Identification data

Name : Mad Shah

SD : SD00069771
Age : 58
Gender : Male
Occupation : Machine Operator
Address : Puchong Perdana
Date of admission : 13/2/2016
Date of clerking : 16/2/2016
Ward : 7B

Introduction

Mr Mad, 58 year old Malay gentleman with comorbidity of diabetes mellitus

admitted to Hospital Serdang with a chief complain of hemoptysis 1 day prior to
admission.

History of presenting illness

This was the second time patient came for this problem. First time was 2/2/2016.
Previously, he was having cough for one month prior to admission. It was non productive
cough
The cough was intermittent in type, lasted for ten minutes and with 5 minutes
interval time before it started again. It was non productive cough, however, there were
hemoptysis twice in this period. He said that it was blood-streaked sputum with estimated
volume of two tablespoon. He did take cough syrup to suppress it but his effort was
useless.
At the same time, the patient developed a high grade fever as he described that his
body was very hot. The fever was on and off with same intensity until admission to
Hospital Serdang and it was always worsened in the evening. The fever was associated
with night sweat, but without chill and rigor. He took paracetamol to relieve it, but all in
vain. Beside that, he started loosing his appetite and weight since he developed cough and
fever.
He has a history contact with Burmese worker, who was diagnosed as tuberculosis
patient. There was no history of recent travel to jungle, rubber estate or palm estate.

SYSTEMIC REVIEW

Cardiovascular
He did not complain any chest pain and shortness of breath. There was no history
of orthopnoea, paroxysmal nocturnal dyspnoea, and ankle swelling or intermittent
claudication.

Respiratory
Apart from fever and productive cough, there was no history of wheezing,
hoarseness of voice or pleuritic pain.

Gastrointestinal
There was no history of abdominal pain, jaundice and pruritus, anorexia, vomiting
or nausea.

Neurological
There was no history of loss of sensory and motor function. Patient did not
complain any headache, dizziness or syncope.

Other system was unremarkable.

Past medical history

 This was his second hospitalization. He was diagnosed having diabetes mellitus
10 years ago by public clinic. He is on medication and under follow-up regarding to this
problem. The latest fasting sugar level was 6.3. Otherwise, there was no history of
hypertension, asthma, tuberculosis or any other chronic illnesses. No surgical has been
done to him.

Drugs and Food Allergy History

He was currently on metformin treatment for diabetes. In three days

hospitalization, he was given intravenous antibiotic and cough syrup. He denied any
traditional complementary medication and any supplements. He had no known drug
allergy and food allergy.

Family history

He was the second child from five siblings. His father was passed away due to
prostate cancer in the age of 76. His mother was diagnosed hypertensive but he cannot
recall when his mother first experience of hypertension. All of his siblings live healthy
and well. There was no history of same illness in his family.

Social history

He is a machine operator and lives with his family at single-storey terrace house.
He is a smoker. He started smoked since 15 years old and currently smoked 1 pack per
two days. He did not consume alcohol and no history of sexual promiscuity. His
occupational place was dirty and there were many foreign workers.
Physical examination

General examination

Patient was conscious, alert and very co-operative. He was toxic-looking and
lying comfortably on his bed. He was pallor but not jaundiced or cyanosed. His
hydrational and nutritional status were good. There was branular attached on him. He was
tachypnoiec. He had finger clubbing but no stigmata of infective endocarditis, palmar
erythema, leuconychia, dupuytren contracture, hypertrophic pulmonary ostreoathropathy
or tendon xanthomata.There was no periorbital oedema, flapping tremor, pedal oedema
and abnormal facies seen. BCG scar was noted at the left arm.There were no evidence of
Pembertons sign and Horners syndrome noted . There were no enlargement of cervical
and axillary lymph nodes.

His vital signs were as follows:

Pulse rate : 88 beats/minute, regular rhythm, normal volume, no collapsing
pulse.
Respiratory rate : 24 breaths/minute (tachypnoiec )
Blood pressure : 126/80 mmHg ( normotensive )
Temperature : 38.4C ( febrile )

Respiratory examination

The trachea was centrally located and there was no tracheal tug. The chest was

normal in shape, no scar, no visible pulsation and no dilated vein. Apex beat at the 5th

intercostal space, 1 cm medial to mid-clavicular line. Examination of the lung revealed

consolidation in the middle zones on both side with evidence of dullness to percussion,

increased of vocal resonance, bronchial breath sound and fine crepitation. The chest

expansion was reduced on the both side.

Cardiovascular examination

All peripheral pulses were present, palpable and equal bilaterally. There were no

radioradial delay and no radiofemoral delay. Jugular venous pressure was normal. There

were no parasternal heave and palpable heart sound. The S1 and S2 were audible and no

added sound and murmur detected.

Abdominal examination

The abdomen appeared symmetrical and moved with respiration. There was no
visible pulsations, dilated vein, surgical scar or scratch mark. No stigmata of chronic liver
disease such as Dupuytrens contracture, palmar erythema or hepatic flap detected.
Umbilicus was centrally located. On palpation, the abdomen was soft. Shifting dullness
was positive suggestive of ascites.There was no hepatosplenomegaly, both kidney were
not ballotable. Hernia orifices were intact and bowel sound was present. No bruit was
detected.

Neurological examination

The higher mental function and cranial nerves were intact. On inspection, there
were no obvious muscle wasting, fasciculation, drifting or tremor. Examination for tone,
power, reflex, coordination and sensory both upper and lower limb revealed no
abnormalities. His gait was stable and steady.
Summary

This is a 40 year old man, traditional healer, with background of diabetes melitus

presented to HUKM because of fever and productive cough one month prior to

admission. There was history contact with TB patients. Examination of the lung revealed

consolidation in the middle zones on both side with evidence of dullness to percussion,

increased of vocal resonance, bronchial breath sound and fine crepitation. The chest

expansion was reduced on the both side.

Provisional diagnosis

Pulmonary Tuberculosis

Differential diagnosis

Pnuemonia
Lung Abscess

Pulmonary Tuberculosis

Points for: 1. Persistent fever with night sweat

2. Chronic productive cough
3. History of loss of weight and appetite
4. Sign of consolidation
5. History contact with TB patients

Points against: 1. No haemoptysis

2. No chill or rigor
Pneumonia

Points for: 1. Fever

2. Chronic cough
3. Sign of consolidation in the lung

Points against: 1. No pleuritic chest pain

2. Long duration of fever is not a pattern of pneumonia

Lung Abscess

Points for: 1. Fever

2. Cough with yellowish to greenish sputum

Points against: 1. No haemoptysis

2. No foul smelling sputum
Investigation

1. Full Blood Count ( 9/8/2002 )

Component Percentage Result Units Range
White cell 8.7 x 109/ L 4.0-10.0
count
Red cell count 4.86 x 1012/ L 4.5-6.3
Haemoglobin 12.1 g/ L 14.0-17.0
Hematocrit 36.4 ratio 39.0-52.0
Mean cell 74.8 Fl 77.0-91.0
volume
Mean cell 24.8 Pg 26.0-32.0
haemoglobin
Mean cell 33.1 g/ dl 32.0-36.0
haemoglobin
concentrated.
RDW 20.6 11.3-14.6
Mean platelet 6.7 % 6.3-10.2
volume
Platelet 735 x 109/ L 150-400
Neutrophil 80.6 7.0 x 109/ L 2.0-7.5
Eosinophilss 0.6 0.1 x 109/ L 0.1-0.5
Basophils 0.1 0.0 x 109/ L 0.0-0.1
Lymphocytes 12.0 1.0 x 109/ L 1.5-4.0
Monocytes 6.7 0.6 x 109/ L 0.2-0.5

Impression: Thrombocytosis and anemia hypochromic microcytic were suggestive of

chronic infection i.e TB.

2. Renal Profile ( 9/8/2002 )

Component Value Normal Unit
Sodium 131 135-150 mmol/ L
Potassium 3.0 3.5-5.0 mmol/ L
Urea 4.9 2.5-6.4 mmol/ L
Creatinine 61 62-133 Umol/ L
Creatin kinase 674 27-204 IU/ L
Impression : Hyponatremia and hypokalemia may be present in severe disease i.e TB.
Creatini Kinase is increased due to inflammation of the heart or muscle.

3. Liver Function Test ( 9/8/2002 )

Component Value Normal value Unit
Total protein 87 67-88 g/ L
Albumin 30 35-50 g/ L
Total bilirubin 25 <123 Umol /L
ALP 288 32-104 U/ L
ALT 128 <44 U/ L

Impression: Impaired liver function test is occasionally seen in TB.

4. Mantoux Test ( 10/8/2002 )

Result : Diameter of induration across the tranverse axis of the arm less than 15 mm.
Impression : This test was negative. However false negative could be occurred due to
tuberculosis itself.

5. Erythrocyte Sedimentation Rate ( 10/8/2002 )

Result : 105 mm/ h ( normal 1-15 mm/ h )

Impression: The ESR was markedly raised indicative for tuberculosis.
6. Chest X-ray ( 10/8/2002 )

Result : There were consolidation and cavitation at the middle zone on both sides.
Impression: Cavitation and consolidation shadows strongly suggest tuberculosis.

7. Bronchoalveolar Lavage AFB Culture ( 11/8/2002 )

Result : More than 3 acid-fast bacilli has been found.

Impression: The result was positive for tuberculosis.
8. HbA1C Test ( 12/8/2002 )

Result : 8.2% ( normal 4.4-6.4 % )

Impression: Patient diabetes mellitus is poorly controlled due to underlying disease.

9. Arterial Blood Gases ( 9/8/2001 )

Component Value Normal

PH 7.44 7.35-7.45
pCO2 30.2 35 45 mmHg
Std bicarbonate 23.6 24 32 mmol/ L
Base excess -1.6 (+/-)2 mmol/ L
PO2 93 75 100 mmHg
O2 saturated 97.6

Impression: pCO2 and Std Bicarbonate were slightly reduced. A compensatory

respiratory alkalosis occurred due to hyperventilation.

Further investigation.

1. Bronchoschopy
2.Ultrasound of liver
3. Sputum culture on Lowenstein-Jensen medium

Final diagnosis.
Pulmonary Tuberculosis

Discussion of Diagnosis

Based on the patient history, physical examination and investigation results, the
most likely diagnosis is pulmonary tuberculosis. Features like fever, night sweat, chronic
productive cough, loss of weight and appetite are typical for tuberculosis.
The long duration of unresolved fever and productive cough are common
manifestation of Mycobacteriun Tuberculosis infection. It usually takes 3 to 8 weeks after
infection to develop immune responses against M.Tuberculosis infection. The earliest
manifestation in tuberculosis is night sweat. This happens because human body tries to
 reduce the temperature by excreting sweats as much as possible. Another feature of
tuberculosis is a chronic productive cough with yellowish or greenish sputum showing an
infection.
The examination on this patient revealed signs of consolidation in the middle zone
on both side such as dullness in percussion, bronchial breath sound, fine crepitation and
increased in vocal resonance. The chest x-ray of this patient showed that consolidation
and calcification in the middle zone. Consolidation and tuberculosis are always related.
Full blood count showed thrombocytosis together with low level of haematocrit
and haemoglobin indicative for underlying and chronic disease. Hypokalemia in this
patient, probably, due to compensatory alkalosis. Patient developed dilutional
hyponatremia, may be, due to excessive fluid input and less output.
Although Mantoux test was negative, the false negative can occur due to severe
bacterial infection including Tuberculosis. Bronchioalveolar lavage AFB culture clarified
that this patient was having tuberculosis. However, sputum culture on Lowenstein-Jensen
medium should be done because this is the gold standard test for diagnosing tuberculosis.
The patient is also diabetic by looking at the HbA1C test. A long-time diabetic
patient is immunosuppressive, thus, infection can easily happen. Although this patient has
got BCG vaccination in the childhood, but then, many studies have approved that
vaccination can only prevent 90% of not getting tuberculosis.

Department of Medicine
Faculty of Medicine
National University of Malaysia
1st case write-up
 Pulmonary Tuberculosis

ABDULLAH HUSAM BIN A SHUKOR

A 74829

GROUP F, PHASE 1

SUPERVISED BY:

DR DAUD BIN SULAIMAN

References

1. P. Chandrasoma, C.R. Taylor 1995, Concise Pathology, Lange Medical

Book , 3rd Edition

2. B.I. Churchill Livingstone Pvt Ltd, New Delhi-110 001

3. McGraw-Hill International Editions, Medical Microbiology &

Immunology , Examination & Board Review

4. Davidsons, Principles and Practice of Medicine, 18th edition

TREATMENT AND MANAGEMENT

Treatment of this patient was done by taking anti-tuberculosis regimen that

include Isoniazid ( 300 mg ), Rifampicin ( 600 mg ), Pyrazinamide ( 1.5 g ) and
Ethambutol ( 1.2 g ) for 6 months. This treatment was monitored by doing bacteriological
examination, radiological assessment and ESR level.
At the same time, monitoring of the body weight should be done to see
progression of the treatment. Beside that, pulse rate, blood pressure, temperature and
respiratory rate should be monitored too.
 Meanwhile, as the patient is diabetics, proper treatment is given i.e Metformin to
control it.
As for the management, the patient should be advised with anti-tuberculosis
treatment compliance. Beside that, he should be advised to control his diet as apart of his
diabetes mellitus treatment.