Age: 42

Add: muar

Occupation: unemployed

*Known case of HIV, Hepatitis C and recovered pulmonary tuberculosis. Patient is an IVDU.


Chief complaint:

Fever for 4 months

Cough, shortness of breath and fever for the past 3 weeks


History of presenting illness:

Fever:

Low-grade fever for the past 4 months.

Continuous fever.

Patient will have fever for 3-5 days then it resolves for a week. Patient will again have fever after that.

No chills and rigor.

No night sweat.
 


Cough:

Patient has been coughing for the past 3-4 years but it has progressively worsened in the past 3 weeks.

Productive cough: sputum initially is thick and white in color but is green in color now. Amount is around one teaspoon a day.

It is not foul smelling or blood stained.

No postural variation.

Cough is worst in the morning.

No associated chest pain.

Severe coughing episodes are associated with attacks of dyspnoea.   


Shortness of breath:

Functional class 3 dyspnoea. Breathless after walking less than 10 meters at a normal pace.

Previously had no problems with shortness of breath.

No orthopnoea and PND.

Not associated with chest pain.

Aggravating factor: coughing and exertion

Relieving factor: rest (SOB subsides after 10-15 minutes)

Past history:
Diagnosed with HIV and Hepatitis C for the past 6 years. He is on Douvir and Stockin.

Patient was diagnosed with pulmonary tuberculosis a year back and now has recovered following ATT for 6 months.

NO history of asthma, hypertension or diabetes mellitus. 


Personal history:

Patient smokes 20ciggarettes a day for the last 25 years

Does not consume alcohol.

He was an intravenous drug user (cocaine) since 20 years old but has quit 2 years back. He is currently on replacement therapy with SuperTec and Domicom. He gives a history of needle sharing.

He also gives a history of having multiple sexual partners and visiting sex workers. He however claims that he uses a condom on each occasion.

Bowel and bladder habits are normal.

No disturbance of sleep.

Appetite is normal but he has lost 3kg in the past month.


Social history:

He lives with his mother in muar.

His sisters and brothers financially support him.


Provisional diagnosis:

Acute exacerbation of chronic obstructive disease

Pneumonia

Recurring pulmonary tuberculosis
 


General examination

Patient is conscious and alert.

He appears tachypnic.

He is averagely built and poorly nourished.

Clubbing is noticed

Multiple marks of previous intravenous injection seen on the cubital fossa and dorsum of the foot.

NO pallor, jaundice, cyanosis, oedema or lymphadenopathy.


Pulse rate: 104 beats/min. regular rhythm, normal volume and no vessel wall thickening.

Respiratory rate: 22 breaths/min

BP: 100/60mmHg

Temperature: afebrile


Respiratory system

Inspection:

Horizontal scar at the sternum at the level of 3rd intercostals space measuring around 4cm.

Trachea appears central.

Chest is elliptical in shape.

Chest movement is symmetrical.

There is supraclavicular hollowing.
 


Palpation:

Trachea is central.

Chest expension is normal and equal.


Percussion:

Resonant in all areas except in the right supramammary and mammary area, which is dull.


Auscultation:

Generalized ronchi.

generalized coarse inspiratory crepitations.


Cardiovascular system

Apex beat is at the 5th intercostals space, 2 cm lateral to the midclavicular line.

JVP is normal.

No collapsing pulse.

S1 and S2 heard with no added sounds or murmurs


Abdominal system

It is soft and non-tender.

No palpable mass felt.


Significant investigations findings:

RBC: 3.11 X 10^6

Hb: 12.1gm/dl

Hematocrit: 35.5%

MCV: 114.1 fL

MCH: 38.9 pg

MCHC: 34.1%

ESR: 76 mm/hrs


Sputum:

TB smear: no significant pathogen

C/S: no significant pathogen


Urine C/S: no significant pathogen
 
 



Diagnosis:

Bronchopneumonia

Chronic obstructive airway disease