24/12/2025
Clinical Case received about six months ago
(received at 8pm)
A 74yr old male who presented with cough and fever of 3days duration
History dates 3days ago when pt developed an unproductive cough,persistent with no duinal variation,no exacerbating factor.associated to R lateral chest pain ,piercing in nature,graded 5/10 per vns,non radiating ,aggravated by coughing with no notion of worsening on deep inspiration and difficulties in breathing .Evolution 1 day later was marked by an onset of an ungraded intermettent fever associated to anorexia where pt auto medicated with carbocysteine 5% syrop and Artemeter lumefantrine cp and paracetamol cp which mild relief symptoms. Persistence of cough with addition of fatigue prompted consultation to our service .
Past History
PMH:History of Dry/unproductive cough for the past 1yr,Has had multiple consultations in the past.An xray done 2 months ago revealed heterogeneous nodules on R lung.
-Known hypertensive >5yrs ago being followed up with Amlodipine 10mg (1cp/jr),HCT 25mg(1cp/jr) compliant to meds.
-HX of osteosarcoma of R lower jaw since 3 years after presenting with painless mass on R lower jaw.
-PSH:Nil
-Immunoallergy:Blood group and electrophoresis unknown,No hx of any transfusion.
-Toxicology Hx:Does not smoke,Consumes alcohol occasionally
-Social Hx:Does not stay in a crowded area,1 person coughing around him.
FamilyHx;No history of cancer in the family.
Review of systems
Asthenia(+),Anorexia(+), Unquantifiable weight loss since 6months ago,Cough(+),chest pain at R lateral chest wall,SoB(-), otypnea(-),palpitations (-),pedal oedema (-),Abdominal pain (+),vomiting(-),Urinary incontinence(+),Weakstream(+),Straining(-),dysuria(-),Intermitency(-),Incomplete emptying (-).Urgency(-), Frequency (-)
Physical exam
Pt is calm,Conscious oriented to person,place and time
Bp;147/67mmhg
P:92%
P:56blm
T:36,7delgree celcuis
FBS:1.05g/dl
Pink conjunctivae,anicteric sclerae,Hard mass at lower R jaw around mandibles,nontender,non movable,about 18mm in size, no palpable lymphadenopathy.
No signs of respiratory distressTenderness on palpatikn of right later chest wall,Increase tactile vocal fremitus on R lung,fine crackles on both lung fields but more marked at middle and lower lobes of right lungs,S1S2 heart sounds present with no added sounds
No suprapubic globe,Abdominal tenderness marked at hypochondriac,Epigastric and suprapubic region.
DRE:revealed enlarged prostate,rubbery,mildly tender,symmetric,smooth.
Rest of physical exam unremarkable
Diagnosis
1) Community acquired pneumonia (Hx of cough,chest pain,fever,Consolidation syndrome on right side,Acute onset )
-Diff Dx
1)Metastatic Lung Cancer (Hx of mandibular osteosarcoma,long standing Hx of cough,Tumoral syndrome:Asthenia,Anorexia,unquantifiable weight loss
Points against:Absence of other functional signs like Dyspnea,Hemotypsis.
2) Pulmonary TB( Hx of Cough,fever,Constitutional symptoms)
Point against:Absence of risk factors
(Leaving in crowded area,immunocompromised)
Associated diagnosis
Benign prostatic hypertrophy (Hx of Urinary incontinence and weak stream..Enlarged smooth,rubbery,symmetric prostate)
Workup
1)Chest xray PA view
2) NFS
3) CRP
4) PSA
5) urea,Creat
6)BU
7)Ionogram simple
😎 Germ xpert
Results
WBC:5000cells/mm3
Gran :3200cells/mm3
Hb:13g/dl
CRP: 96mg/dl
Urea:0.47g/l
Creat:13mg/l
Na:133mmol/l
K:5.8mmol/l
Chlo:78mmol/l
PSA:45ng/l
Rest of results still pending
Plan
1)N/S o.9% 500cc 12hrly
+ 1bco
2)Amoxiclav 1g/8hrly inj
3)Acupan 20mg/8hrly inj
4) Omeprazole 40mg/24hrly
Follow up this morning
Pt is calm conscious
Vitals
Bp:126/76mmhg
P;56b/m
Spo2:95%
T:36.6delgree celcuis
Clo Headache,Cough
Chest pain(+),Epigastric pain(+)
Physical exam unchanged as of yesterday
Ass stationary
Plan
1)Do ECG
2) Continue ongoing treatment
