Wonca Europe 2014, Lisbon: anamnesis
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Anamnesis, anamnesis, anamnesisAuthors: Gemma Rovira , Beatriz JimnezEAP 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 visitSlight fever + night sweatsLoss 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 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-anamnesisInfectious diseases: Mycobacteria (TBC) Atypical pneumonia Pneumocystis Aspergillum HIV primary infection
Interstitial lung disease
Neoplasia: AdenocarcinomaCarcinomatous lymphangitis LymphomaToxic syndrome+ Mild fever / sweats + Cough/expectoration + Low back painDifferential Diagnosis
Good general healthBP 80/60 mmHg , HR 95 beats/min, RR 20 breaths/min, T 35'5Accurate 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 examinationCardiovascular exam was normal, not signs of heart failure Neurological exam was normal (no motor or sensory abnormalities. Reflexes ok, not neurological deficit)Physical ExaminationSuspecting 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 TestNa 125mEq/l, K 4'1 mEq/l, Leuc 11.030 x109/l, Hb 129g/dl, Platelet 436 103/mm3, Lymphocyte 770/mm, Cr 64, Ur 3'9, MDRD(ml/min/1,73m2) > 60, RCP 95 mg/L, DHL 199 UI/LSerology- CMV, EBV, HSV-6, HBV, HCV, Mycoplasma NEGATIVE- Screening test for HIV-Ab was non reactive. Auto antibodiesNormalUrine AgS. pneumoniae and Legionella: NegativeSputum culturesNegative ZN. Mycobacteria RCP. Negative Blood cultures (x7)NegativeExtra 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 drugsLUMBAR SPINE CTLytic 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
Pott's disease (D8, D9, D10) + paravertebral Spinal cold abscess + partial chord commitment (anterior third)Final DiagnoseSuspect 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 diagnosisConclusionsThank you so much for your attention!