? Pulmonary TB

71-year-old Chinese man presented with cough with white sputum for 6 months, lethargy and lost of appetite for 2 months, marked weight lost and generalized skin itchiness for a month. It was associated with gradual reduced in effort tolerance as he had shortness of breath with 100m walk. There was no fever, night sweat, chest or abdominal pain, jaundice, dark urine, pale stool or pruritus. Systemic review, past medical and family histories were not significant. He quit smoking for more than 30 years and drinks beer occasionally. Physical examination was not done.

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Below is his posterior-anterior view chest X-ray. Sorry for the bad quality. Just wondering if there is a cavitation on the left apex of the lung?

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Was bringing my grandfather to a nearby private clinic. Rather disappointed with the quality of the doctors nowadays. When I started telling my grandpa's history by mentioning cough, she scribbled "URTI" (upper respiratory tract infection) on the record card without waiting for me to finish. Well, she did ask further about the signs and symptoms of URTI and prescribed him antibiotic.

"He never had fever, why is antibiotic indicated?" I asked.

"So you wanna do a chest X-ray?" She replied.

I agreed and requested liver function test to be done. She did, but with a lot more tests such as renal profile, thyroid function test, lipid profile, blood glucose, Hepatitis and HIV screening. Some are totally not indicated but it came in a "package", and of course the consultation fee was sky high! I left with no choice but to agree as weekend is the only time when I am home and government clinics are closed. On top of that, my grandpa is a typical traditional Chinese old man who refused to be seen by doctor regardless of how sick he is. We could hardly drag him there what more to spend hours waiting in the government setting.

She ended up to still prescribe him amoxicillin, cough syrup, anti-histamine, folic acid and multivitamins. I seriously could not think of any reason why some of the medications were prescribed except to make more money. The only wise thing I did was to ask for a referral letter for hospital admission. And her referral letter was the worst one I'd ever read. It comprised only ~10% of what I have just mentioned! And she said if everything was done completely, the hospital doctor will not investigate further. Gosh! What a lame excuse!

Guys, it's time to raise the standard!

Hope my grandpa is willing to be admitted for investigation and further treatment. By the way, I suspected TB, but what explains the itchiness? What do you think?

Sorry to say that he did spit everywhere along the roadsides. If it is truly TB, the germs are in the air! :(