Presentation by Cathy Yaa Gyamfua Asante Akosua Ampomah Asomaning

NAME : Miss F. C AGE : 37 years SEX : female MARRITAL STATUS : single with two children OCCUPATION : Trader (plastics and footwear) RELIGION : Christian (Baptist) ADDRESS : Sefwi Bekwai Referral from Sefwi Wiawso government hospital

PRESENTING COMPLAINTS

Cough - 3/12 Abdominal Swelling - 2/12 Breathlessness - 3/52

HISTORY OF PRESENTING COMPLAINTS

Patient was in usual state of health until 3months ago when she started coughing. The cough has increased gradually in severity. It was initially productive of yellowish sputum which later had streaks of blood. It was associated with chest pains which were stabbing in nature and worst on breathing. She resorted to herbal medication which only slightly improved the cough. A month after the onset, she noticed a gradual distension of her abdomen, which was associated with generalised vague abdominal pains and early satiety. She reported to the Bibiani hospital where she was given medication on outpatient basis, however, her abdomen continued to increase in size.

3 weeks ago, she experienced the gradual onset of breathlessness. Initially she became breathless on walking for about 100m and had to stop and rest. Later she became breathless even at rest and reported at Sefwi Wiawso Hospital a week ago where a series of investigations were carried out and it was revealed to her she was HIV positive. She was referred to KATH for expert management. At KATH a series of investigations were done and she was put on medication and a chest tube was inserted and fluid drained from her chest.

PAST MEDICAL AND SURGICAL HISTORY

This is the first episode of such a presentation. Shes had two previous admissions in the past 2 years. The first was on account of profuse diarrhoea and vomiting and the second on account of a febrile illness. Shes had no surgeries nor haemotransfusion and she has no known history of chronic illness like diabetes mellitus, hypertension, sickle cell disease, heart disease nor tuberculosis.

 DRUG HISTORY

She occasionally takes paracetamol. Ibuprofen and flagyl. She also takes oral herbal medication. There is no known drug allergy. FAMILY HISTORY There is no known family history of tuberculosis, hypertension, diabetes and sickle cell disease.

SOCIAL HISTORY
The patient has two children who are 20years and 13 years old. She separated from the father of her 2 children 13 years ago because of family pressures. Her ex husband however died 5 years ago from an unknown cause. She has since had 2 sexual partners and she does not know the HIV status of both her partners and her children. She used to take alcohol occasionally but stopped 2 years ago and she does not smoke cigarette.

 Currently she lives with her younger child in a single

room apartment which has two windows and there is no history of contact with anyone with chronic cough. They drink from a community bore hole and use a public KVIP. She is registered under the NHIS.

ON DIRECT QUESTIONING
The patient has fever chill and night sweat and loss of weight. There is hematochezia and jaundice, no diarrhoea, no nausea no vomiting. She has orthopnoea , easy fatigability and pedal swelling but no palpitations and no paroxysmal nocturnal dyspnoea. There is coca- cola like urine, no dysuria, no nocturia. She has headache, dizziness and numbness in her limbs but no paraesthesia, no blurred vision and no seizures.

SUMMARY
37 year old Miss F. C. presenting with a 3month history

of cough,2 month history of abdominal swelling and a 3week history of breathlessness. There is associated haemoptysis, jaundice and marked weight loss with night sweats. She was diagnosed as retroviral positive a week ago.

EXAMINATION
On general examination, the patient is a young woman lying propped up in bed. She is conscious and alert. She looks wasted,(weight-40kgs) and her abdomen is distended. There is a chest tube insitu draining hemorrhagic fluid (700mls) There is pallor, jaundice, cervical and axillary lymphadenopathy, pedal swelling but no clubbing,no cyanosis and oral hygiene is good VITALS pulse 90bpm, BP 130/80, temp 37.90C

 CHEST

Respiratory rate is 20cpm . There is no chest deformity, no scars, trachea is central and there is no tracheal tagging. Chest expansion is symmetrically reduced, tactile fremitus is bilaterally reduced on the lower lung zones and percussion note is stony dull. Air entry is reduced bilaterally, breath sounds are vesicular and vocal fremitus is bilaterally reduced on the lower lung zones.

 PRECORDIUM

Apex beat is in left 5th intercostal space mid clavicular line. There are no thrills and no parasternal heave. First and second heart sounds are heard in all 4 ascultatory areas and there are no murmurs.

 ABDOMEN Symmetrically distended and moves with respiration. Umbilicus is flat and there are straie. There are no distended veins and no scars. There is generalised tenderness. The liver and spleen are ballotable. The liver is firm and about 18cm below the right costal margin and the spleen about 6cm below the left subcostal margin. Shifting dullness and fluid thrill are positive and bowel sounds are present.

 CENTRAL NERVOUS SYSTEM the Glasgow Coma Score is 15/15. there is no

nuchal rigidity and Kernigs sign is negative. MOTOR SYSTEM The tone is normal in all limbs and the power is 5 out of 5 in all limbs. Reflexes are normal. CRANIAL NERVES The cranial nerves are all grossly intact. SENSATION No sensory loss.

DIFFERENTIALS
Retroviral infection with: extrapulmonary tuberculosis Chronic liver disease ? Viral hepatitis or alcoholic hepatitis.

MANAGEMENT PLAN
Investigations
FBC BUN,Cr n electrolytes

ESR
Hep B & C screen LFTs

Retroviral screen
Gp & X-match

 CXR
Abdominal USG Ascitic tap microbiology and biochemistry Pleural tap culture & sensitivity,

biochemistry

RESULTS
LFTs

Albumin 1 g/dl (low); ALT 32 - (normal); GGT 58 (high) AST 102 ( high); total protein 7.9(normal) PLEURAL FLUID RBC : 10-15 HPF WBC : 5 10 HPF No organism seen on gram stain; no bacterial growth. Ascitic fluid LDH 23(low); glucose 8.7 (normal); total protein 1.8 (low) ESR 10(normal) Hepatitis B surface antigen - positive

treatment
Intranasal oxygen
IV furosemide 40mg bd Spirinolactone 25mg dly IV metronidazole 400mg bd IV cipro 500mg bd IV cefuroxime 1.5mg stat; then 250mg tds Haematinics

Tb Cotrimoxazole 960mg dly

inj Dexamethasone 12mg st., then 4mg 6 hourly Paracetamol 1g tds

 Seen at the chest clinic and anti-TB medication

started. To start anti-retrovirals later.