` A T I Q A H B I N T I A B . R A H M A N

I H S A N U D D I N B I N I B R A H I M

A Z M A N B I N Z A K A R I A

CHRONIC COUGH

PATIENT ID

Name : Muhammad Lokman Hakim Bin Mazlan

Age : 14 years old

Origin : Kampung Panji

Gender : Boy

Race : Malay

Marital status : Single

Occupation : Student

Date of admission : 8th December 2014

Date of clerking : 9th December 2014

CHIEF COMPLAINT

Presented with prolonged history of SOB for 1 week and worsening 2 days prior to admission.

HOPI

He is underlying:

AIDS on HAART and under Paediatrics Clinic follow up.

He is unaware of his latest CD4/CD8 count or viral load

PTB

Diagnosed in November 2011

Frequent defaulted treatment and follow up before

Currently on anti- TB medications

He was previously well until 4 years prior to admission when he first experience shortness of breath preceded by productive cough. Before this, he had multiple hospitalization almost thrice per year since 4 years ago due to the same complaints and his latest ward admission was on 26 November 2014.

For current admission, he presented with shortness of breath for 1 week and worsening 2 days prior to admission.

Sudden

On and off

Preceded and worsen by cough

Relieved by rest

Had productive cough for 3 days prior to admission. It was on and off, aggravated at night, no relieving factor, and associated with copious greenish sputum about 1 table spoon each time he cough. However, no blood or foul smelling associated.

Complaint of loss of appetite but no loss of weight.

No night sweats, no hoarseness of voice and no noisy breathing.

He had history contact with TB patient in which his mother and maternal grandfather had PTB and had pass away due to it. Previously, patient stayed with grandfather after his mother pass away.

He also experienced right side chest pain upon coughing. The pain was sudden in onset, pricking in nature, localized, aggravated on exertion, relieve by rest and pain score given was 5/10. He deny pleuritic chest pain. He also complaint with orthopnea and PND since 1 year ago

He also presented with mild fever, on and off and relieved temporarily with medications. No temperature recorded at home. Not associated with night sweats and chills or rigor.

No history of recent travel to endemic area, no recent fogging activity at his house area and no history of contact with person who had fever.

Also presented with fatigue and palpitation but no headache, no faintness and no bleeding tendency.

Upon admission, he was nebulized and given antibiotics and few investigations had been done. Currently, patient stable, good oral intake and his symptoms have improved.

REVIEW OF OTHER SYSTEMS

CENTRAL NERVOUS SYSTEM

No blurring of vision

No drowsiness

No loss of consciousness

No fitting

GENITOURINARY SYSTEM

No hematuria

No dysuria

No urgency

No frequency

GASTROINTESTINAL SYSTEM

Abdominal pain

No vomiting

No nausea

No change in bowel habit

No hematochexia

No malaena

MUSCULOSKELETAL SYSTEM

No joint and bone pain

No joint swelling

PAST MEDICAL HISTORY

He had multiple ward admissions due to complications of PTB.

He has no underlying any other chronic illness such as bronchial asthma.

PAST SURGICAL HISTORY

He had no past surgical history.

PAST DRUG AND ALLERGIC HISTORY

On HAART Zidovudine

Lamivudine

Efavirenze

Co-trimoxazole

Anti TB Rifampicin

Isoniazide

No history of traditional medications or supplement intake.

Deny any history of allergy towards any kind of food or drug.

FAMILY HISTORY

He is 7th out of 8 siblings 1st sibling- female, had CP, bed ridden and died 2 years ago (unaware of exact causes). 2nd sibling- 28 y/o, female, healthy 3rd sibling- 26 y/o male, healthy 4th sibling- 22 y/o female, healthy 5th sibling- 21 y/o male , healthy 6th sibling- 18 y/o male, healthy 8th sibling- 11 y/o female, healthy

2nd and 3rd siblings had married and living with their own family. 4th to 7th siblings stay together in one house. 8th sibling stays with aunty in Thailand.

Father 55 years old, ex-IVDU, unemployed, had second wife and both of them had HIV, under Infectious Disease Clinic follow up and on HAART.

Mother, Siamese, HIV positive, history of PTB on treatment and pass away 9 years ago due to endometrial cancer.

PERSONAL HISTORY

Previously he studied at Sekolah Menengah Kebangsaan Bukit Besar but stop attending the class since 1 year ago due to his conditions.

Not so active in school activities and not having much friends at school.

Currently, he lives with his 4th to 6th siblings in single storey house with adequate facilities. He is financially supported by his sister(babysitter) and brothers (labourers) .

Non-smoker

Otherwise, he denied any high risk behaviour.

SUMMARY

14 years old boy underlying AIDS, on HAART, and PTB on anti-TB treatment, had 4 years history of productive cough and currently presented with worsening shortness of breath 2 days prior to admission. He also presented with mild fever, chest pain upon coughing, fatigue, palpitation, loss of appetite, orthopnea, paroxysmal nocturnal dyspnea and abdominal pain. He had history of contact with TB patient and both of his parents are positive HIV.

GENERAL EXAMINATION

Inspection:

Thin built Malay boy, sitting comfortably, he looked cachexic, generalized muscle wasting and slightly weak but alert, conscious and well orientated to time place and person. There was generalized hyperpigmented skin lesion. He was not in pain, not in respiratory distress and his hydrational status was fair. There was branulaattached to his left dorsum.

Vital signs:

Blood pressure: 96/68 mmHg (hypotension)

Pulse rate : 120 bpm with regular rhythm,good volume (tachycardia)

Respiratory rate : 20 bpm

Temperature : 37 degree celcius

BMI : 10.7 (underweight)

Height and weight below 3rd centile.

HAND

Palm -warm , pale, dry

-no palmar erythema

-no stigmata of infective endocarditis

-no flapping tremor

Nail - capillary refill less than 2 seconds

- clubbing (drumstick appearance)

- no peripheral cyanosis

- no koilonychias

- no leukonychias

EYE

No jaundice (sclera white)

Not anemic ( conjunctiva pink)

MOUTH

No angular stomatitis

Oral hygiene was good

Hydrational status was fair

No central cyanosis

Uvula was centrally located

Throat was not injected

LEGS

Dorsalis pedis & posterior tibial pulses were present bilaterally

No pitting edema

LYMPH NODES

No lymphadenopathy at neck and any other regions.

SYSTEMIC EXAMINATION

Respiratory examination:

Inspection

Chest move symmetrically with respiration and generalized hyperpigmented skin. There was no chest deformity, no surgical scar, no dilated vein and no visible pulsation.

There was BCG scar, no anhidrosis, no ptosis and no miosis.

Palpation

The trachea was centrally located. The apex beat was at the 5th intercostals space medial to midclavicular line. The chest expansion and vocal fremitus were normal and equal on both sides anteriorly and posteriorly.

Percussion

The lungs were resonant at all zones bilaterally.

Auscultation

There were vesicular breath sound at all zones of lungs. Normal air entry bilaterally. Generalized coarse crepitation at all zones bilaterally. The vocal resonance was normal at all the zones on both sides.

Cardiovasular examination:

Inspection

Chest move symmetrically with respiration and generalized hyperpigmented skin. There was no chest deformity, no surgical scar, no dilated vein and no visible pulsation.

Palpation

Apex beat was at 5thintercostal space, medial to midclavicularline. There were no palpable thrill or parasternal heaves.

Auscultation

First and second heart sounds were heard with no added sound or murmur. There was no bibasal crepitation noted.

Abdominal examination: Cannot do proper abdominal examination because

patient cannot lying flat. Inspection

Grossly, abdomen was not distended. There were no surgical scar, no visible dilated vein, no visible peristalsis and no visible pulsation.

Palpation Abdomen soft but tender on deep palpation at right upper quadrant. Cannot access any hepatospleenomegaly or shifting dullness.

Percussion Unable to access

Auscultation There was normal bowel sound heard and no renal bruit.