Anamnesis, anamnesis, anamnesis

Authors: Gemma Rovira , Beatriz JiménezEAP Sardenya, Barcelona

– Cough with scanty non purulent expectoration.

– Progressive dyspnea on moderate-large efforts.

– Week history of low-grade fever.

– Progressively added low back pain and paresthesia

(both hands and lower limbs).

– OD: Respiratory tract infection + Mechanical low back pain.

TREATMENT:

– NSAIDs (Ibuprofen) + Amoxicillin Clavulanate for 7 days.

39 years old year man presenting with :

First Primary Care visit

• Slight fever + night sweats

• Loss of 14kg weight in last month

• Lumbar pain at rest (Not mechanical)

• Stocking-glove paresthesia

– Natural of Pakistan (living in Barcelona for 2 years).

– Smoking ½ pack / day (> 10 years).

– No pathological background known. Denies toxic consume.

– Job: Exposure to gases and toxic chemicals (painter/construction).

– Family House: live with 5 people (no TB cases reported).

– Sex: possible promiscuity.

Re-consult/ Re-anamnesis

Infectious diseases:

• Mycobacteria (TBC)

• Atypical pneumonia

• Pneumocystis

• Aspergillum

• HIV primary infection

Interstitial lung disease

Neoplasia:

• Adenocarcinoma

• Carcinomatous lymphangitis

• Lymphoma

Toxic syndrome+ Mild fever / sweats

+ Cough/expectoration + Low back pain

Differential Diagnosis

Good general health

BP 80/60 mmHg , HR 95 beats/min, RR 20 breaths/min, T 35'5º

Accurate oxygen 2L/min by mild dyspnea at rest. SaO2 94% (air)

Fine bilateral (Left base and left middle lung field) rales. Generalized

hypophonesis

Abdominal findings were normal.

No signs of lower extremity deep venous thrombosis

No lymphadenopathy, no pain at column examination

Cardiovascular exam was normal, not signs of heart failure

Neurological exam was normal (no motor or sensory abnormalities.

Reflexes ok, not neurological deficit)

Physical Examination

Suspecting extrapulmonary TB with probable extra pulmonary involvement in

hemodynamically unstable patient, contact isolation was performed and the patient was

referred to the hospital where treatment (Ethambutol, Isoniazid, Pyrazinamide,

Rifampin) was started in the ER due to high clinical suspicion.

Blood Test

Na 125mEq/l, K 4'1 mEq/l, Leuc 11.030 x109

/l, Hb 129g/dl, Platelet 436 103/mm3, Lymphocyte

770/mm³ , Cr 64, Ur 3'9, MDRD(ml/min/1,73m2)

> 60, RCP 95 mg/L, DHL 199 UI/L

Serology

- CMV, EBV, HSV-6, HBV, HCV, Mycoplasma

NEGATIVE

- Screening test for HIV-Ab was non reactive.

Auto antibodies Normal

Urine Ag S. pneumoniae and Legionella: Negative

Sputum cultures Negative ZN. Mycobacteria RCP. Negative

Blood cultures (x7) Negative

Extra Exams

X-Ray: Suggestive alveolar pattern with white - cottony bilateral

infiltrates with air bronchograms without acute signs of condensation.

TUBERCULIN SKIN

TEST (PPD)< 10 mm

BRONCHOALVEOLAR

LAVAGE (BAL)Negative for acid fast bacilli. RCP Negative.

BRONCHOASPIRATE M. complex PCR POSITIVE

CULTURES GROWINGM. tuberculosis POSITIVE. Susceptibility test did

not show any resistance to first line drugs

LUMBAR SPINE CT

Lytic focus in vertebral bodies D8, D9 and D10

with prominent concentric paravertebral abscess

that reduces caliber in about one third of its

diameter. Sacroiliac joint involvement.

Chest CT: confirms the presence of innumerable small pulmonary

nodules, which have a centrilobular predilection.

Disseminated pulmonary tuberculosis

Sacroiliac monoarthritis

Pott's disease (D8, D9, D10) + paravertebralSpinal cold abscess + partial chord commitment (anterior third)

Final Diagnose

Suspect and make the initial diagnosis of TB in a high risk patient is part of the competence of GP

A good history is important especially to rule out a possible involvement of extra pulmonary TB

Do not forget the biopsychosocial context of the patient in making a differential diagnosis

Conclusions

Thank you so much for your attention!