CASE BASED TUTORIAL for Internal Medicine
- 1. CASE BASED TUTORIAL TUTOR; DR ADOLF BYAMUKAMA PRESENTERS: DR AHIMBISIBWE GIDEON DR NIWAGABA DANSON
- 2. HISTORY DEMOGRAPHICS: Name; Nyesigamukama Libert Age;20 years Sex; Male Tribe:Munyankole Religion;Anglican Occupation; Not working(prisoner at Mbarara prisons) Address:Mbarara prisons
- 3. HISTORY Next of kin: Date of Clerkship:27th October,2024 Date of Admission: Refferal:Self
- 4. HISTORY PC: Chest pain x1/12 HPC: 2O year old male NYN(verbal) non DM non HTN non smoker non alcoholic previously managed for CAP on antibiotics at a peripheral clinic presented with a month history of generalised chest pain , originated in the right side,non radiating,sharp in nature, exacarbated on doing simple tasks, sitting forward and coughing, alleviated on rest, it was on and off and it was associated with shortness of breath, dry unproductive cough, palpitations, easy fatigability however there was no PND, orthopnea,Lower limb swelling, no early satiety, no odynophagia,no dysphagia, no vomiting, no diarrhea, no constipation, passing brown stool, no dark coloured stool, no abdomial distension, no easy fatigability however there was no PND, orthopnea,Lower limb swelling, no early satiety, no odynophagia,no dysphagia, no vomiting, no diarrhea, no constipation, passing brown stool, no dark coloured itching, normal urine output( about 500mls a day), no dysuria, no painful micturition and no lower back pain.
- 5. HISTORY Review of other systems: • CNS: No loss of consciousness, no headache, no fevers, no focal neurological deficits, no photophobia, no neck stiffness • Musculoskeletal; No joint pain, no joint swelling • Endocrine: No excessive sweating,no recent weight gain or weight loss, no excessive thirst
- 6. HISTORY • Intengumentary system: No skin lesions, no skin itching Past Medical History: Second admission, first admission was for CAP No drug or food allergies No chronic illness or chronic medications
- 7. HISTORY Past Surgical History: No history of Road traffic accidents, major or minor surgeries, no history of blood transfusions Family social History: No history of chronic illness like hypertension ,chronic kidney,liver, and heart disease, unmarried, non smoker, non alcoholic, no history of TB contact
- 8. HISTORY Summary; 20 year old male NYN(verbal) non DM non HTN non alcoholic non smoker with previous history of CAP presented with a month history of generalised sharp non radiating on and off chest pain, originated in right chest,associated with shortness of breath, dry unproductive cough,palpitations but no PND, orthopnea, LL swelling,normal micturition and bowel habits.
- 9. Differentials • Pneumonia • Tuberculosis • Empyema • Acute coronary syndrome • Pulmonary embolism • Pneumothorax, hemothorax, chylothorax • Pericarditis • GERD
- 10. EXAMINATION GENERAL EXAMINATION: Middle aged man sitting calmly in bed,afebrile, not in respiratory distress, had a chest tube in situ draining pus, had palmar pallor, but no scleral jaundice,no finger clubbing, no lymphadenopathy, no dry mucous membranes, no central cyanosis, no edema. Vitals: Temperature:36.5 C
- 11. EXAMINATION • BP:119/78 mmHg • PR:118bpm • RR: 18cpm • SPO2:99% RA
- 12. EXAMINATION • Respiratory exam: no chest deformity, no scars or marks, unequal chest expansion,decreased tactile vocal fremitus right anterior side compared to the left,decreased vocal resonance right anterior side compared to left side, stony dull percussion note in right anterior and right posterior( supra mammary, mammary and infra mammary) but a resonant in left side.
- 13. EXAMINATION Reduced air entry on right side compared to left, brochovesicular sounds and no added sounds. CVS: Warm peripheries, capillary refill time less than 2 seconds,pulse present, regular,PR 118bpm,BP 119/78mmHg, normal active precordium, no heaves or thrills, PMI 5th ICS MCL, Heart sounds 1 and 11 heard , no added sounds and no murmurs.
- 14. EXAMINATION • PA: Normal fullness, moving with respiration,no scars or marks,no tenderness on superficial, no organomegalies,kidneys non ballotable, resonant percussion note, 3 bowel sounds in a minute • CNS: Fully conscious, alert, GCS 15/15 E-4 V-5 M- 6, Neck soft and PEARL Tone, reflexes and power of 5/5 in all limbs, cutaneous intact, babinski negative, intact joint position sense.
- 15. Differentials • empyema secondary to- TB -Pneumonia -Malignancy • Emphysema
- 16. Investigations • Chest Xray(PA View) • Pleural tap for pleural fluid analysis -macroscopy -biochemistry( glucose , protein, albumin,LDH), cell count and differentials -microscopy(Gram staining,KOH) -Others( Gene Xpert, ADA,Culture and sensitivity) • CBC • LFTs, RFTs, Abdominal USS
- 17. FOLLOWUP • Chest xray: revealed right pleural effussion • Abdominal Pelvic USS: Normal • CBC revealed ( HGB 9.4 g/dl, MCV 81 fl, MCHC 26.7 pg) • Pleural fluid analysis revealed - macroscopy(pale yellow and turbid) -albumin 1.67g/dl -protein 7.36g/dl
- 18. Follow up Cell counts 340cells/mm3 RBC 20 cells/mm3 Differentials not done Microscopy: pus cells +++ seen red blood cells + seen Gram staining –no organisms Culture and sensitivity- no growth KOH- Negative Gene Xpert- negative ADA +VE 55U/L
- 19. Follow up • LFTs -Serum albumin 2.04 g/dl -ASAT/GOT 20 -ALAT/GPT 14 -ALP 103 -Bilirubin Direct 0.82 mg/dl -Bilirubin total 1.15 mg/dl • RFTs -creatinine 0.58mg/dl -urea 12.4 mg/dl • RCT -Negative
- 20. Management • Drained pleural fluid using chest tube • Started on anti Tbs first line, intensive phase(2 RHZE) which will be followed by 4RH • Advised to do gram staining at 2 months and also do routine liver function tests,screen for colour blindness, • Educated on advantages of adherence and side effect profile of the different drugs.