 3 months daily isoniazid plus rifampicin
• 4 months daily rifampicin
• 6 to 9 months isoniazid when shorter regimens are unsuitable

Case-sheet treatment plan wording

Tuberculosis Treatment: Viva Questions and Answers

1. What is the standard treatment for new drug-susceptible pulmonary TB?

• Intensive phase, 2 months: H + R + Z + E
  Isoniazid, Rifampicin, Pyrazinamide, Ethambutol
• Continuation phase, 4 months: H + R
  Isoniazid and Rifampicin

2. Expand HRZE.

• H: Isoniazid
• R: Rifampicin
• Z: Pyrazinamide
• E: Ethambutol

3. Why are four drugs used initially?

• Rapidly reduce bacillary load
• Prevent emergence of drug resistance
• Cover possible initial resistance until drug-susceptibility results are available
• Treat bacilli in different metabolic states and sites

4. What is the usual adult daily dose?

• Isoniazid: 5 mg/kg, maximum 300 mg/day
• Rifampicin: 10 mg/kg, maximum 600 mg/day
• Pyrazinamide: 20-25 mg/kg/day
• Ethambutol: 15-20 mg/kg/day

5. Why is pyridoxine given with isoniazid?

6. What are the important adverse effects of first-line anti-TB drugs?

7. Which drug causes orange discoloration of urine?

8. Which anti-TB drug causes peripheral neuropathy?

9. Which anti-TB drug causes optic neuritis?

10. Which anti-TB drug causes hyperuricemia?

11. Which drugs are hepatotoxic?

12. How do you monitor a patient on treatment?

• Clinical improvement: fever, cough, appetite, weight
• Treatment adherence
• Sputum follow-up as per national protocol
• Drug-susceptibility results
• Adverse effects, especially hepatitis, neuropathy, and visual symptoms
• Liver function tests when indicated
• HIV testing and blood glucose assessment
• Contact tracing and screening of household members

13. What is DOT?

14. What is MDR-TB?

• Isoniazid, and
• Rifampicin

15. What is rifampicin-resistant TB?

16. What should be done if rifampicin resistance is detected?

• Obtain complete drug-susceptibility testing.
• Refer to a TB specialist or drug-resistant TB program.
• Use an individualized WHO/national-program recommended all-oral regimen.
• Do not manage it with the routine 6-month first-line regimen alone.

17. Is steroid therapy used in TB?

• Tuberculous meningitis
• Tuberculous pericarditis

18. How is extrapulmonary TB treated?

• TB meningitis
• Bone and joint TB
• Spinal TB

19. How is latent TB different from active TB?

• Latent TB infection: Patient has TB infection but no symptoms, no infectivity, and no evidence of active disease.
• Active TB disease: Symptomatic or clinically/radiologically/microbiologically evident disease that needs multidrug treatment.

20. One-line viva answer

Tuberculosis Investigations: Viva Questions and Answers

1. What are the investigations for suspected pulmonary TB?

1. Sputum examination
   • AFB smear microscopy
   • Rapid molecular test, for example Xpert MTB/RIF or Xpert Ultra
   • Mycobacterial culture
   • Drug-susceptibility testing
2. Chest X-ray
3. Baseline blood investigations
   • CBC
   • ESR/CRP
   • Liver function tests
   • Renal function tests
   • Blood glucose
   • HIV test after consent
   • Pregnancy test where applicable
4. Tests for extrapulmonary TB, based on site involved:
   • FNAC/biopsy
   • Pleural fluid examination
   • CSF analysis
   • USG/CT/MRI as appropriate

2. What is the most important initial test?

3. What does Xpert MTB/RIF detect?

• DNA of Mycobacterium tuberculosis complex
• Mutations associated with rifampicin resistance

4. What is the role of sputum AFB smear microscopy?

• Cheap, quick, widely available
• Helps assess infectiousness

• Less sensitive than molecular tests and culture
• Cannot reliably distinguish TB from nontuberculous mycobacteria
• Does not provide complete drug-susceptibility information

5. What stain is used for AFB?

• Ziehl-Neelsen stain
• Auramine-rhodamine fluorescent stain may also be used

6. Why are mycobacteria called acid-fast?

7. What is the gold-standard test for TB diagnosis?

8. What are the culture methods?

• Solid culture: Lowenstein-Jensen medium
• Liquid culture: MGIT system

9. How many sputum samples should be sent?

10. What if the patient cannot produce sputum?

• Induced sputum
• Bronchoscopy with bronchoalveolar lavage, if needed
• Gastric aspirate in children
• Test a sample from the involved extrapulmonary site, such as lymph-node aspirate, pleural fluid, CSF, or tissue biopsy

11. What are the chest X-ray findings in pulmonary TB?

• Upper-lobe infiltrates
• Cavitary lesions, especially in reactivation TB
• Fibrosis and volume loss
• Hilar/mediastinal lymphadenopathy, more common in primary TB
• Miliary nodules in disseminated TB
• Pleural effusion

12. Can a normal chest X-ray exclude TB?

13. What is the role of CT chest?

• Small cavities
• Tree-in-bud nodules
• Mediastinal lymph nodes
• Miliary disease
• Complications such as bronchiectasis or pleural disease

14. What is the role of ESR?

15. What is the role of Mantoux test?

• TB infection
• Past TB
• BCG vaccination
• Exposure to nontuberculous mycobacteria

16. What is IGRA?

• QuantiFERON-TB Gold
• T-SPOT.TB

17. What is CBNAAT?

18. What baseline tests are done before anti-TB treatment?

• Weight for weight-band drug dosing
• CBC
• Liver and renal function tests when indicated
• Blood glucose
• HIV test
• Pregnancy test if relevant
• Visual acuity and red-green color vision testing before ethambutol
• Hepatitis evaluation when indicated

19. What is drug-susceptibility testing?

20. One-line viva answer

COPD Case History Format

1. Identification Data

• Name:
• Age/Sex:
• Address:
• Occupation:
• Date of admission/examination:
• Informant and reliability:

2. Chief Complaints

• Breathlessness for 5 years, progressive for 6 months
• Cough with expectoration for 4 years
• Increased breathlessness, cough, and purulent sputum for 3 days

3. History of Present Illness

A. Breathlessness

• Onset and duration
• Gradual or sudden onset
• Progressive or episodic
• Present at rest or only on exertion
• Severity according to activity:
  • Walking fast
  • Walking on level ground
  • Climbing stairs
  • Bathing/dressing
  • At rest
• Orthopnea or paroxysmal nocturnal dyspnea, to consider cardiac disease
• Relief with rest, inhalers, or nebulization

B. Cough

• Duration: chronic cough is common
• Dry or productive
• Worse in morning, night, winter, or exposure to smoke/dust
• Relation to exertion or posture
• Hemoptysis: if present, evaluate for infection, bronchiectasis, tuberculosis, or malignancy

C. Sputum

• Quantity: scanty/moderate/copious
• Character: mucoid, mucopurulent, purulent
• Change in color or amount
• Foul smell
• Blood-streaked sputum

D. Wheeze and Chest Tightness

• Intermittent or persistent
• Nocturnal/early-morning variation
• Triggered by smoke, dust, cold air, infection, or exercise
• Marked variation may suggest asthma or asthma-COPD overlap

E. Symptoms of Acute Exacerbation

• Increased dyspnea
• Increased cough
• Increased sputum quantity
• Change to yellow/green or purulent sputum
• Fever, sore throat, coryza
• Reduced exercise tolerance, confusion, drowsiness, or cyanosis

4. Risk-Factor History

Smoking

• Cigarette/bidi/hookah smoking
• Number smoked per day
• Duration in years
• Pack-years = packs per day × years smoked
• Current smoker, ex-smoker, or passive smoking exposure
• Prior quit attempts

Environmental and Occupational Exposure

• Biomass-fuel smoke: wood, dung, crop residue, charcoal
• Indoor cooking without ventilation
• Dust, chemical fumes, paint, textile, mining, construction, welding, or factory exposure
• Outdoor air pollution

Other Risk Factors

• Childhood recurrent chest infections
• Prematurity or poor lung development
• Family history of emphysema/COPD
• Young age with emphysema: consider alpha-1 antitrypsin deficiency

5. Past History

• Previous similar episodes/exacerbations
• Number of exacerbations in the past year
• Emergency visits, hospitalization, ICU stay, intubation, or NIV use
• Previous diagnosis of asthma, TB, bronchiectasis, pneumonia, or heart failure
• Previous spirometry and chest X-ray reports
• Home oxygen use or long-term inhaler use
• Diabetes, hypertension, ischemic heart disease, arrhythmia
• Gastroesophageal reflux disease
• Anxiety, depression, osteoporosis
• TB contact/history and anti-tubercular treatment

6. Treatment History

• Previous or current inhalers and technique of use
• Short-acting bronchodilator use and frequency
• LABA/LAMA/inhaled corticosteroid use
• Nebulization, oral steroids, antibiotics
• Compliance and affordability
• Vaccination history:
  • Influenza
  • Pneumococcal
  • COVID-19
  • RSV vaccine where eligible

7. Personal History

• Smoking and alcohol history
• Appetite and weight loss
• Sleep disturbance
• Bowel and bladder habits
• Functional limitation:
  • Ability to walk, climb stairs, work, bathe, dress, and sleep
• Nutritional status

8. Family History

• COPD, asthma, emphysema
• Smoking exposure at home
• Alpha-1 antitrypsin deficiency or unexplained early lung disease

General Physical Examination

• Respiratory rate and pattern
• Pulse, blood pressure, temperature, SpO₂
• Cyanosis
• Use of accessory muscles
• Pursed-lip breathing
• Tripod position
• Cachexia or low BMI
• Pedal edema, raised JVP, hepatomegaly suggesting cor pulmonale
• Clubbing: not typical of COPD. If present, look for lung cancer, bronchiectasis, interstitial lung disease, or another diagnosis. Goldman-Cecil Medicine, Clinical Manifestations.

Respiratory System Examination

Inspection

• Barrel-shaped chest
• Reduced bilateral chest movement
• Prolonged expiration
• Intercostal indrawing in severe exacerbation
• Accessory-muscle use
• Pursed-lip breathing

Palpation

• Reduced chest expansion bilaterally
• Decreased tactile vocal fremitus
• Trachea usually central

Percussion

• Hyperresonant note
• Reduced cardiac and liver dullness
• Reduced diaphragmatic excursion

Auscultation

• Diminished vesicular breath sounds
• Prolonged expiratory phase
• Expiratory wheeze/rhonchi
• Occasional crackles
• Distant heart sounds in hyperinflation

Systemic Examination

• Cardiovascular: cor pulmonale, right-heart failure, ischemic heart disease, arrhythmia
• Abdomen: tender hepatomegaly, ascites due to right-heart failure
• CNS: confusion/drowsiness in carbon-dioxide retention
• Lower limbs: pedal edema, signs of DVT

Case Summary Example

One-Line Viva Answer

COPD Treatment for Viva

1. What are the goals of COPD treatment?

• Relieve symptoms and improve exercise tolerance
• Prevent exacerbations and hospitalizations
• Improve quality of life
• Slow further lung-function loss by stopping smoking/exposure
• Treat hypoxemia, respiratory failure, and comorbidities

A. Stable COPD

2. What is the most important non-drug treatment?

• Avoid biomass smoke, dust, and occupational fumes
• Vaccination: influenza, pneumococcal, COVID-19, and RSV where eligible
• Pulmonary rehabilitation
• Exercise, nutritional advice, and inhaler-technique education

3. What are the main drugs used in COPD?

4. What is the rescue inhaler?

5. What is the preferred maintenance treatment?

• LABA or LAMA
• If symptoms persist: LABA + LAMA

6. When is inhaled corticosteroid added?

• Recurrent moderate/severe exacerbations despite dual bronchodilators
• Elevated blood eosinophil count
• Coexisting asthma

7. What is pulmonary rehabilitation?

• Supervised exercise training
• Breathing techniques
• Education and self-management
• Nutritional and psychosocial support

8. When is long-term oxygen therapy indicated?

• PaO₂ ≤55 mmHg or SaO₂ ≤88%, or
• PaO₂ 55-60 mmHg with pulmonary hypertension, cor pulmonale, or secondary polycythemia

9. What advanced options may be considered?

• Lung-volume reduction surgery or bronchoscopic lung-volume reduction
• Bullectomy for giant bullae
• Lung transplantation in carefully selected end-stage disease

B. Acute Exacerbation of COPD

10. Define acute exacerbation of COPD.

• Increased breathlessness
• Increased cough
• Increased sputum volume
• Purulent sputum
• Wheeze or chest tightness

11. How do you manage an acute exacerbation?

12. What bronchodilators are used in an exacerbation?

• Nebulized or inhaled salbutamol
• With or without ipratropium

13. What is the role of oxygen?

14. What steroid is given in an exacerbation?

• Prednisolone 40 mg orally once daily for 5 days, if no contraindication

15. When are antibiotics indicated?

• Increased sputum purulence with increased sputum volume and/or increased dyspnea
• Severe exacerbation requiring ventilation
• Clinical/radiological suspicion of bacterial pneumonia

16. When is NIV indicated?

• Respiratory acidosis on ABG
• Severe dyspnea with increased work of breathing
• Persistent hypoxemia or hypercapnia despite initial therapy

17. When is invasive ventilation required?

• Respiratory arrest
• Failure or contraindication to NIV
• Worsening acidosis or hypoxemia
• Reduced consciousness/inability to protect airway
• Hemodynamic instability

18. Are methylxanthines routinely used?

Short Viva Summary

Pneumonia Case History Format

1. Identification Data

• Name:
• Age/Sex:
• Address:
• Occupation:
• Date of admission/examination:
• Informant and reliability:

2. Chief Complaints

• Fever for 5 days
• Cough with expectoration for 5 days
• Breathlessness for 2 days
• Right-sided chest pain for 2 days

3. History of Present Illness

A. Fever

• Onset and duration
• High-grade or low-grade
• Continuous, intermittent, or remittent
• Chills and rigor
• Sweating
• Response to antipyretics
• Headache, myalgia, malaise, or confusion

B. Cough

• Onset and duration
• Dry or productive
• Frequency, especially nocturnal cough
• Blood-streaked sputum or frank hemoptysis
• Relation to posture or exertion

C. Sputum

• Quantity
• Color: mucoid, yellow, green, rusty, blood-stained
• Purulent or foul-smelling sputum
• Difficulty in expectoration

D. Breathlessness

• Onset: acute or gradual
• At rest or on exertion
• Progression
• Ability to walk, talk, eat, and sleep
• Wheeze, cyanosis, confusion, or drowsiness
• Orthopnea or paroxysmal nocturnal dyspnea, to exclude heart failure

E. Chest Pain

• Site, severity, radiation
• Pleuritic nature: increases on coughing or deep inspiration
• Associated breathlessness or hemoptysis

F. Other Symptoms

• Chills/rigors
• Sore throat, rhinorrhea, recent flu-like illness
• Nausea, vomiting, diarrhea
• Altered sensorium, especially in elderly patients
• Weight loss, night sweats, prolonged cough: consider tuberculosis or malignancy

4. History Suggesting Severity

• Breathlessness at rest
• Respiratory distress or inability to speak full sentences
• Cyanosis
• Confusion, drowsiness, reduced urine output
• Hypotension, dizziness, syncope
• Poor oral intake or repeated vomiting
• Recent hospitalization or ICU admission

5. Risk-Factor History

• Age over 65 years
• Smoking, alcohol use
• COPD, asthma, bronchiectasis, interstitial lung disease
• Diabetes mellitus, chronic kidney disease, liver disease, heart failure
• HIV, steroid therapy, chemotherapy, transplant, other immunosuppression
• Recent influenza or viral respiratory infection
• Poor dental hygiene or aspiration risk
• Stroke, seizures, reduced consciousness, dysphagia, vomiting
• Recent hospitalization, antibiotic use, intubation, or mechanical ventilation
• Exposure to TB, COVID-19, sick contacts, animals/birds, travel

6. Past History

• Previous pneumonia, TB, COPD, asthma, bronchiectasis
• Prior hospital or ICU admission
• Previous intubation or NIV
• Recurrent respiratory infections
• Diabetes, hypertension, ischemic heart disease, heart failure
• Immunocompromised state
• Previous chest X-ray abnormalities
• Drug allergy, especially beta-lactam allergy

7. Treatment History

• Antibiotics already taken and duration
• Antipyretics, cough syrups, inhalers, nebulization
• Response to treatment
• History of recent antibiotics or hospitalization, which may affect antibiotic selection
• Vaccination status:
  • Influenza
  • Pneumococcal
  • COVID-19

8. Personal and Family History

• Smoking and alcohol
• Appetite, sleep, bowel and bladder habits
• Occupational exposure to dust, fumes, animals, or birds
• Recent travel and sick contacts
• TB in household or close contact
• Family history of asthma, TB, or chronic lung disease

Examination

General Physical Examination

• Temperature
• Pulse rate, blood pressure
• Respiratory rate
• Oxygen saturation by pulse oximetry
• Pallor, icterus, cyanosis, clubbing
• Hydration status
• Level of consciousness
• Cervical lymphadenopathy
• Signs of sepsis or shock

Respiratory System Examination

Inspection

• Tachypnea
• Reduced movement of affected side
• Use of accessory muscles
• Intercostal retractions
• Cyanosis in severe disease

Palpation

• Reduced chest expansion on affected side
• Increased tactile vocal fremitus over consolidation
• Tracheal deviation if large pleural effusion, collapse, or pneumothorax is present

Percussion

• Dull note over consolidation
• Stony dullness suggests pleural effusion

Auscultation

• Bronchial breath sounds
• Crepitations/crackles
• Increased vocal resonance
• Whispering pectoriloquy
• Egophony

Systemic Examination

• Cardiovascular: shock, heart failure, arrhythmia
• CNS: confusion, meningism, focal deficits
• Abdomen: hepatosplenomegaly, abdominal source of sepsis
• Lower limbs: edema, DVT signs, which may suggest pulmonary embolism

Case Summary Example

Important Differentials

• Acute exacerbation of COPD with lower respiratory infection
• Pulmonary tuberculosis
• Acute bronchitis
• Viral pneumonia, including influenza or COVID-19
• Aspiration pneumonia
• Pulmonary embolism
• Acute left ventricular failure
• Lung malignancy with post-obstructive pneumonia

One-Line Viva Answer

Pneumonia Treatment for Viva

1. One-line answer

2. Initial Management

• Assess airway, breathing, circulation, mental status, and sepsis.
• Record respiratory rate, blood pressure, pulse, temperature, and SpO₂.
• Give oxygen if hypoxemic.
• Obtain chest imaging and relevant samples before antibiotics if this does not delay treatment in a seriously ill patient.
• Assess severity using CURB-65 or another validated severity tool.

CURB-65

• Confusion
• Urea >7 mmol/L
• Respiratory rate ≥30/min
• Blood pressure: systolic <90 mmHg or diastolic ≤60 mmHg
• Age ≥65 years

3. Supportive Treatment

• Oxygen for hypoxemia, with target SpO₂ usually 94%-98%.
• In patients at risk of hypercapnic respiratory failure, such as severe COPD, use controlled oxygen with a target usually 88%-92% pending arterial blood gas results.
• IV or oral fluids as needed, while avoiding fluid overload.
• Antipyretics, for example paracetamol, for fever/pain.
• Adequate hydration and nutrition.
• Bronchodilator if wheeze or associated COPD/asthma is present.
• DVT prophylaxis for admitted patients with reduced mobility.

4. Antibiotic Treatment of Community-Acquired Pneumonia

A. Outpatient, non-severe CAP

• Amoxicillin as first-line therapy
• Doxycycline if suitable
• A macrolide, such as azithromycin, only where pneumococcal macrolide resistance is low and according to local policy

B. Inpatient, non-severe CAP

• A beta-lactam, such as ceftriaxone or ampicillin-sulbactam, plus azithromycin

• A respiratory fluoroquinolone where appropriate, considering adverse-effect risks and antimicrobial stewardship.

C. Severe CAP or ICU admission

• IV beta-lactam, such as ceftriaxone, cefotaxime, or ampicillin-sulbactam
  plus
• Azithromycin or a respiratory fluoroquinolone

5. What is the usual duration of antibiotics?

6. When are corticosteroids used?

7. When is ICU care required?

• Need for invasive mechanical ventilation
• Septic shock requiring vasopressors
• Severe hypoxemia or worsening respiratory failure
• Persistent hypotension
• Altered consciousness
• Multilobar involvement with rapid clinical deterioration

8. What are the complications to look for?

• Sepsis and septic shock
• Acute hypoxemic respiratory failure or ARDS
• Parapneumonic pleural effusion
• Empyema
• Lung abscess
• Acute kidney injury
• Decompensation of heart failure or COPD

9. Aspiration Pneumonia

• Oxygen and supportive treatment
• Assessing swallowing and aspiration risk
• Treating the precipitating cause
• Antibiotics when bacterial aspiration pneumonia is likely

10. Prevention

• Influenza, pneumococcal, and COVID-19 vaccination where eligible
• Smoking cessation
• Good oral hygiene
• Aspiration-risk assessment in stroke, dysphagia, or impaired consciousness
• Optimize chronic diseases such as COPD, diabetes, and heart failure

Short Viva Summary

Pleural Effusion Long Case

1. Identification Data

• Name:
• Age/Sex:
• Address:
• Occupation:
• Date of admission:
• Date of examination:
• Informant and reliability:

2. Chief Complaints

• Breathlessness for 1 month
• Dry cough for 1 month
• Right-sided chest pain for 10 days
• Fever and loss of weight for 1 month

3. History of Present Illness

A. Breathlessness

• Onset, duration, and progression
• Exertional or at rest
• Grading by mMRC scale or daily activity limitation
• Orthopnea and paroxysmal nocturnal dyspnea, suggesting heart failure
• Sudden onset pleuritic pain or hemoptysis, suggesting pulmonary embolism
• Relief after sitting up or after previous pleural-fluid aspiration

B. Cough

• Dry or productive
• Duration and severity
• Nature and quantity of sputum
• Hemoptysis
• Chronic cough with weight loss, fever, or night sweats, suggesting tuberculosis or malignancy

C. Chest Pain

• Site and radiation
• Pleuritic pain: worsens with deep inspiration or cough
• Sudden severe pain: consider pulmonary embolism, pneumothorax, or cardiac cause

D. Fever and Constitutional Symptoms

• Fever pattern, chills, rigors
• Night sweats
• Loss of appetite and weight
• Fatigue
• These raise suspicion for tuberculosis, pneumonia, empyema, or malignancy.

E. Symptoms of the Underlying Cause

• Orthopnea, PND
• Pedal edema
• Palpitations
• Reduced exercise tolerance

• Abdominal distension
• Jaundice
• Hematemesis/melena
• Pedal edema
• Alcohol use

• Facial puffiness
• Frothy urine
• Reduced urine output
• Generalized edema

• Marked weight loss, anorexia
• Hemoptysis
• Hoarseness of voice
• Bone pain
• Breast lump in females
• Smoking history

• Evening fever
• Night sweats
• Chronic cough
• Loss of weight/appetite
• TB contact or previous TB treatment

• Sudden dyspnea
• Pleuritic chest pain
• Hemoptysis
• Unilateral leg swelling
• Recent surgery, immobility, malignancy, pregnancy, or previous DVT/PE

4. Past History

• Previous pleural effusion, tuberculosis, pneumonia, or empyema
• Previous anti-tubercular treatment
• Heart failure, ischemic heart disease, hypertension, valvular heart disease
• Chronic liver disease, hepatitis, cirrhosis
• Chronic kidney disease or nephrotic syndrome
• Rheumatoid arthritis, SLE, pancreatitis
• Malignancy and previous chemotherapy/radiotherapy
• Recent hospitalization, surgery, central venous catheterization, trauma
• Prior thoracentesis, chest-tube drainage, or pleurodesis

5. Personal History

• Smoking: pack-years
• Alcohol intake
• Appetite and weight loss
• Bowel and bladder habits
• Exposure to TB contacts
• Occupation: asbestos, mining, construction, chemical or dust exposure
• Travel, immobilization, and recent surgery
• Drug history: amiodarone, methotrexate, nitrofurantoin, and other relevant medicines

6. Family History

• Tuberculosis contact
• Malignancy
• Chronic cardiac, renal, hepatic, or autoimmune disease

7. General Physical Examination

• Fever, tachycardia, tachypnea, hypotension
• SpO₂ on room air
• Pallor, icterus, cyanosis, clubbing
• Lymphadenopathy, especially cervical/supraclavicular nodes
• Cachexia or weight loss
• Pedal edema
• Raised JVP
• Signs of chronic liver disease: spider angioma, ascites, gynecomastia
• Signs of renal disease: facial puffiness, edema
• Signs of malignancy: breast lump, hepatomegaly, hard lymph nodes

8. Respiratory System Examination

Inspection

• Affected side may appear fuller
• Reduced movement of the affected hemithorax
• Intercostal fullness or widened intercostal spaces in a massive effusion
• Tracheal deviation to the opposite side in massive effusion
• Tachypnea and use of accessory muscles in severe breathlessness

Palpation

• Reduced chest expansion on affected side
• Reduced tactile vocal fremitus
• Trachea:
  • Deviated to opposite side in massive effusion
  • Central in moderate effusion
  • Deviated toward affected side if associated with lung collapse/fibrosis

Percussion

• Stony dull note over the effusion
• Upper border may be curved upward laterally, called the Ellis-Damoiseau line
• Traube's space may be dull in left-sided pleural effusion

Auscultation

• Markedly reduced or absent breath sounds over the effusion
• Reduced vocal resonance
• Bronchial breathing and egophony may be heard just above the upper level of fluid due to compressed lung
• Pleural rub may be heard early in pleurisy, before a large effusion develops

9. Other Systemic Examination

Cardiovascular system

• Raised JVP
• Displaced apex beat
• Murmurs, especially mitral stenosis
• Features of heart failure

Abdomen

• Hepatomegaly
• Ascites
• Splenomegaly
• Abdominal mass
• Signs of chronic liver disease

Central nervous system

• Confusion due to hypoxemia/sepsis
• Neurological deficits or reduced consciousness that increase aspiration risk

Lower limbs

• Pedal edema
• Unilateral calf swelling or tenderness suggesting DVT

10. Clinical Diagnosis

Example

11. Differential Diagnosis

• Pleural thickening
• Massive lung consolidation
• Lung collapse
• Elevated hemidiaphragm
• Subphrenic abscess
• Large intrathoracic mass

12. Investigations

A. Basic Investigations

• Complete blood count
• ESR and CRP
• Renal function test, liver function test
• Blood glucose
• Serum protein, albumin, and LDH
• ECG
• HIV test where indicated
• NT-proBNP if heart failure is suspected

B. Imaging

1. Chest X-ray PA view
   • Blunting of costophrenic angle
   • Meniscus sign
   • Homogeneous lower-zone opacity
   • Mediastinal shift in massive effusion
2. Ultrasound chest
   • Confirms fluid
   • Detects septations/loculations
   • Guides safe thoracentesis
3. CT chest with contrast
   • Pleural thickening or nodularity
   • Lung mass
   • Mediastinal lymph nodes
   • Pulmonary embolism or loculated effusion

C. Diagnostic Thoracentesis

• Appearance
• Cell count and differential
• Protein and LDH, with simultaneous serum protein and LDH
• Glucose
• pH, especially if infection is suspected
• Gram stain and bacterial culture
• AFB smear, TB culture, NAAT where available
• Adenosine deaminase, particularly in a high-TB prevalence setting
• Cytology for malignancy
• Triglyceride if chylothorax is suspected
• Amylase if pancreatitis or esophageal rupture is suspected

13. Light's Criteria

1. Pleural-fluid protein / serum protein ratio >0.5
2. Pleural-fluid LDH / serum LDH ratio >0.6
3. Pleural-fluid LDH > two-thirds the upper limit of normal serum LDH

14. Pleural Fluid Clues for Viva

15. Management Outline

If heart-failure-related

• Salt restriction
• Diuretics
• Optimize heart-failure treatment
• Therapeutic thoracentesis if large and causing significant dyspnea

If tuberculous pleural effusion

• Confirm as far as possible with fluid tests or pleural biopsy
• Start anti-tubercular therapy according to national guidelines
• Therapeutic aspiration if breathlessness is significant

If parapneumonic effusion/empyema

• Appropriate antibiotics
• Pleural-fluid pH, glucose, Gram stain, and culture
• Intercostal chest drain if pus, positive Gram stain/culture, loculation, or complicated effusion

If malignant pleural effusion

• Therapeutic aspiration for symptom relief
• Pleurodesis or indwelling pleural catheter according to lung expansion, prognosis, and patient preference
• Treat underlying malignancy where appropriate

If massive symptomatic effusion

• Controlled therapeutic thoracentesis
• Avoid overly rapid large-volume drainage because of risk of re-expansion pulmonary edema. Tintinalli's Emergency Medicine, p. 473.

16. Sample Long-Case Presentation

Treatment of Polyarthritis in Medicine

One-line viva answer

1. Initial Management

• Rest during acute severe inflammation, followed by graded physiotherapy and range-of-motion exercises.
• Local ice or heat depending on comfort.
• Paracetamol for pain.
• NSAIDs for pain and inflammation if no renal disease, peptic-ulcer disease, heart failure, or bleeding risk.
• Gastroprotection, such as a proton-pump inhibitor, when NSAIDs are indicated in high-risk patients.
• Assess and manage disability, nutrition, mood, and occupational limitations.

Do not give steroids or immunosuppressive drugs until septic arthritis is reasonably excluded, especially if there is fever, a very painful hot joint, immunosuppression, or acute onset.

2. Treatment According to Cause

Rheumatoid Arthritis Treatment

A. Disease-modifying treatment

First-line

• Methotrexate: anchor DMARD, generally given once weekly
• Add folic acid to reduce adverse effects

If methotrexate is contraindicated or not tolerated

• Leflunomide
• Sulfasalazine
• Hydroxychloroquine

B. Glucocorticoids

• Short-term low-dose oral glucocorticoid or intra-articular steroid may be used as a bridge while DMARDs begin to work.
• Use the lowest effective dose for the shortest possible period.
• Avoid prolonged steroids because of diabetes, osteoporosis, infection, cataract, hypertension, and adrenal suppression.

C. If disease remains active

• Combination conventional DMARDs
• Biologic DMARDs, for example TNF inhibitors, abatacept, tocilizumab, rituximab
• Targeted synthetic DMARDs, such as JAK inhibitors

D. Treat-to-target principle

Important Monitoring for RA Treatment

Important Viva Point: Septic Arthritis

• Fever
• Acute, severe painful swollen joint(s)
• Marked restriction of movement
• High inflammatory markers
• Immunosuppression or prosthetic joint

Short Viva Summary

CPR: Cardiopulmonary Resuscitation

Adult Basic Life Support: Steps

1. Ensure safety

2. Check responsiveness

• Tap the shoulders and shout: “Are you okay?”
• If unresponsive, call for help.

3. Activate emergency response and get AED

• Call local emergency services.
• Send someone to bring an AED and emergency trolley, if available.

4. Check breathing and pulse

• Check breathing and carotid pulse simultaneously for no more than 10 seconds.
• If there is no normal breathing, or only gasping, and no definite pulse, start CPR.
• If you are a lay rescuer and unsure about pulse, start chest compressions.

5. Start chest compressions: C-A-B

Correct compression technique

• Place the heel of one hand on the center of the chest, on the lower half of sternum.
• Place the other hand over it, fingers interlocked.
• Keep arms straight and shoulders vertically above hands.
• Compress hard and fast.

6. Open airway

7. Give rescue breaths

• Give 2 breaths, each over 1 second.
• Look for visible chest rise.
• Avoid excessive ventilation.

8. Attach and use AED as soon as available

• Turn AED on and follow voice prompts.
• Attach pads to the bare chest.
• Stop touching the patient during rhythm analysis and shock delivery.
• If shock advised, give one shock and immediately resume CPR for 2 minutes.
• Do not check pulse immediately after a shock unless there are obvious signs of return of circulation.

Adult Advanced Life Support: Viva Points

Shockable rhythms

• Ventricular fibrillation, VF
• Pulseless ventricular tachycardia, pVT

Management

1. CPR
2. Defibrillation as early as possible
3. Resume CPR immediately for 2 minutes after shock
4. Obtain IV/IO access
5. Adrenaline 1 mg IV/IO every 3-5 minutes
6. Amiodarone 300 mg IV/IO after refractory VF/pVT, typically after the third shock, with further dosing as per protocol
7. Treat reversible causes

Non-shockable rhythms

• Asystole
• Pulseless electrical activity, PEA

Management

1. High-quality CPR
2. Adrenaline 1 mg IV/IO as soon as possible, repeated every 3-5 minutes
3. Search for and correct reversible causes
4. Defibrillation is not indicated unless the rhythm becomes VF/pVT.

Reversible Causes: 4 Hs and 4 Ts

Signs of Return of Spontaneous Circulation (ROSC)

• Palpable pulse
• Rise in blood pressure
• Improvement in skin color
• Spontaneous breathing or movement
• Sudden rise in end-tidal CO₂, if monitored

• Maintain airway and oxygenation
• Avoid hyperoxia, titrate oxygen appropriately
• Obtain ECG
• Treat hypotension and underlying cause
• Check glucose, temperature, electrolytes, and consider urgent coronary reperfusion when indicated

Important Viva Questions

What is the most important component of CPR?

What is hands-only CPR?

When should CPR be stopped?

• ROSC occurs
• Trained team takes over
• Rescuer is exhausted or unsafe
• A valid do-not-resuscitate decision applies
• Death is clearly irreversible, depending on local protocol

What is the difference between cardiac arrest and heart attack?

• Cardiac arrest: heart stops pumping effectively, causing collapse, absent pulse, and absent normal breathing.
• Heart attack: myocardial infarction due to reduced coronary blood flow. It may lead to cardiac arrest but is not the same thing.

One-line viva answer