Addis Ababa University

Faculty of Medicine

Department of Internal Medicine

Internal Medicine Case Report I

Name: AelafAseged
ID: MDR/9030/02

Submitted to: Dr:abdirashid

Date of submission:March 23, 2012

Tikur Anbessa Hospital Hospital No.

Addis Ababa

Name: Abe Ahmed Age: 49 Sex: M Occupation: prime mister Religion: muslim

Address: TekleHimanot W.5 K.42 H.No. 13Date of Admission: Yekatit 29 2004 Ethnicity: Oromo

Department: Internal Medicine Ward: B-8 Bed No:814.5 Marital Status: Married

Date of Clerking: Megabit 04 2004 Historian: The Patient

Previous Admission

Non

Chief Complaint

Chest Pain and Cough, 4 months

History of Present Illness

The patient was relatively healthy 4 months ago at which time he started to experience cough and chest
pain. The cough was dry and started insidiously. He coughed day and night but more at night. It was
exacerbated by deep breathing. The chest pain started at the same time and it was intermittent, stabbing
and involving the whole area of the chest alternatively. It was aggravated by coughing and deep breathing
while lying on the left side relieved the symptom.

After one month of frequent coughing and chest pain the patient decided to visit a local health center.
There he had a chest x-ray. The result is not available but based on the x-ray and the clinical symptoms the
patient was diagnosed for TB and started on anti-TB medication.

After few days of taking his medication he started experiencing loss of appetite, nausea and vomiting
induced by the smell of food. The cough didn’t disappear but was reduced and accompanied by gradual
increase in production of sputum.The sputum was light brown, didn’t give any odor and wasn’t mingled
with blood .The volume in a sever day was approximately 2 Arabic coffee cups per 24 hours. Gradually he
started losing weight, felt weak and easily tired. His stool production was decreased while his urine output
volume didn’t change. He stopped working few days after because of the fatigue but the patient didn’t stop
taking is anti-TB medication.

Three days before present admission the fatigue became severe enough resulting in inability to do minor
exercises such as sitting up on the bed. He also started to experience shortness of breathat rest which
occurred suddenlyand accompanied bylow grade fever which was worst at night. Due to these symptoms,
he went to ‘rasdesta’ hospital. There he had a chest x-ray, blood and sputum examination the result of
which he doesn’t know but was told he had a sever lung problem and was immediately referred to Black
Lion hospital.

The patient has previous history of recurrent tonsillitis, and mild cough which is relieved by taking
amoxcaciline. He had no night sweats, no chills, no headache, no sore throat, no hemoptysis, orthopnea,
paroxysmal nocturnal dyspnea or leg swelling. No history of smoking or asthma. The patient claims to have
been tested and was found negative for RVI investigation.

In the total 4 months he gradually lost an approximated 15kg. There was no apparent color change noted
by the patient. He came here driven by a car and was carried to his bed since he was too tired to walk.

Past Illnesses

No chicken pox, mumps, small pox or any other childhood diseases.

Functional Inquiry

H.E.E.N.T

Head: No headache or trauma

Ears:No loss of hearing, discharge, earache, vertigo or tinnitus

Eyes: Good vision, no pain, strain, lacrimation, photophobia or itching

Nose: No epistaxis or discharge

Mouse and throat:Poor oral hygiene but no dental pain or bleeding from the gums. Intact tonsils.

Glands:No enlarged lymph node or thyroid gland. No heat or cold intolerance. Both testicles are
descended.

Respiratory System:SEE HPI and Chief Complaint

Cardiovascular system: No hypertension, swelling of feet, syncope or palpitation.

Gastrointestinal system:SEE HPI.No abdominal pain, jaundice or melena.

Genitourinary system: No flank pain, dysuria, urgency, hesitancy, dribbling or pyuria.

Integumentary system: Moist skin, no rashes or ulcers, no changes in hair distribution or pigmentation.

Allergy: No asthma, drug sensitivity, or food allergy.

Locomotory system: No bony deformities, no joint pain but there’s weakness inall the extremities.

Central nervous system: Good memory. No seizures, nervous breakdown or insomnia.

Personal History

Early development: He was born in saqeyogebremahber, dawawereda, shewakiflehager where he lived till
the age of 17. Then he moved to Jimma and stayed there for six years before coming to Addis Ababa. He
spent a healthy childhood.

Education:He has received primary education up to the eighth grade.

Habits: He confesses of drinking 2 glasses of beer every day after work, but denies of any tobacco or chat
use.

Marital Status: He is married and has three sons. All are healthy and living well. His sons have moved out
and are supporting themselves.

Family History

Father and mother:Both his parents are dead. His mom died of a chronic heart problem in her late fifties.
He doesn’t know how his father died.

Siblings: He has three sisters. All are living well.

Family Diseases: There is no family history of tuberculosis, allergy, diabetes mellitus, hypertension, or
sudden deaths.

Physical Examination
General Appearance

The patient appears to be weak and moderately malnourished.He was lying on his left side and was unable
to sit on his bed by himself. He coughed frequently and expectorated light brown sputum.

Vital signs

BP:120/70mmHg, right arm, supinePulse:132/min., regular RR:45/minT0:36.30c, axillary

Weight: 50Kg
 H.E.E.N.T

Head: Normal size, shape and hair distribution, No scar.

Ears: Normal contour of pinna.Clear external ear canal. Good and equal hearing

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. The conjunctiva is
pink. The sclera is not icteric.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge

Mouse and throat:The lips show no fissure, ulceration or herpes. The gums areintact and show no
ulceration but there few carious teeth. The tongue is pink with adherent whitepatches(which can be
scraped off) and reddish spots on the dorsal surface. The tonsils are intact.

Respiratory System

Inspection: There is no cyanosis butthere is clubbing of the fingers and the palms are pale. Breathing is
shallow and is of higher rate. The chest is symmetrical. No deformities, scars, visible pulsations or
dilated vessels.

Palpation: The trachea is central. The total circumferential chest expansion is 1.5 cm along the nipple line
on deep inspiration. Tactile fremitus is normal on the right side but slightly decreased on the left.
Chest expansion is symmetrical.

Percussion:There is dullness in entire left side of the anterior chest but the right side is normal.
Diaphragmatic excursion is 2.5 cm.

Auscultation: Breath sounds are decreased on the left side but are normal on the right. Posteriorly
bronchial sound is heard over the left side but the right side is normal.

Lymphatic and glandular system

No enlarged or tender lymph nodes. The thyroid is not enlarged. No tremor or lid lag.
 Cardiovascular system

Arteries: BP and pulse (see under vital signs). The pulse volume is normal, the rhythm is regular and there
was no abnormal character or unusual condition of vessel wall. Pulse volume can be tabulated as follow:

Carotid Axillary Brachial Radial Femoral popliteal PT DP

Right ++ ++ ++ ++ ++ +++ +++ +++
Left ++ ++ ++ ++ ++ +++ +++ +++

No radio-femoral delay detected.

Veins: There are no distended veins over the neck, chest wall, or leg.

The JVP was not assessed because the bed couldn’t be inclined but the JVP wasn’t visible in the
supine position.

No hepato-jugular reflex.

Precordium

Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse is visible at the fifth intercostal space along the mid clavicular line.

Palpation: The point of maximum impulse is felt where it is visible. There is also no parasternal or apical
heave. There is also no thrill.

Auscultation: The heart sounds are normal over the valvular areas. There is no gallop or murmur.

Gastrointestinal system

Inspection: The abdomen is scaphoid, symmetrical and moves with respiration.There is no flank fullness.
There are no dilated veins, scars or masses. The umbilicus is inverted. Hernia sites are free. No visible
pulsation or peristalsis.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or liver
areas.

Palpation:
  Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was also
no tenderness upon such palpation.
 Deeppalpation: There was no tenderness. The liver was not palpable below the right costal margin.
The spleen was also not palpable.

Percussion: No shifting dullness or fluid thrill. No flank dullness. The total vertical span of the liver along the
right mid-clavicular line is 11 cm.

Integumentary System

The skin is warm with no rash or ulcers. There is normal hair distribution. The nails don’t show spooning but
clubbing (grade II) is present.

Locomotory System

There’s no muscle or bone tenderness. The joints are normal and there’s no bony deformity. But there is
muscles wasting.

Nervous system

Mental Status: The patient is conscious, oriented in person, place and time. He doesn’t show any signs of
depression. His memory status is good.

Cranial Nerves:

N-I: smells alcohol via each nostril.

N-II: Normal visual acuity, good visual fields and color appreciation

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are round,
regular in outline and equal in size.

N-V:He responds to light touch and temperature over the face. Contraction of the temporal and masseter
muscles is normal.

N-VII: The face is symmetrical at rest and during voluntary movements. He can close both eyes equally and
forcefully.
N-VIII: He hears rubbing of the fingers on both ears.

N-IX & X:The soft palate rises in the midline when saying ‘ah!’

N-XI:The SCM and trapezius muscles contract on turning the head and on shrugging the shoulder against
resistance, respectively.

N-XII:The tongue protrudes in the midline and shows no tremor or atrophy.

Motor:

 Musclebulk: There is no muscle bulk difference but is reduced on both sides. There is also no
spontaneous as well as induced fasciculation.
 Muscle toneis normal while thepoweris reduced in the lower extremities.

Sensory:

 Sensation of light touch over the extremities and trunk is intact.

Reflexes:

 Superficial reflexes: All the plantar, abdominal, & corneal reflexes are intact.
 Deep tendon reflexes:

Biceps Triceps Supinators Patellar Ankle

Right + + + ++ ++
Left + + + ++ ++

 Clonus: No clonus
Summary of problems

 Subjective summary:
o Cough (initial nonproductive but later productive lacking blood)
o Chest pain
o Loss of appetite and vomiting
o Low Grade Fever
o Shortness of breath
o Weight loss
o Easy fatigability
 Objective summary:
o Tachycardia
o Tachypnea
o Shallow breathing
o Decreased Chest expansion
o Decreased tactile fremitus, dullness and reduced breath sounds on the left side of the
anterior chest
o Bronchial sound heard on the entire left side of the posterior chest
o Malnourished and wasted
o Palmar pallor
o Clubbing
o White patches on the tongue

Differential diagnosis
 Pulmonary Tuberculosis (MDR)
 Pneumonia (Community Acquired)
 Bronchiectasis
 Chronic bronchitis
 Lung Cancer

Discussion of the differential diagnosis

 Lung cancer. Dyspnea, cough, anorexia,fatigue, weight loss, chest pain, fever and clubbing are
suggestive of carcinoma of the lung. On the other hand lack of hemoptysis, anemia and
lymphadenopathy are not supportive of lung carcinoma.
Even though the patient is above 60, he has no history of smoking but many of the sign and
symptoms don’t allow the exclusion of the diagnosis readily.

 Bronchitis (chronic).Productive chronic Cough, Tachypnea and clubbing are suggestive of chronic
bronchitis but absence of prolonged expiration, useof accessory muscle, cyanosis, barrel chest or
lack of history of smoking aren’t supportive of chronic bronchitis.

The physical examination didn’t reveal any ronchi or wheezing which are very common in a patient
suffering from chronic bronchitis. The fever, tachycardia and weight lossare also not features of
uncomplicated chronic bronchitis.

 Bronchiectasis. The chronic cough with sputum production, anorexia, weight loss, fever, fatigue
and finger clubbing are suggestive of bronchiectasis. But absence history of pneumonia,ronchi,
crackles, wheezing or hemoptysis doesn’t support it.

 Pneumonia (Community Acquired). The chest pain which is aggravated by deep inspiration,
tachypnea, tachycardia, fever, productive cough, fatigue, anorexia and abrupt onset of dyspnea are
suggestive of pneumonia but lack of shaking chills doesn’t support pneumonia.

Even though the symptoms started 4 months back the acute onset of SOB and fever is suggestive of
pneumonia.

Pleural effusion is one of the complications of pneumonia and dullness on percussion, decreased
tactile fremitus, and breath sound on the left chest suggest pleural effusion.

 Pulmonary Tuberculosis (MDR). The chest pain, cough, anorexia, easy fatigability, weight loss,
dullness on percussion and decreased breath sounds of the left chest are suggestive of TB. But
decreased tactile fremitus, lack of hemoptysis, night sweats and fine crackles don’t support it.

The fact that he was being treated for TB for three months and showed only a slight decrease in the
chest pain and cough could also be used as support for MDR TB.
Final diagnosis
MDR TB with acute onset of community acquired pneumonia

Diagnostic Workup
 Complete Blood Count
 Chest X-Ray
 Acid Fast stains from the sputum
 Gram stains from the sputum
 Pulmonary function test
 Lung Biopsy