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Chronic cough
1. ` A T I Q A H B I N T I A B . R A H M A N
I H S A N U D D I N B I N I B R A H I M
A Z M A N B I N Z A K A R I A
CHRONIC COUGH
2. PATIENT ID
Name : Muhammad Lokman Hakim Bin Mazlan
Age : 14 years old
Origin : Kampung Panji
Gender : Boy
Race : Malay
Marital status : Single
Occupation : Student
Date of admission : 8th December 2014
Date of clerking : 9th December 2014
3. CHIEF COMPLAINT
Presented with prolonged history of SOB for 1 week
and worsening 2 days prior to admission.
4. HOPI
He is underlying:
AIDS on HAART and under Paediatrics Clinic follow
up.
He is unaware of his latest CD4/CD8 count or viral load
PTB
Diagnosed in November 2011
Frequent defaulted treatment and follow up before
Currently on anti- TB medications
5. He was previously well until 4 years prior to
admission when he first experience shortness of
breath preceded by productive cough. Before this, he
had multiple hospitalization almost thrice per year
since 4 years ago due to the same complaints and his
latest ward admission was on 26 November 2014.
6. For current admission, he presented with shortness
of breath for 1 week and worsening 2 days prior to
admission.
Sudden
On and off
Preceded and worsen by cough
Relieved by rest
7. Had productive cough for 3 days prior to admission. It was
on and off, aggravated at night, no relieving factor, and
associated with copious greenish sputum about 1 table
spoon each time he cough. However, no blood or foul
smelling associated.
Complaint of loss of appetite but no loss of weight.
No night sweats, no hoarseness of voice and no noisy
breathing.
He had history contact with TB patient in which his mother
and maternal grandfather had PTB and had pass away due
to it. Previously, patient stayed with grandfather after his
mother pass away.
8. He also experienced right side chest pain upon coughing.
The pain was sudden in onset, pricking in nature, localized,
aggravated on exertion, relieve by rest and pain score given
was 5/10. He deny pleuritic chest pain. He also complaint
with orthopnea and PND since 1 year ago
He also presented with mild fever, on and off and relieved
temporarily with medications. No temperature recorded at
home. Not associated with night sweats and chills or rigor.
No history of recent travel to endemic area, no recent
fogging activity at his house area and no history of contact
with person who had fever.
9. Also presented with fatigue and palpitation but no
headache, no faintness and no bleeding tendency.
Upon admission, he was nebulized and given
antibiotics and few investigations had been done.
Currently, patient stable, good oral intake and his
symptoms have improved.
10. REVIEW OF OTHER SYSTEMS
CENTRAL NERVOUS
SYSTEM
No blurring of vision
No drowsiness
No loss of consciousness
No fitting
GENITOURINARY SYSTEM
No hematuria
No dysuria
No urgency
No frequency
GASTROINTESTINAL
SYSTEM
Abdominal pain
No vomiting
No nausea
No change in bowel habit
No hematochexia
No malaena
MUSCULOSKELETAL
SYSTEM
No joint and bone pain
No joint swelling
11. PAST MEDICAL HISTORY
He had multiple ward admissions due to
complications of PTB.
He has no underlying any other chronic illness such
as bronchial asthma.
13. PAST DRUG AND ALLERGIC HISTORY
On HAART
Zidovudine
Lamivudine
Efavirenze
Co-trimoxazole
Anti TB
Rifampicin
Isoniazide
No history of traditional medications or supplement intake.
Deny any history of allergy towards any kind of food or drug.
14. FAMILY HISTORY
He is 7th out of 8 siblings
1st sibling- female, had CP, bed ridden and died 2 years ago (unaware of exact causes).
2nd sibling- 28 y/o, female, healthy
3rd sibling- 26 y/o male, healthy
4th sibling- 22 y/o female, healthy
5th sibling- 21 y/o male , healthy
6th sibling- 18 y/o male, healthy
8th sibling- 11 y/o female, healthy
2nd and 3rd siblings had married and living with their own family.
4th to 7th siblings stay together in one house.
8th sibling stays with aunty in Thailand.
Father 55 years old, ex-IVDU, unemployed, had second wife and both of
them had HIV, under Infectious Disease Clinic follow up and on HAART.
Mother, Siamese, HIV positive, history of PTB on treatment and pass
away 9 years ago due to endometrial cancer.
15. PERSONAL HISTORY
Previously he studied at Sekolah Menengah Kebangsaan Bukit
Besar but stop attending the class since 1 year ago due to his
conditions.
Not so active in school activities and not having much friends
at school.
Currently, he lives with his 4th to 6th siblings in single storey
house with adequate facilities. He is financially supported by
his sister(babysitter) and brothers (labourers) .
Non-smoker
Otherwise, he denied any high risk behaviour.
16. SUMMARY
14 years old boy underlying AIDS, on HAART, and
PTB on anti-TB treatment, had 4 years history of
productive cough and currently presented with
worsening shortness of breath 2 days prior to
admission. He also presented with mild fever, chest
pain upon coughing, fatigue, palpitation, loss of
appetite, orthopnea, paroxysmal nocturnal
dyspnea and abdominal pain. He had history of
contact with TB patient and both of his parents are
positive HIV.
17. GENERAL EXAMINATION
Inspection:
Thin built Malay boy, sitting comfortably, he looked
cachexic, generalized muscle wasting and slightly weak
but alert, conscious and well orientated to time place and
person. There was generalized hyperpigmented skin
lesion. He was not in pain, not in respiratory distress and
his hydrational status was fair. There was branula
attached to his left dorsum.
19. HAND
Palm -warm , pale, dry
-no palmar erythema
-no stigmata of infective endocarditis
-no flapping tremor
Nail - capillary refill less than 2 seconds
- clubbing (drumstick appearance)
- no peripheral cyanosis
- no koilonychias
- no leukonychias
EYE
No jaundice (sclera white)
Not anemic ( conjunctiva pink)
20. MOUTH
No angular stomatitis
Oral hygiene was good
Hydrational status was fair
No central cyanosis
Uvula was centrally located
Throat was not injected
LEGS
Dorsalis pedis & posterior tibial pulses were present bilaterally
No pitting edema
LYMPH NODES
No lymphadenopathy at neck and any other regions.
21. SYSTEMIC EXAMINATION
Respiratory examination:
Inspection
Chest move symmetrically with respiration and generalized hyperpigmented skin.
There was no chest deformity, no surgical scar, no dilated vein and no visible
pulsation.
There was BCG scar, no anhidrosis, no ptosis and no miosis.
Palpation
The trachea was centrally located. The apex beat was at the 5th intercostals space
medial to midclavicular line. The chest expansion and vocal fremitus were normal
and equal on both sides anteriorly and posteriorly.
Percussion
The lungs were resonant at all zones bilaterally.
Auscultation
There were vesicular breath sound at all zones of lungs. Normal air entry
bilaterally. Generalized coarse crepitation at all zones bilaterally. The vocal
resonance was normal at all the zones on both sides.
22. Cardiovasular examination:
Inspection
Chest move symmetrically with respiration and generalized
hyperpigmented skin. There was no chest deformity, no
surgical scar, no dilated vein and no visible pulsation.
Palpation
Apex beat was at 5thintercostal space, medial to midclavicular
line. There were no palpable thrill or parasternal heaves.
Auscultation
First and second heart sounds were heard with no added
sound or murmur. There was no bibasal crepitation noted.
23. Abdominal examination:
Cannot do proper abdominal examination because
patient cannot lying flat.
Inspection
Grossly, abdomen was not distended. There were no surgical scar, no
visible dilated vein, no visible peristalsis and no visible pulsation.
Palpation
Abdomen soft but tender on deep palpation at right upper quadrant.
Cannot access any hepatospleenomegaly or shifting dullness.
Percussion
Unable to access
Auscultation
There was normal bowel sound heard and no renal bruit.
