Case Write Up Internal Medicine (Pulmonary Tuberculosis)

Patient Details

Name : Zakaria bin Abdullah

Age : 52 years old

Gender : Male

Race : Malay

Religion : Muslim

Address : Setapak, Kuala Lumpur

Date of clerking : 22/01/2018

Date of admission : 21/01/2018

Chief Complaint

Patient came to the hospital due to chest pain past 1 months

History of Presenting Illness

Patient is not known of any medical illness and never admitted to ward before. Prior to admission the illness started with fever for 1 month. It started gradually at night while the patient was resting and intermittent in nature. The fever was high grade but patient denies of having chills, rigor or sweating. It was associated with malaise and was not relieved by the use of Paracetamol.

Then, patient started having chest pain suddenly about one hour after having the fever. The pain was localized at the left axillary area. It was sharp in nature and initially lasted for about 10 minutes. It occurred about twice a day at random times with severity of 4 from 10. After about two weeks, it progressively worse to a peak prior to admission with a frequency of at least 5 times a day, lasting about 10 minutes each for each episode at random times of the day with a severity of 8. There was no radiation of pain. The pain was relieved by the use of illicit drugs such as morphine and there are no exacerbating factors. It is associated with weight loss of 7kg (61 to 54kg) in the last two months. There was no cough, dyspnea, hemoptysis, sputum production, leg swelling, decreased exercise tolerance, night sweats, orthopnea and PND.

Past Medical History

The patient was not a known case of any medical condition prior to this episode.

No previous history of any hospitalization before this.

Past Surgical History

Patient has not undergone any surgery before.

Past Medication History

The patient was not on any known medication.

There was no prescribed, over-the-counter and traditional medication used.

Allergy History

The patient is allergic to seafood and suffers from red rashes all over the body upon consumption. Otherwise the patient is not known to be allergic to any other food or medication.

Family History

  

His father was passed away at the age of 50 due to suicide with no known underlying medical illness.

His mother was divorced and left the family when he was still young.

His four siblings aged 55, 54, 53 and lastly 50 respectively.

His elder brother passed away at the age of 53 last year in 2016 due to complications related to AIDS.

Otherwise, there were no history of similar medical problems, malignancy or congenital defects in the family.

Social History

Patient is a chronic smoker started at the age of 17 with 3 packs of cigarettes a day.

He is an illicit drug user which was methamphetamine, marijuana and currently on morphine.

He denies of any use of intravenous drug use.

Otherwise the patient claimed to not have consume alcohol, maintain a strict diet nor exercise regularly.

There was poor social support system with a poor relationship with the family members, all of whom are also illicit drug users except his mother.

He is living on the streets at Setapak near mosque.

He is currently unemployed. A social welfare officer approached him two weeks ago, and since then he has been staying in Renewal Life Home, which is a place that homes rehabilitating drug addicts.

It was a crowded place and always had contact with foreign workers. Among his friends whom is a known case of tuberculosis for the past one year and currently not on any form of treatment or follow-ups. He claimed to have had only a single partner before. His last occasion was more than 10 years and claimed used to be frequent. He also claimed uses no protection.

Review of Systems

CVS : No palpitations, tachycardia, orthopnea or paraxosymal nocturnal dyspnea (PND)

GIT : No change in appetite or bowel habits with no nausea, constipation, diarrhoea, melena, vomiting or abdominal pain.

MSK : No muscle or joint pain, redness or swelling of joints.

URI : No frequency, urgency, hematuria or dysuria.

ENDOCRINE : No temperature intolerance, excessive sweating or increased thirsty.

CNS : No headache, fainting, tremors or fits.

Summary

Mr Z is a 52 years old Malay male who presented with a chief complaint of fever and chest pain for the past one month. The patient is a chronic smoker and illicit drug user for the past 35 years. The patient has a poor socioeconomic background with history of contact with a known tuberculosis patient.

General Examination

The patient is an old age Malay male with an average height and is slightly cachexic. He is alert, conscious and responsive and is not in any pain or distress. He is oriented to time, place and person.

There is a branula attached to his right hand and a chest tube attached to his left chest wall along the axillary line.

Vital signs

CRITERIA	VALUES
Temperature	37.0 ˚C
Blood Pressure	138/88 mmHG
Pulse Rate	100 beats per minute
Respiratory Rate	20 breaths per minute
Body Height	170 cm
Body Weight	54 kg
BMI	18.7 kg/m2

Hands

The hands were moist, pink and warm. There are no signs of pallor or peripheral cyanosis. Capillary refill time is less than 2 seconds. There was no clubbing, tar stains, fine tremors, palmar erythema, wasting of muscles, asterixis, Janeway lesions, Osler nodes & splinter haemorrhage.

Face

There was no facial edema, ptosis or miosis

Eyes

The patient’s eyes show equally dilated pupils that is reactive to light.

There was no corneal arcus, pallor or jaundice.

Nose

There was no abnormal shape of the nose with no nasal discharge, nasal polyp or deviated nasal septum.

Mouth

The oral hygiene is poor. Otherwise the hydration status is good with no central cyanosis or ulcers.

Neck

There was no raised JVP, tracheal deviation or cervical lymphadenopathy.

Legs

There was no pedal oedema on both legs and dorsalis pedis pulse was felt on both legs.

Respiratory Examination

Inspection

There is a pectus excavatum deformity of the chest wall.

Otherwise it was symmetrical and no scars seen.

Palpation

The apex beat was palpable on the 5^th intercostal space at the midclavicular line.

Chest expansion was reduced on the left side.

Percussion

The percussion noted was slightly dull on the left inframammary area but is otherwise resonant in all other areas.

Tactile fremitus is lightly reduced on the left inframammary region.

Auscultation

Air entry is reduced on both sides.

There was bronchial breath sounds heard with a short inspiratory and expiratory phase with no other added lung sounds.

Cardiovascular Examination

Inspection

There is pectus excavatum deformity of the chest wall but is otherwise symmetrical with no scars seen.

Palpation

The apex beat was palpable on the 5^th intercostal space at the midclavicular line.

There were no heaves and thrills.

Auscultation

Both heart sounds are heard in all areas with splitting of the heart sounds nor any additional heart sounds.

Abdominal Examination

Inspection

The abdomen is scaphoid in shape with no visible scars seen.

The umbilicus is centrally located and inverted.

There was no dilated veins.

Palpation

There were no tenderness, rebound tenderness or guarding seen.

There is no palpable mass and the liver and spleen is not palpable.

Auscultation

Bowel sounds are heard every 2 seconds and is gurgling in nature.

There are no renal or aortic bruits heard.

Provisional Diagnosis

Pulmonary Tuberculosis

Differential Diagnosis

Pneumonia

Acute Exacerbation of Chronic Obstructive Airway Disease (AECOAD)

Pulmonary Embolism

Investigation

1) Full Blood Count

Test	Value	Units
WBC	6.6	X 103/ µL
RBC	4.15	X 103 / µL
HGB	12.0	g/Dl
HCT	36.8	%
MCV	88.7	fL
MCH	28.9	pg
MCHC	32.6	g/dL
PLT	340	X 103 / µL
LYM%	18.7	%
MXD%	16.5	%
NEUT%	64.8	%
LYM#	1.2	X 103 / µL
MXD#	11.1	X 103 / µL
NEUT#	4.3	X 103 / µL
RDW	46	fL
PDW	8.6	fL
MPV	7.6	fL
P-LCR	9.1	%

2) Blood Urea & Serum Electrolyte (BUSE)

Code	Test Name	Results	Reference Interval	Units	Comments
BUN	Blood Urea Nitrogen	2.8	2.5 – 6.4	mmol/L	Normal
Na	Sodium	139	136 – 145	mmol/L	Normal
K	Potassium	3.6	3.5 – 5.1	mmol/L	Normal
Cl	Chloride	105	98 – 107	mmol/L	Normal
TP	Total Protein	73.7	64.0 – 82.0	g/L	Normal
GLOB	Globulin	50.1	30.0 – 62.0	g/L	Normal
ALB	Albumin	23.6	34.0 – 50.0	g/L	Low
TB	Total bilirubin	11.3	3.0 – 17.0	µmol/L	Normal
ALT	Alanine Transaminase	26	12 – 78	U/L	Normal
ALP	Alkaline Phosphatase	68	46 - 116	U/L	Normal

3) Mantoux test

Result : 7mm (normal)

4) Sputum Collection

Gram stain

* no leucocyte seen

* moderate epithelial cells seen

* numerous gram positive cocci seen

* moderate gram positive bacilli seen

* scanty gram negative bacilli seen

* scanty yeasts seen

Culture

* no significant growth (Culture & Sensitivity)

5) HIV Serology

HIV 1 & 2 Combo Ab+Ag (CMIA) : Non-reactive

6) Hepatitis Serology

*Hbs Antigen detected

*Anti HCV Screen (CMIA) : Reactive

*HCV Ab detected in this blood sample

7) Lactate Dehydrogenase

Result : 378 U/L (Normal : 240-480)

8) Pleural Biopsy & Tapping

*multiple adhesions seen

*adhesions with unhealthy looking parietal pleura

*white patches thick layer covering the parietal pleura

*no sago nodules seen

Test	Result	Unit
Fluid Type	Pleural	-
Fluid pH	7	-
Fluid Glucose	4.0	mmol/L
Fluid LDH	354	U/L
Fluid Total Protein	49.2	g/L

9) ECG

10) Chest X-ray

Management

Continue anti-TB drugs (Akurit-4)

Off Tramal

Trace pleural biopsy, MTB C&S and Pathogen

Keep ICT

Refer for chest physio

Discussion

This patient is 52 years old gentleman living at Setapak, Kuala Lumpur who presented with a chief complaint of fever and chest pain for the past one month. From the history, the patient lived at overcrowded place, had close TB contact, illicit drug user, chronic smoker and alcoholic which are the important high risk factor according to CPG.

Patient presented with chest pain and fever for 6 months, however, adult patients with active PTB typically presents with a history of chest symptoms such as productive cough, hemoptysis and chest pain and also nonspecific constitutional symptoms such as loss of appetite, unexplained weight loss, fever, night sweats and fatigue. This patient does not have hemoptysis, productive cough, dyspnea and night sweats.

The diagnosis of TB is supported by imaging and laboratory tests. However, diagnosis is confirmed by isolating Mycobacterium tuberculosis from clinical samples. In this patient, FBC, BUSE, Mantoux test, sputum culture, HIV serology, hepatitis serology, lactate dehydrogenase, pleural biopsy and tapping, ECG and chest X-ray. Out of that, the positive findings were low albumin in BUSE, presence of moderate gram positive bacilli seen in sputum gram stain, presence of HCV Ab in hepatitis serology test, multiple adhesions seen in pleural biopsy and tapping and left sided lower and middle zone opacity in chest X-ray.

This patient was continued with anti-TB drugs which is Akurit-4. Akurit-4 are combination of ethambutol, isoniazid, rifampicin and pyrazinamide. 4 drug combination : Isoniazid 75 mg, Rifampicin 150 mg, Pyrazinamide 400 mg and Ethambutol 275 mg tablet.

References

1. CPG- Management of Tuberculosis (3rd Edition)

2. Davidson's Principles and Practice of Medicine - 23rd Edition