grand round 3

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Title: grand round 3

1
GRAND ROUND PRESENTATION

GROUP MEMBERS
- ABDULRAHMAN IDARUS
- IDA JOHN BUSHAIJA
- CHANCE OCTORVIAN
- FATEMA JAFFER
- ALINANUSWE MPETA
FACILITATORS
- Dr. CATHERINE CHACHA
- Dr. BILQIS NASSOR

2
PATIENT PARTICULARS

PATIENT INITIALS KHS
D.O.B 15/09/1993 (30 YEARS)
SEX MALE
ADRESS KINONDONI
TRIBE MUHA
OCCUPATION COOK
RELIGION MUSLIM
NEXT OF KIN MOTHER
MARITAL STATUS SINGLE
SELF REFFERAL
DATE OF ADMISSION 27/11/2023 DATE OF
CLERKING- 5/12/2023
DAYS IN THE WARD- 8 DAYS
INFORMANT- PATIENT

3
CHIEF COMPLAINT

COUGH 2/12
DIFFICULT IN BREATHING 4/7

4
HISTORY OF THE PRESENTING ILLNESS

The patient was apparently well until 2 month ago
when he started experiencing dry cough of gradual
onset, more marked at night, aggravated when
smoking cigarettes, partially relieved by
medication.
One month later the cough worsened which was
associated with on and off fever, night sweats,
fatigue and weight loss such that his clothes
dont fit him anymore.
It was also accompanied with sharp right sided
chest pain radiating to the back and aggravated
by deep breaths.

5
HISTORY OF THE PRESENTING ILLNESS

He also presented with difficult in breathing for
4 days which was of sudden onset which occurred
through out the day aggravated by lying on the
right side and relieved by changing to the left
side or sitting upright and was not associated
with wheezes.
He denied awareness of heartbeat, shortness of
breath and lower limb swelling.
He was transferred from surgical ward where he
was admitted for 3 days as he had abdominal pain,
which was treated by medication and referred to
medical ward due to difficult in breathing, cough
and drenching night sweats.

6
REVIEW OF THE OTHER SYSTEM

GASTROINTESTINAL SYSTEM
No abdominal pain
No vomiting
No passage of loose stool
No inability to pass stool

URINOGENITAL SYSTEM
No painful urination
No blood in urine
No waking up at night to urinate
No overwhelming desire to urinate
No change in frequency of urination
No genital itching
No urethral discharge

NERVOUS SYSTEM
No headache
No blurry vision
No dizziness
No convulsion
No loss of consciousness
No numbness
No tingling sensation

ENDOCRINE SYSTEM
No excessive hunger
No excessive thrist
No cold or heat intolerance
No excessive hair growth
No loss of libido.

MUSCULOSKELETAL SYSTEM
No joint or muscle pain
No joint or muscular swelling
No joint deformities
HEMATOLOGICAL SYSTEM
No easy bruising
No bleeding tendencies

INTEGUMENTARY SYSTEM
No skin rashes
No itching
No hair loss
HEENT
No pain, discharge or swelling on eyes, ears or
nose
No throat pain or neck swelling.

PAST MEDICAL HISTORY
This is his 1st admission
He had few OPD visits of which he doesn't
remember the reasons
Positive history for a minor surgical procedure
on the thumb to remove an abscess, which was
successfully done as an outpatient 5 years ago at
a health dispensary.
No history of blood transfusion
No history of any chronic illness

FAMILY HISTORY
He is the 2nd child out of 3 children.
Patients mother is known hypertensive patient
and the patient's father was diabetic but is now
deceased, the cause of his death was not
determined.

SOCIAL HISTORY
He is cohabitting with his fiance , have no
children
Is a cook for 7 years.
He is a smoker for the past 11 years and smokes
17 cigarettes per day ( pack years- 9.35)
Has a history of smoking marijuana in some
ocassions. About 1- 2 pc every 1 week.
He lives on a small house not well ventilated and
is surrounded by friends who smoke Cigarretes
No positive hx of TB contact.
No history of alcohol use
The patient exercises regularly by running more
than 1 hour per day, every 3 days a week.

DIETARY HISTORY
The patient takes 3 meals
Morning the patient takes cassava or buns with
tea
Afternoon he takes ugali, meat and vegetables
Evening he takes potatoes and fruits.
He also takes about 4 liters of water, as he
spends more time near heat during cooking.
His diet is satisfactory

ALLERGY HISTORY
The patient has no known allergy to food or drugs
DRUG HISTORY
Patient has no HX of using long term medications

17
SUMMARY 1

I present to you a 30 years old male known smoker
who presented with dry cough, pleuritic chest
pain, difficult in breathing, night sweats, fever
and weight loss with no wheezes.

18
Clinical diagnosis based on history

1. Pulmonary Tuberculosis
Reason for a) cough
b) night sweat
c) weight loss
d) fever
e) difficult in breathing
f) chest pain

19
DDX due to history

1. community acquired pneumonia
reason for a) cough
b) fever
c) chest pain
reason against a) No sputum production
b) chronic cough
Lung malignancy
Reason for a) positive hx of smoking
b) positive hx of B Symptoms

20
PHYSICAL EXAMINATION

GENERAL EXAMINATION
-The patient was conscious ,ill-looking, with a
green cannula on his left hand and urinary
catheter in situ which had 100mls of dark
yellowish urine collected over 8hrs. The hair
distribution ,texture and color was normal and
was not easily pluckable, he was not pale, not
jaundiced, not cyanosed, no angular chelitis.
-The axillary lymph nodes were bilaterally
enlarged/palpable about 2 cm, warm, mobile,
tender and firm.
-There was finger clubbing and presence of
nicotine stain on finger tips,no splinter
hemorrhages, no oslers nodes or janeway lesion,
no palmar erythema,no dupuytren contracture, no
koilonychia, no leukonychia.
-No lowerlimb edema.

VITALS
Temperature 36.5 degrees centigrade
pulse rate 88bpm
respiratory rate 20 breaths per minute
blood pressure 130/88mmHg
spo2 97 on RA

SYSTEMIC EXAMINATION
Respiratory Examination
On inspection
Abnormal chest contour, the chest was inclining
more towards the right.
RR- 20 B/MIN
Presence of traditional markings at the center of
chest.
Right sided of the chest below the axilla was
expanded.
- Respiratory pattern was normal
- There was no sign of respiratory distress such
as nasal flaring exhale through pursed lips or
use of accessory muscles
There was diminished chest movements on the right
side
Chest tube insitu at right side 5th intercostal
space along axillary line, draining about 2000
mls of pinkish frothy fluid.

On palpation
- The trachea was deviated to the left side.
Tenderness on right sided of chest.
Cardiac apex beat was at 5th ICS deviated lateral
to the MCL
- There was diminished chest expansion on the
right side
Tactile vocal fremitus was diminished on the
right side.
No palpable/ enlarged LN on supraclavicular and
cervical area

On percussion
The right side of the chest was dull to
percussion along the right lung fields.
On auscultation
There were diminished breath sounds on the right
lung fields
- There was decreased vocal resonance on the
right side of the chest.

2. Cardiovascular system
Capillary refill was less than 2 sec.
The right radial pulse rate was 104 beats per
minute with regular rhythm, normal character, non
collapsing and synchronous with other arteries
(radial, brachial, carotid, femoral).
The blood pressure was 130/88 mmHg at Korotkoff
phases 1 and 5.
Neck veins were not distended.

Precordial examination
On inspection,
- there were no surgical or traditional scars.
- There was no precordial hyperactivity or
bulging.
- There was no prominent superficial veins.
On palpation,
- the apex beat was located on the left fifth ICS
lateral to the mid clavicular
line.
- It was non tapping and non heaving.
- There were no heaves and thrills.

On auscultation,
S1 and S2 were audible on the 4 valvular areas.
- No added or abnormal sounds.

3. Gastrointestinal system
On examining the mouth, there were no lesions in
the oral cavity.
The tonsils were not enlarged and not hyperemic.
Grayish discolouration on the hard palate
On per abdomen inspection,
Normal abdominal contour.
Abdomen moved with respiration.
- The umbilicus was inverted and retracted.
- There were no surgical or traditional scars.
- There were no distended veins or visible
pulsations

On palpation,
- there was no superficial or deep tenderness.
- No palpable organomegaly or masses
On percussion
Dull note was heard at upper right quadrant
Tympanic note on the rest of the abdomen
On auscultation,
- there were no renal or hepatic bruits.
- Bowel sounds were heard 3 in a minute.

4.Nervous system

CENTRAL NERVOUS SYSTEM
Higher centers
The patient had GCS of 15/15.
He had good concentration
He had normal speech and coherent language.
Both long term and short term memories were
intact.
He was calm and oriented to person, place and
time.

Cranial nerves
CN 1 (olfactory)
The patient could smell an orange peel with each
nostril.
CN 2 (optic)
The patient had normal visual field and visual
acuity of 20/20 on both eyes.
Pupil reflex was normal on both eyes.
CN 3, 4 and 6 (oculomotor, trochlear, abducens)
-The patient could move his eyes in all
directions.

CN 5 (trigeminal)
- The patient sensed fine touch on his facial
divisions of the ophthalmic, maxillary and
mandibular branches on both sides.
- The masseter and temporalis muscles were
palpable on clenching his teeth.
- He could open his mouth against resistance.

CN 7 (facial)
- The patient could taste on anterior two-thirds
of the tongue.
- He could raise his brows, close his eyes shut
equally on both sides
- could blow his cheeks with air and was able to
hold when resistance was applied.

CN 8 (vestibulocochlear)
- Able to hear normal sound and whisper
- Air conduction was better than bone conduction
in both ears as demonstrated by Rinnes tests.
- Webers test was negative as he heard equally
on both ears.
CN 9 and 10 (glossopharyngeal, vagus)
- Patient could swallow.
- Uvula was not deviated.

CN 11 (accessory)
- The patient could shrug his shoulders against
resistance
- Could turn his neck sideways against
resistance.
CN 12 (hypoglossal)
The patient could protrude his tongue and move it
side to side.
- No deviations or tremors were present.

PERIPHERAL NERVOUS SYSTEM
Motor examination

R.U.L L.U.L R.L.L L.L.L
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movements NIL NIL NIL NIL
Gait - - - -
Tone NORMAL NORMAL NORMAL NORMAL
Power 5/5 5/5 5/5 5/5

Coordination Coordination was intact as
performed by the finger nose test and Rapid
alternating movements of the hand.

7. Reflexes

DEEP TENDON REFLEXES RIGHT SIDE LEFT SIDE
BICEPS REFLEX NORMAL NORMAL
TRICEPS REFLEX NORMAL NORMAL
PATELLA REFLEX NORMAL NORMAL
ACHILLES REFLEX NORMAL NORMAL
BABINSKI DOWNWARD DOWNWARD

SUPERFICIAL REFLEXES Abdominal reflexes present.

Sensory examination
-He could sense pain, pressure and crude touch on
both upper and lower left and right sides.
-He could perceive vibrations and fine touch on
both upper and lower limb.
-Joint position was intact.

Summary 2
I present to you a 30 years old male known smoker
who presented with dry cough, pleuritic chest
pain, difficult in breathing, night sweats, fever
and weight loss. However he denies awareness of
heartbeat, lower limb swelling, wheezing.
On physical examination the patient had
bilaterall palpable axillary lymph nodes with
finger clubbing and nicotine finger stains. On
respiratory system examination there was abnormal
chest contour, expanded on the right side with
diminished movement, reduced tactile vocal
fremitus, dull on percussion and decreased vocal
resonance on the right side.

Diagnosis based on history and examination.
Right sided pleural effusion secondary to
pulmonary TB.
Reasons for
Cough.
Night sweats.
Pleuritic chest pain.
Fever.
Diminished chest movements, decreased tactile
vocal fremitus, dullness on percussion,
diminished breath sounds on the right side of the
chest.

Differential diagnosis
Community acquired pneumonia
Reasons for
Cough.
Fever.
Reasons against
Night sweats.
Weight loss
2. Lung malignancy
Reason for a) positive hx of smoking for long
time
b) positive hx of B Symptoms

42
INVESTIGATIONS DONE

Complete blood count
S.creatinine

Serum electrolytes

1st chest xray before treatment

Control XRAY after Underwater Seal Drainage

46
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47
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48

Treatment in the wards.
IV ceftriaxone 1g od for 3 days.
IV metronidazole 500 mg tds for 3 days.
IM diclofenac 75 mg tds
Anti-TB drugs rifampicin, isoniazid,
pyrazinamide and ethambutol for two months.
Followed by 4 months of rifampicin and isoniazid.
Chest tube connected to underwater seal drainage.
Chest physiotherapy

49
Further investigations required

Stool for gene xpert
Pleural fluid analysis including- ADA

PULMONARY TUBERCULOSIS
DISCUSSION

51
INTRODUCTION

Its the oldest disease known to be affecting
humans
Caused by various strains of Mycobacteria,
usually Mycobacterium Tuberculosis.
Usually affects the lungs,
but also other body parts like lymph nodes, bowel
and brain.
( hematogenous, from adjacent organs).

52
Epidemiology

Tuberculosis (TB) is the ninth leading cause of
death worldwide and the leading cause from a
single infectious agent, ranking above HIV/AIDS.
In 2016, 2.5 million people fell ill with TB in
the African region, accounting for a quarter of
new TB cases worldwide.
An estimated 417,000 people died from the disease
in the African region (1.7 million globally) in
2016. Over 25 of TB deaths occur in the African
Region

53
Transmission

Inhalation via aerosolized, infected droplet
nuclei
Expelled when the infected person cough, sneezes
or speaks
per cough , patient can release 3000 infectious
nuclei.
Sputum smear ve can give 105-107 AFB /ml
Ingestion of unpasteurized milk( less frequent)
Skin inoculation
Transplacental route ( rare)

54
Risks from exposure to infection depends on

Presence of co-morbid conditions like DM and HIV
Use of immunosuppresants
Age e.g in children and old
Health care workers
Duration of contact with infected person
Crowding in poorly ventilated room
Individual innate immunity
Malnutrition
Smoking

55
s/s of Active TB

Chronic/persistent cough (gt14days) with
low grade fever ( more in the night, excessive
night sweats.)
Weight loss
Hemoptysis
Fatigue
Chest pain
SOB
Other symptoms depends on the affected site
e.g. TB spine, pt presents with lower back pain.

56
Classification
PTB 80 EXTRA PTB 20
Primary disease LN TB
Secondary disease Skeletal TB
Pleural TB
TB of the upper air way
Genital urinary TB
Miliary TB
Tuberculous meningitis.
57
Pathogenesis

Once inhaled the organism lodge in the lung
alveoli and initiate
recruitment of macrophages and lymphocytes,
macrophages transform into epithelioid and
Langerhans.
Then aggregates with lymphocyte forms tuberculous
granuloma
( primary lesion)
The primary lesion/Ghons focus,
Is pale yellow caseous nodule,
Situated in the peripheral area of the lung,
The same pathological reaction occurs to hilar
LN.
Combi of primary lesion regional LN form
primary complex of ranke.

58
Pathogenesis cont

Ghons complex
Made up of primary TB lesion and the enlarged
media sternal lymph node.
i.e Tuberculous infection with an associated LN.
Implantation of inhaled bacteria in lung (Ghons
focus),
followed by drainage of the bacilli to adjacent
LN (usually hilar)
Body ctrls this infection,
and hence this focus almost always fibroses and
eventually calcifies.
Common in children
they can retain bacteria and can be a source of
infection later in life.

59
Pathogenesis cont

Later calcification occurs
Limit the spread of infection
Become LATENT TB
Risk of developing disease after primary inf is
10
Lymphatic and hematogenous spread can
occur before established immunity.
Affect other organs like liver and kidney

60
Investigations

PTB
Sputum/phlegm, (2 samples taken)
For Ziehl-Neelsen /AF stain (AFB will stain
bright red, and the background will stain blue)
Gene- expert- PCR based rapid molecular assay
Auramine stain (AFB visualized by fluorescence
microscope will appear yellow or orange)
Culture test
Lowenstein- Jensen medium (mycobacterium
tuberculosis appear brown)
8-14 days.
Radiographic
CXR
CT scan
Blood test i.e. interferon-gamma release assay/
IGRA
Other inv.
WBC count
ESR