NAME:

AGE: 38

SEX: MALE

ADDRESS: MARRIED

TRIBLE: KIGOGO

OCCUPATION: PEASANT

RELIGION: CHRISTIAN

M/STATUS: MARRIED

INFORMANT: HIMSELF

REFERRAL: FROM HOME

DOA: 13/07/2024

DOC: 14/07/2024

1 DAY POST ADMISSION

No known chronic illness

M/C: Cough for 1/12

HISTORY OF PRESENTING ILLNESS

The patient was apparent well until 1month prior to admission when he started to experience ough that
was of sudden onset, productive in nature, the sputum was yellow in color with no foulish smell later
become stained with blood, amount was approximately ½ of cup of tea(100ml) in each episode of
cough. Having no specific periodicity but become more marked during night, it has no aggravated
factor or relieving factor. It associated with chest tightness and night sweats, no history of chest pain
and difficult in breathing. However, he was diagnosed with pulmonary tuberculosis fifteen years ago,
patient has history of using 3 units of beer and 2 cigarettes per day. After arriving at Amana hospital
blood and urine sample was taken for investigations, he is now in medications with good progress

REVIEW OF OTHER SYSTEM

GIT: No history of difficulty in swallowing, abdominal pain or distension, vomiting, nausea and difficult in
passing stool.

CVS: No history of heart palpitation, orthopnea, shortness of breath, difficulty in breathing on lying flat

GUS: No history of painful urination, frequent urination, blood in urine, urine retention

MSS: No joint stiffness or pain, muscle spasms or pain

HEENT: No history of pain, bleeding or discharge

PAST MEDICAL HISTORY

Patient was admitted 15 years ago because of pulmonary tuberculosis, no history blood transfusion, no
history of trauma or surgical intervention, no history of food and drug allergy, no history of chronic use
of medications and herbs

FAMILY AND SOCIAL HISTORY

The patient is the sixth born in a family of 9 children on his paternal and maternal side he said there is
no history of any chronic disease or hereditary disease likes diabetes, heart diseases and hypertension.
The patient takes 3 units of beer and 2 cigarettes per day. He is married with four children, all are alive
and healthy, his education level is standard seven living in his own house

DIATERY HISTORY

The patient takes meal three times per day. He has no habit of using vegetables and fruits frequently
and no allergy to any kind of food.

SUMMARY: 01

38 years old male presented with cough that was productive in nature, the sputum was yellowish later
stained with blood, it associated with night sweats and chest tightness. Uses alcohol and cigarette
smoking, he was diagnosed 15 years ago with pulmonary tuberculosis.

PHYSICAL EXAMINATION

GENERAL EXAMINATION

The patient is ill looking, he is now conscious, febrile, moderate paleness, not cyanosed, not jaundiced,
no dehydration, not dyspneic, no angular stomatitis, oral hair leukoplakia and oral ulcers, no finger
clubbing, presence nicotine stain, no edema, no jane way lesions and osseous node, no
lymphadenopathy.
Temp: 36.8 Respiratory Rate 22 breaths/min

Blood pressure: 124/78mmHg SPO2:99% Pulse rate 88 beats per min

Pulse rate was 88 beats per minute, regular-regular, strong volume, non-collapsing, radial pulse was
synchronized with contralateral femoral pulse

SYSTEMIC EXAMINATION

RESPIRATORY EXAMINATION

INSPECTION: The patient has normal chest shape, no scars and chest wall are moving with respiration

PALPATION: The trachea is centrally located, increase of tactile vocal fremitus in all lung fields anteriorly
and posteriorly

PERCUSSION: dullness sound was heard

AUSCULTATION: Presence of crackles

CENTRAL NERVOUS SYSTEM EXAMINATION

HIGHER CENTERS

The patient has both short and long term memory, can orient to place person and time with

Patient was able to sense on different positions and able to sense vibrations and pain

REFLEXES

Deep tendon reflexes; There was no hypoflexia or hyperflexia elicited at patella ankle and triceps

Superficial reflexes; Babinski’s extensor plantar response was negative, superficial abdominal, corneal
and plantar were all present

Meningeal signs; kerning sign and brudzinski sign were negative

CARDIOVASCULAR EXAMINATION

INSPECTION: normal shape of precordium, no visible cardiac impulse, Jugular veins were not prominent

PALPATION: No swelling or tenderness at precordium, apex beat was palpable at fifth intercostal space
along mid-clavicular line
AUSCULTATION: First and second heart sounds were heard at mitral, aortic, tricuspid and pulmonary
areas. No murmur

PER ABDOMINAL EXAMINATION

INSPECTION: Normal abdominal contour, moves with respiration, umbilicus is centrally located and
inverted, no visible peristalsis, no traditional or surgical scars

PALPATION: no tenderness was observed on superficial palpation and on deep palpation no any
tenderness, or mass observed, kidney, liver and spleen were not palpable. No renal angle tenderness

PERCUSSION: Normal tympanic note was heard

ON AUSCULTATION: 2 bowel sounds/min, no abdominal bruits

INTERGUMENTARY SYSTEM

Hair; well distributed hair, no alopecia, normal texture and color

Skin; No hypopigmentation, rashes, subcutaneous swelling sores and swelling

Nails; No koilonychias, bleeding from nail bed color change, shape change or pain

Mucous membrane; No bleeding, change in color or soreness

SUMMARY 02

38 years old male presented with cough that was productive in nature, the sputum was yellowish later
stained with blood, it associated with night sweats and chest tightness. Uses alcohol and cigarette
smoking, he was diagnosed 15 years ago with pulmonary tuberculosis. On physical examination there is
decrease in tactile vocal fremitus’ dullness sound on percussion and crackles on auscultation.

PROVISIONAL DIAGNOSIS

Pulmonary tuberculosis

DIFFERENTIAL DIAGNOSIS

Chronic obstructive disease

bronchiectasis

INVESTIGATION

Full blood picture and serum electrolyte

Chest x ray
Bronchoscopy

Culture and sensitivity

MANAGEMENT

Frequent monitoring of vital signs

Standard treatment of TB involves 6 months treatment with Isoniazid and rifampicin supplemented in
first 2months with pyrazinamide and ethambutol.