History

(Case 1)
 General Data

MR, 75, male, married, born and residing in

Quezon City, admitted for the first time at QCGH
on Jan 27, 2020.
 Chief Complaint

Cough
 History of Present Illness

2 months prior to admission, the patient experienced moderate

productive cough with yellow sputum that occurred intermittently
without associated fever, throat pain, dyspnea, nausea and
vomitting. No consultation was done. He self-medicated with
Erythromycin and Butamirate citrate (Sinecod forte)
simultaneously with unrecalled dose, 3x a day for 7 days, the
symptom then subsided after taking medications, but re-emerged
a few days later after the medication was stopped. There was no
consultation done. He self-medicated again with Erythromycin and
Butamirate citrate (Sinecod forte) simultaneously with unrecalled
doses, 3x a day for 7 days. The symptom then again subsided after
taking medications, but re-emerged a few days later after the
medication was stopped. There was still no consultation done. He
resumed the same medication for the next 2 months.
 3 weeks prior to admission, the patient still experienced
moderate productive cough with yellow sputum, but with
associated pleuritic pain at the right lower lobe, this prompted
him to sought consult at De Los Santos Medical Center. He was
diagnosed with Pneumonia and was prescribed with
Acetylcysteine (Fluimucil) 600 mg, 1x a day for 5 days,
Montelukast + Levocetirizine HCl (Zykast) 10 mg, 1x a day for 7
days.
6 days prior to admission, the patient was switching on the
light when he suddenly lost his balance and fall on his right hip,
the patient was admitted in Philippine Orthopedic Center due to
right hip fracture. He was then advised and transferred to QCGH
due to severe cough and a request for CT-Scan. The patient was
then diagnosed with unrecalled diagnosis. He was treated with
Rifampicin 150 mg + Isoniazid 75 mg + Pyrazinamide 400 mg +
Ethambutol HCl 275 mg, once a day for 6 months.
 Past Medical History
• He has unrecalled childhood vaccination
• He has unrecalled childhood illness
• He had surgical procedure for appendicitis but unrecalled age,
had cataract surgery 7 years ago at Mandaluyong Hospital.
• He was previously diagnosed with Parkinsons Disease, 2018
at Delos Santos Medical Center and was prescribed with
Levodopa (Lavida)
• He had his blood transfusion, 1 bag of unrecalled content.
• He denies having allergies to foods and drugs 
Family History

75
Personal and Social History
• He attained 3rd year college BS in
Mechanical Engineering at FEU Manila
• He was a mechanic since 14 years old and a
driver at Saudi
• He is married with 1 child
• He smoke at least 10 sticks per day (18
pack/years) and drinks 1 bottle of beer
occasionally
• He sleeps for 8 hours and 30 minutes a day
Personal and Social History

• He prefers to eat fruits, vegetables and meat

• He drinks 5 glasses of water and 1 cup of coffee
per day
• He lives with his wife in their own house, two stories
high with 2 rooms, 1 CR, well
ventilated, and
located near the highway road and river
• Water supply is from Maynilad
• Garbage disposal was collected every Monday and
Wednesday
• There is no history travel
 Review of System

• General: (-) body weakness, (-) weight gain, (-) fatigue, (-) chills (+) loss of appetite
• Integument: (-) excessive seating/dryness, (-) cyanosis, (-) itchiness, (-) pallor, (-)
jaundice, (+) erythema
• HEENT:
• Head: (-) headache, (-) dizziness, (-) vertigo
• Eyes: (-) pain (-) excessive tearing (-) doubling vison, (+) blurred vision (+) use of
glasses
• Ears: (-) hearing loss (-) tinnitus (-) earache (-) discharge
• Nose and Sinuses: (-) change in smell, (-) nasal obstruction, (-) pain, (-) itching (-)
nose bleeding
• Throat: (-) hoarseness (-) sore throat, (-) toothache, (-) gum bleeding, (+)
disturbance in taste
• (+) feeling of obstruction
• Neck: (+) limitation of movement (-) pain (-) lump
 Review of System
• Breast: (-) pain, (-) lumps, (-) discharge
• Pulmonary: (-) hemoptysis (-) wheezing
• CVS: (-) chest pain (-) palpitations (-) syncope, (-) easy fatigability
• GIT: (+) loss of appetite (-) dysphagia (-) nausea and vomiting (-) diarrhea,
(-) constipation, (-) pain, (-) hematemesis, (-) melena, (-) hematochezia
• GUT: (-) frequency (-) dysuria (-) urgency (-) hematuria (-) discharge (-)
incontinence (-) pruritus
• Musculoskeletal: (-) edema (+) swelling of joints (-) numbness (+)
limitation of movement (+) stiffness
• Neuropsychiatric: (+) tremors (-) loss of consciousness (-) focal weakness
(-) paresthesia (-) speech disorder (-) loss of memory (-) confusion
• Endocrine: (-) polydypsia (-) hot or cold intolerance (-) polyuria (-)
polyphagia (-) excessive sweating
• Hematology: (-) bleeding tendency (-) easy bruising
Physical Examination
 General Survey:
• Patient is lethargic, coherent with normal
speech, less cooperative and bedridden, with
small body built, post op hip fracture, no
jaundice, no pallor, not in cardio respiratory
distress.
 Vitals signs:
• BP – 120/90 mmHg, sitting, left arm
• RR – 21 cpm
• PR – 63 bpm
• T – 36.6 °C
 Integument:
• Brown skin, abundant freckles, dry, mobile,
less elastic, poor skin turgor, normal
vascularity, (+)scar on right medial aspect of
the foot.
• Hair – white and unevenly distributed
• Nails – pink nail bed, with good capillary refill,
no swelling of nail folds
 HEENT
Hair – white, unevenly distributed, no flakes
Scalp – no tenderness, no masses
Face – no facial asymmetry, no tics, with appropriate facial expression
Eyebrow – evenly distributed
Eyelid – not puffy, no ptosis
Eyelashes – present in both upper and lower eyelids
Conjunctiva – Pink
Sclera – anicteric, no dilated blood vessels
Cornea – transparent
Iris – brown, no lesion
Pupils – equal, round, reactive to light and accommodation
Lens – Transparent
Ears
No deformities, no tenderness of pinna and mastoid
Ear Canal – No lesion, no discharge

Nose
Nasal septum – midline. No flaring of ala nasi, patent nostrils
Nasal Vestibule – pink, no lesion, no discharge
Paranasal sinuses – No tenderness

Oral Cavity
Lips – Pink, no lesions
Teeth – No dental Carries
Gums – Pink, no bleeding, no hypertrophy
Buccal Mucosa and palate – pink, no lesion
Uvula – Midline
Tonsils – Not enlarged
Pharynx – Not congested
Neck
Trachea – midline
Thyroid – not enlarged
(-) Lymphadenopathies
 Chest and Lungs

Chest is elliptical and symmetrical, no dilated

superficial blood vessels, no skin lesions, no
scars, no widening or narrowing of the
intercostal spaces, no retractions, normal tactile
fremitus on anterior chest, resonant on
percussion on anterior chest, vesicular breath
sounds, no crackles and wheezes on anterior
chest.
Cardiovascular:
• Precordium – adynamic, apex beat is in the 5th ICS
LMCL, no heaves no thrills
Normal S1 and S2 as to intensity,
(-) S3 (-) S4 (-) murmur (-) friction rub

• Vasculature - no neck vein engorgement (R) Neck, (-)

carotid bruit (R) Neck, carotid (R) Neck, brachial, radial
are strong equal peripheral Pulses with regular rate and
rhythm.
Peripheral pulses not done.

 
 Abdomen:

• Flat abdomen symmetrical, no skin lesions no

striae, (+) appendectomy scar, no prominent
blood vessels, hyperactive bowel sounds, no
bruit on the abdominal aorta.
• Palpation and percussion not done.
 Extremities

(+) Status Post Op (R) hip fracture

(+) (R) Condylar External fixator
(+) (R) Hip Swelling
Partial Range of Motion on Shoulder, Hip, Knees,
Ankle and Toes
No Tenderness
 Neurologic Exam

Cerebral Function – Lethargic, Coherent,

oriented to time place and person, with good
immediate recall, recent, remote memory,
speaks with ease and fluency, can calculate, can
follow simple and complex command
Cranial Nerve Exam:
CN I – able to smell alcohol with eyes closed in both nostrils tested
separately
CN III, IV, VI – Full Extraocular muscle movement
CN V – Can Clench teeth, can feel light touch on both sides of face
CN VII – can smile and frown without facial asymmetry
CN VIII – Can repeat whispered word on both ears tested
separately
CN IX, X – (+) gag reflex
CN XI – Can turn head side to side
CN XII – Can protrude tongue

Cerebellar Function
(+) Tremors
can do finger to nose test
Case 1
Primary Impression and Basis
PRIMARY IMPRESSION: Pulmonary Tuberculosis

BASIS:
 75 y/o
 Lives in the Philippines
 Chronic cough (8 weeks)
 Pleuritic pain
 Loss of appetite
 Automotive mechanic worker
 smoker
Signs and Symptoms

( Clinical Manifestations )
 Cough

Ward Case 1: Tuberculosis

Clinical Manifestation
Presented by:
John Joshua Lacson
Source: Harrison’s Principle of Internal Medicine 20th Edition, Part 2: Cardinal Manifestations and Presentation of Diseases,
Section 5: Alterations in Circulatory and Respiratory Functions, 34 Cough; Christopher H. Fanta, P.230-232
 Cough
• Sudden forceful noisy expulsion of air from the Lungs
• Essential protective function for Human Airways and Lungs

– Ineffective Cough Reflex (at risk for):

• Infection
• Atelectasis
• Respiratory compromise

– Excessive Coughing can be exhausting and harmful

• Complicated by:
– Emesis
– Syncope
– Muscular pain
– Rib Fractures
• Aggravated by:
– Low back pain
– Abdominal hernia
– Inguinal hernia
– Urinary incontinence
 Impaired Cough

• Weak or Ineffective Cough

– Compromises the ability to clear Lower Respiratory Tract secretions,
predisposing to more serious infections and their sequelae
Table 34-1 Causes of Impaired Cough
Decreased Respiratory Muscle Strength
Chest Wall or Abdominal Pain
Chest Wall Deformity (severe kyphoscoliosis)
Impaired Glottic Closure or Tracheostomy
Abnormal Airway Secretions
Central Respiratory Depression (anesthesia, sedation, coma)
 Symptomatic Cough

Cough Onset Cough Duration Possible Etiology

Acute Cough < 3 weeks Respiratory Tract Infection
Aspiration
Inhalation of Noxious Chemicals
Smoke Inhalation
SubAcute Cough 3 – 8 weeks Tracheobronchitis residuum
Pertussis
PostViral Tussive Syndrome
Chronic Cough > 8 weeks Cardiopulmonary Diseases
Inflammatory
Infectious
Neoplastic
Cardiovascular
 Assessment of Chronic Cough
• Proper History and Physical Examination
• Chest Radiograph
– Abnormal Chest Film:
• prompts an evaluation aimed at explaining the radiographic abnormality
• Chronic Productive Cough:
– Sputum Examination
• Purulent: routine Bacterial Culture, Mycobacterial Culture
• Mucoid: Cytologic Examination
• to assess for Malignancy, Oropharyngeal Aspiration
• to distinguished Neutrophilic from Eosinophilic Bronchitis
• Blood Expectoration: special approach to assessment and management
 Chronic Cough with Normal Chest
Radiograph
• Chronic Unexplained Cough are most
commonly related to one or a combination of:
– Post Nasal Drainage
– Gastroesophageal Reflux
– Cough-Variant Asthma
– Drugs (ACEI)
 Symptom-Based Treatment of Cough
• Empiric Treatment of Chronic Idiopathic Cough:
– Inhaled Corticosteroid, Inhaled Anticholinergic Bronchodilators and Macrolide
Antibiotics has been tried without consistent success
• Cough Suppressants: modestly effective
• Narcotic Cough Suppressants
– Codeine or Hydrocodone: act in the Brainstem (cough center), cause drowsiness
and constipation, and potential for addictive dependence limit their appeal for long
term use
• Central Acting Cough Suppressants
– Dextromethorphan: fewer side effects and less efficacy
• Non-Narcotic Oral Antitussive
– Benzonatate: inhibit neural activity of sensory nerves in the cough-reflex pathway
– Generally free of side effects
– Effectiveness in suppressing cough is variable and unpredictable
 PULMONARY TB (Primary TB)
• Asymptomatic
• Fever
• Pleuritic Chest Pain (occasional)
• Ghon Focus (lesion accompanied by Transient
Hilar or Paratracheal Lymphadenopathy)

• Erythema nodosum (legs)

• Phlyctenular conjunctivitis
 PULMONARY TB (Post-Primary/Adult-type)
(Reactivation/Secondary TB)

• Non-specific, Insidious
• Diurnal fever, Night Sweats
• Weight loss
• Anorexia
• General Malaise, Weakness
• Cough (90%)
• Hemoptysis (20-30%)
• Pleuritic Chest Pain(+subpleural parenchymal
lesions/ pleural disease)
EXTRAPULMONARY TB (Tuberculous Lymphadenitis)
(Lymph Node TB)

• Painless swelling of the Lymph nodes

(Scrofula)
– Posterior cervical
– Supraclavicular
 EXTRAPULMONARY TB (Pleural TB)
• Fever
• Pleuritic Chest Pain
• Dyspnea
• Pleural Effusion
– Dullness to percussion
– Absence of breath sounds
 UPPER AIRWAYS TB (Larynx, Pharynx,
Epiglottis)

• Hoarseness
• Dysphonia
• Dysphagia
• Chronic Productive Cough

• Ulceration
 Genitourinary TB
• Asymptomatic
• Urinary frequency
• Dysuria
• Nocturia
• Hematuria
• Flank/Abdominal pain
• Female (more common)
– Infertility
– Pelvic pain
– Menstrual abnormalities
• Male
– Orchitis
– Prostatitis
 SKELETAL TB (Bones and Joints)
• Spinal TB (Pott’s Disease/Tuberculous Spondylitis)
– Upper Thoracic Spine (children)
– Lower Thoracic and Upper Lumbar Vertebra (adult)

– Paraplegia (catastrophic complication)

• TB of the Hip Joints
– Pain (involving head of the femur)
• TB of the Knee
– Pain
– Swelling
 TUBERCULOUS MENINGITIS AND TUBERCULOMA

• TB of the Central Nervous System

– Young Children (most often)
– Headache
– Low-grade fever
– Malaise
– Anorexia
– Irritability
– Slight mental changes
– Coma
 GASTROINTESTINAL TB
• Abdominal pain
• Swelling
• Obstruction
• Hematochezia
• Palpable mass
• Fever
• Weight loss
• Anorexia
• Night Sweats
PERICARDIAL TB (TUBERCULOUS PERICARDITIS)
• Subacute-Acute onset
• Dyspnea
• Fever
• Dull retrosternal pain
 MILIARY/DISSEMINATED TB
• Non specific
• Yellowish granulomas (1-2 mm)
• Fever
• Night Sweats
• Anorexia
• Weakness
• Weigh loss
• Cough
• Hepatomegaly
• Splenomegaly
• Lymphadenopathy
• Choroidal Tubercle (pathognomonic)
Pathophysiology
 PRIMARY TUBERCULOSIS SECONDARY TUBERCULOSIS

• Unexposed person • Exposed person

• Exogenous organism • Usually after Latent infection

• 90% contained • Re-exposure

• Can progress to Progressive type • Apex involvement

Differential Diagnosis
 Differential Diagnosis:
• Pneumonia
• Acute Bronchitis
• COPD
• Emphysema
• Lung abscess
Laboratory Work-Up
Diagnostic Tests
• Radiologic Study
– Chest X-ray
• AFB smear microscopy and culture
• Molecular Method
– Nucleic Acid amplification test
• The Xpert MTB/RIF assay
• Gene Xpert
Treatment
Diagnostic Tests
• Radiologic Study
– Chest X-ray
• AFB smear microscopy and culture
• Molecular Method
– Nucleic Acid amplification test
• The Xpert MTB/RIF assay
• Gene Xpert