Week 2_Patient Case Report_Mar 13-19

Name: JOSEPH HAMIS

HKMU ID:HK/MD/13/1050

PATIENT PARTICULARS
NAME: D J K
AGE: 45
SEX: MALE
DOB: 1972
TRIBE: HEHE
RESIDENCE: KIMARA
MARITAL STATUS: MARRIED
LEVEL OF EDUCATION: GRADE SEVEN
OCCUPATION: DRIVER
NEXT OF KIN: WIFE
REFERRAL: SELF REFERRAL
DATE OF ADMISSION: 11/3/2017
DATE OF CLERKSHIP: 16/3/2017
HOSPITAL DAY NUMBER: 5 DAYS POST ADMISSION.
CHIEF COMPLAINT
COUGH for 3 weeks
FEVER for 2 weeks
HISTORY OF PRESENT ILLNESS
D JK is a 45 years old known IDS patient on regular medication for 6years who
appeared well until 2 weeks ago, when he presented with cough. It was gradual in
onset and worsened over time, initially it was non productive cough which
progressed to productive cough with foul yellow-greenish and eventually blood
spot sputum. It was noticeable during the day and night, no any aggravated factor.
Initially the cough was relieved with cough syrup but in the long run it could not
respond to syrup any more. The condition was accompanied with difficulty in
breathing, chest pain, fever and loss of weight. It was not associated with whistling
sound, using pillow on lying flat, waking up at night seeking for air and lower
limbs swelling
One week after cough started he developed gradual onset of on and off fever which
worsened over time markedly during the night with no any aggravated factor
encountered. It was relied by taking paracetamol and was associated with night
sweat, cough, loss of appetite and headache. It was not associated with loss of
consciousness, confusion, vomiting, nausea, Diarrhea, abdominal or back pain,
urethral discharge, painful urination, frequent urination, Blood in urine, and pain
below the umbilicus.
However the patient explained that he was taking care of his wife who suffered
from TB six years ago.
He presented to the hospital five days ago because of cough and fever which
progressed and became more severe that he could not able to tolerate any longer.
Upon reaching to the hospital the following were done.
INVESTIGATION
Full Blood Picture
Sputum for AFB
Chest X ray
Vital: BP 137/86, SPO2 94%
MANAGEMENT
Paracetamol, IV fluid, ceftriaxone inj then changed to TB
treatment (HRZE) after two days following Lab result.
REVIEW OF OTHER SYSTEM
MUSCULOSKELETAL SYSTEM
No muscular pain
No joint pain
No any deformity
No any lesion
PAST MEDICAL HISTORY
PAST 3 ADMISSION
The patient was diagnosed as HIV patient at first in 2012 when he presented his
wife to the hospital who was suffering from TB, due to doctor’s advice that both
couple should know their status is when they were found to be HIV positive, hence
started ARV treatment .
In 2015 he was admitted due to severe pneumonia at Amana hospital.
Also he had two admissions due to severe malaria in 2016 at Amana hospital
He had no history of surgery,
He has no history of blood transfusion,
He has no history of food or drug allergy

FAMILY AND SOCIAL HISTORY

FAMILY HISTORY
The patient is the second born among 4 children in the family, 3 of them are alive
but one died due to the accident
No history of chronic illness in the family
He is married with 3 children, two are girls and one is a boy. First born 13 years
old, second 11 years old and last born 8 years old, both are health and studying
primary school.
SOCIAL HISTORY
He had no history of alcohol intake
He had history of smoking 6 to 8 sticks of cigarette for almost 20 years but stopped
in 2015 after he was admitted due to pneumonia
He had several multiple sexual partners before he was diagnosed HIV positive.
NUTRITION HISTORY
The patient explain that he takes three meals per day
Breakfast: tea, porridge, bread, burns, chapatti, mtori, soup
Lunch: ugali, meat, bean, fish, and little amount of vegetable.
Dinner: rice, meat, ugali, beans, fish. Chips chicken
Patient claimed that he rarely take fruits, as well as taking high
salt and fat dietary.
Water consumption is about 2 to 3 liters per day.
COMMENT: The food is adequate in quantity but not in quality
since he takes little amount of vegetable and fruits.
SUMMARY 1
DJK is the 45 years old man known IDS case who presented with 3 weeks of
gradual progressive cough accompanied with difficulty in breathing, chest pain and
loss of weight and 2 weeks of fever accompanied with sweat, cough, loss of
appetite and headache
IMPRESSIONS
Pulmonary TB

Pneumocystic jiroveci

Bacterial Pneumonia

COPD

Cryptococcus Meningitis

Bacterial Meningitis

Pulmonary Embolism

PHYSICAL EXAMINATION
VITAL SIGNS:
TEMPERATURE: 38.2 C (Axillary temperature)
PULSE RATE: 97beats/min
BLOOD PRESSURE: 132/84 mmHg
OXYGEN SATURATION: 94%
RESPIRATORY: 31breath/min
GENERAL EXAMINATION
The patient is alert, well oriented to place, people, and time, sick
looking, slightly wasted, cannula on the right proximal part of the
hand.
Head: normal shape, normal colour, good texture, evenly
distributed not easily plucked off
Ears: no lesion on the pinna, no discharge.
Eyes: no periorbital edema, no sclera jaundice, no conjunctival
pallor, no discharge, no sunken eyes, normal pupil reflex.
Nose: no discharge, no polyps, normal mucosal membrane, no
inflammation.
Mouth: normal lips, there is oral thrush, no central cyanosis,
normal teeth arrangement, no angular stomatitis, normal soft and
hard palate.
Lymph Node: Cervical lymph node were palpable anteriorly and
posteriorly. No lymph node enlargement on, submental, sub-
mandibular, pre and postauricular, supraclavicular, axillary and
inguinal lymph node were not palpable
Upper Limbs: no peripheral cyanosis, no palmar erythema, no
janeway lesion, no Osler’s node, no sphincter hemorrhages, no
finger clubbing no pallor of the palms, normal capillary refill on
the nail, no koilonychias no fungal infection of the nail.
Lower limbs: No pedal, ankle edema, no lesion and no fungal
infection on the nail.
Neck stiffness kernig and Brudzinski's sign were negative

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:
Inspection: Bilateral symmetrical chest, bilateral symmetrical
chest movement with respiration, no use of accessory muscle, no
chest deformity, no therapeutic or surgical scars.
Palpation: trachea centrally located, symmetrical chest
expansion, no palpable mass, no tenderness, decreased tactile
vocal fremitus.
Percussion: stone dullness in the left lung.
Auscultation: crackles heard on the right and left lower lungs
posteriorly
.
CARDIOVASCULAR SYSTEM
Rate and rhythm were symmetrical the radial pulse and
synchronized with carotid pulse
Inspection: no cyanosis, no finger clubbing, no splinter
hemorrhage, no lesion, no surgical or traditional scars or marks,
no precordium hyperactivity.
Palpation: no tenderness, apex beat felt on left fifth intercostal
midclavicular space
Auscultation: S1 and S2 were heard, there is no any added
sound
.
PER ABDOMEN:
Inspection: symmetrical shaped,no distention, normal abdominal
wall movement with respiration, inverted umbilicus, no tradition
or surgical scars.
Palpation: no tenderness, no superficial mass on superficial
palpation, no organomegaly, tenderness or deep mass on deep
palpation.
Percussion: normal tympanic note.
Auscultation: normal bowel sound heard.

SUMMARY 2
DJK is the 45 years old man known IDS case who presented with 3 weeks of
gradual progressive cough accompanied with difficulty in breathing, chest pain and
loss of weight and 2 weeks of fever accompanied with sweat, cough, loss of
appetite and headache. On examination he was sick looking, febrile, slightly
wasted, tachypneic, presence of oral thrush, palpable anterior and posterior lymph
node non tender, mobile, about two centimeter not matted. Also diminished tactile
vocal fremitus on palpation, stone dullness on the left Lung on percussion and
crackles heard on the right and left lower lungs posteriorly on
auscultation.

PROVISIONAL DIAGNOSIS
Pulmonary Tuberculosis (cough, fever, loss of weight, night sweat)
DIFFERENTIALS DIAGNOSIS:
Pneumocystic jiroveci (IDS, fever, chest, cough)
Cryptococcal Meningitis (IDS patient, headache, fever, weakness,
but no confusion, no convulsion, neck stiffness kernig and
Brudzinski's sign were negative)
Bacterial pneumonia (due to cough, weakness, crackles, fever but
presence of hemoptysis)
COPD (cough, chest pain, history of smocking but would not
expect persistent fever for more than one week)
Pulmonary Embolism (due to cough, lower than expected oxygen
saturation, but chest pain persisted for more than two weeks and
localized)
INVESTIGATION
Full blood Picture (FBP)
Sputum for AFB
Chest X-ray
Sputum Culture
Pleural fluid tap (Under water sill drainage for Diagnosis and treatment)
MANAGEMENT
Antipyretic Drug to reduce fever Paracetamol 1g tds
1 line treatment of TB for the first two month (Intensive Phase)
st

Rifampicin 150 mg
Isoniazid 75mg
Pyrazinamide 400mg
Ethambutol 275mg
For the rest of four month (continuous phase)
Rifampicin 150 mg
Isoniazid 75mg
Underwater seal drainage for Diagnosis and treatment of pleural Effusion
Co-trimoxazole 1920 tds for 21 days
COUNSELLING:
Adherence to course of treatment for six month

Household members should be given anti-TB prophylaxis (Rifampin)

Ensure good and adequate Dietary intake.

Physical exercise