HISTORY NO.

2
Group 1-Section A
Abalos, Nikko Ryan C’zare A.
Agustin, Candy P.
GENERAL DATA
RJL, 51 years old, male, married, Roman
Catholic, Filipino, vegetable vendor, born on
September 9, 1967 in Manila, currently living in
Mindanao Avenue, Quezon City, was admitted
for the second time in QCGH on February 7,
2019.
CHIEF COMPLAINT

“Nahihirapan akong huminga”

HISTORY OF PRESENT ILLNESS
1 week PTA while the patient was hand-sawing a wood, he
experienced difficulty of breathing described as “parang nahahapo”
which occurred only while he is doing household chores requiring
moderate strength as well as walking approximately 100 yards. It is
accompanied with left chest pain described as “makirot” graded as
4/10 radiating to his left back. There were no associated sign and
symptoms noted such as cough, fever and chills. According to the
patient, the difficulty of breathing was relieved when he stopped
the activity and gets enough rest. No medications and herbal
remedies taken. That day, he consulted in Project 8 health center,
wherein they get the O2 saturation of the patient and was revealed
as 89% and then they gave him an oxygen via nasal cannula for
30minutes. After few a hours, his condition improved, he was sent
home and was given an advice to seek consultation on bigger
hospital but failed due to monetary problem.
 5 days PTA, still with the above symptoms but still manageable.
The patient wasn’t able to do any household chores due to difficulty
of breathing. He did deep breathing exercises and rested to help cope
with the current situation. That time, he started to drink smoothie
composed of malunggay leaves, carrots and bawang.

4 days PTA, he went back to public hospital to have his follow-up

check up regarding his past problem-cardiomegaly. He undergone
chest xray and it was revealed that he has a mass on right lung and
blebs on the left lung. He was then advised to be admitted but he
refused. No medications were taken.

Few hours PTA, patient experienced severe shortness of breath

which he described as “parang may nakasakal,” his son
immediately brought him to QCGH hence the admission.
INTERVAL HISTORY
He was diagnosed to have tuberculosis last
2015- treatment completed but still remain
positive despite completing supervised DOTS
treatment of 6 months, with that he undergone 8
months retreatment which again he completed.
Last October 2018, he was rushed to hospital
due to difficulty of breathing , he undergone
chest xray and it was found out that he has
cardiomegaly
PAST MEDICAL HISTORY
Patient had unrecalled childhood immunization and got a
chickenpox when he was 10 years old. No adult
immunization received. He was diagnosed to have
tuberculosis last 2015- treatment completed but still remain
positive despite completing supervised DOTS treatment of
6 months, with that he undergone 8 months retreatment
which again he completed. Last October 2018, he was
rushed to hospital due to difficulty of breathing , he
undergone chest xray and it was found out that he has
cardiomegaly. He stayed at hospital for 5 days. He is taking
carvedilol 6.25mg twice a day and apixaban 2.5mg twice a
day as his maintenance and according to patient he was
compliant. No surgical procedures in the past, no blood
transfusion as well as allergy to any food and drugs.
FAMILY HISTORY
Patient’s parents are both diabetic. His brother was
also diabetic. His grandmother died due to
complications of diabetes mellitus. The rest of the
family are apparently well. No history of
heredofamilial diseases such as cancer, hypertension
and stroke.
PERSONAL AND SOCIAL
HISTORY
Patient highest educational attainment was 3rd year HS. At the
age of 27 he worked as a factory worker, at 30 he became a
construction worker for 5 years then became a vegetable vendor at
Quiapo up to present. He started smoking cigarette at the age of 17
consumed 1 pack per day but stopped in the year 2009. He was an
occasional alcoholic drinker and denies substance abuse. Currently
living with his parents, one sibling and one son in a studio type
house with 3 windows. Preferred to eat nilagang baboy and any
dish with soup with 1 cup of rice. He usually consumes 2 cups of
coffee and 2 bottles of softdrinks every day. The patient did
exercise such as weight lifting every day for about 2hours. Usual
sleep pattern is 5-6 hours. Source of water is NAWASA. Garbage
disposal on MWFSat. Patient owns a pet cat.
REVIEW OF SYSTEMS
General: (+) chills (+) fatigue (+) weight loss
Skin: (+)color change
Hair: (+) gray hair
Head: (+) headache (+)dizziness
Eyes: (+) blurred vision (+)photophobia (+)lacrimation
Ears: (+) tinnitus
Mouth and Throat: (+)dentures (+)hoarseness
Neck: (+)stiffness
Cardiovascular: (+) easy fatigability
Respiratory: (+) cough
GENERAL SURVEY
The patient is conscious, alert and coherent and is
oriented to time, place and person. He is well
nourished, clean, well-groomed, and has appropriate
clothing. No gross deformities noted. He answers to
questions appropriately, cooperatively and calm with
no slurring in speech. He is ambulatory and afebrile.
Not in cardiorespiratory distress at the time of
examination.
VITAL SIGNS
Temperature: 36.5

Pulse Rate: 93bpm

RR: 23 bpm

BP: 110/80mmHg

SKIN
The patient’s skin is brown in color,dry, and warm to touch. There is tattoo
marking about 4 inches on his right arm. Skin turgor, elasticity and mobility
was good. Nail beds are pinkish with normal capillary refill of less than 1-2
seconds. Nails are clea, well-trimmed and no clubbing or cyanosis was noted.
HEENT
HEAD: Hair is gray in color, abundant, well-distributed, smooth and dry, no
lesion, no flakes and lice noted. The cranium is normocephalic. Scalp is
slightly movable along with the cranium, no deformities, masses and
tenderness. Temporal arteries are not visible but palpable.

FACE: Skin is brown, smooth, no lesion. Face is symmetrical, no abnormal

facies and facial movement.

EYES:Eyebrows are black and evenly distributed. Eyelashes are black, short
and present in both upper and lower eyelids. Eye lids have no edema, no
lesions, negative for lid lag, and negative for exophthalmos and
enophthalmos.
Periorbital area are not sunken, and swollen. There is no tenderness of
the eyeball upon palpation. Conjunctiva are pinkish, no swelling and no
hematoma. Sclera are anicteric and no lesions. Cornea are transparent, no
opacities, no foreign body no ulcers and. Iris are round and brown.
Pupils are round, symmetrical, about 2mm in diameter upon constriction.
Pupils are equally reactive to light and accommodation. Both lens are
transparent and no opacities. No gross defects in visual field were observed
in confrontation test.
EARS:
Patient has normal set of ears, symmetrical, no deformities and no lesions.
No tenderness over the pinna, tragus and mastoid area upon palpation. The
external auditory canal is patent. The walls are pinkish in color, with
cerumen. The tympanic membrane is pearly white in color with good cone
of light, no bulging nor retraction noted. In Weber test, both ears hear the
sound equally. In Rinne Test, the air conduction time is twice as long
compared to bone conduction.

NOSE:
Nose is located in the midline, symmetrical and blunt. No redness, bone
deformity or tenderness upon palpation. No alar flaring of the nose noted.
Nasal vestibule is patent. Nasal mucosa is reddish and abundant black hairs
not exceeding in both nostrils. No foreign body, bleeding and obstruction.
Nasal septum is in the midline without perforation and deviation. Nares are
patent and without lesion. Turbinates are pinkish, and no edema. Paranasal
sinuses are not tender upon palpation. The sinuses transilluminated equally
and well. No visible inflammation and clouding.
ORAL CAVITY
Lips are brown, moist, symmetrical, and no sores. Buccal mucosa is
moist, pinkish, no ulcers, and no visible masses. Tongue is pink in color, no
lesions, not hypertrophied nor atrophied.No deviation of tongue noted.
No dental carries and no malocclusion. Gingiva are pinkish, no bleeding,
no ulcers, and no gingival recessions. Uvula is at the midline. Tonsils are not
enlarge. Pharyngeal wall is pinkish without exudates.

NECK
Skin is brown in color, no deformity, symmetrical, and range of motion is
good. Trachea is slightly deviated to the left. Neck is supple. Thyroid
gland is palpable but not visible, and moves with deglutition. No tenderness
upon palpation.

LYMPH NODES
No preauricular, posterior auricular, occipital, submandibular, submental,
posterior cervical, anterior cervical, and supraclavicular lymph adenopathy.
Cardiovascular System
• There is no bulging or depression of the thorax with adynamic
precordium. There are no visible pulsations upon tangential
lighting.
• Carotid pulse is palpable, strong and bounding. There is jugular
vein distention, the jugular venous pressure is 7.5 cm H20.
• The apex beat is in 6th intercostal space, left midclavicular
line. No palpable thrills, heaves and lifts noted. Heart rate is 85
bpm for 1 full minute. S1 is louder in the at the apex and S2 is
louder at the base. No S3 or S4 heard. No extra heart sounds
heard.
• Peripheral pulses are bilaterally palpable with equal amplitude
and strength.
CHEST AND LUNGS
• Skin is brown in color, warm to touch. There is no
visible subcutaneous vessels, with normal muscle
development. There are no visible contractions of
accessory muscles of respiration. Bony thorax is
elliptical in shape, symmetric with no gross
deformities noted. AP diameter is 1/3 of transverse
diameter. The respiratory rate us 23 bpm with
normal depth and rhythm. There is symmetric chest
expansion, no bulging and widening of the
intercostal spaces. No chest lagging.
• There are no tenderness and masses noted upon
palpation. Patient has symmetrical lung expansion.
There is decreased breath sounds on the left lung.
Upon percussion there is hyper resonance on the
left upper lobe whereas the left lower lobe is
resonant. There is dullness in the right middle and
lower lobe and resonance on the right upper lobe.
• Upon bronchopony, sounds are muffled on the left
lung and audible in the right lung. Upon doing
whispered pectoriloquy, sounds are indistinct and
cannot be clearly heard on the left lung and clearly
heard in the right lung.
ABDOMEN
Patient’s abdominal circumference is 35 inches at the level of the
umbilicus. Abdomen is flat and symmetrical. There are no skin lesions,
superficial veins, scars, striae, and no skin discoloration. Umbilicus is
inverted. No visible pulsations or peristalsis is noted.

There are 8 bowel sounds per minute. It is normoactive. No bruit heard

over abdominal aorta, right and left renal arteries and right and left iliac
arteries.

Abdominal wall is soft with no tenderness. No superficial masses upon

light palpation. Liver, spleen, and kidneys are not palpable, no direct,
rebound and jar tenderness and no masses noted on single, bimanual, and
deep palpation.

Abdomen exhibits general tympanism. Liver span is within normal

range at 7cm. Spleen dullness is absent at Traube’s space.
SPINE AND EXTREMITIES
• TMJ. No swelling, redness, malalignment, deformities, crepitus. Able to open and
close mouth, and jut jaw forward
• Hands, wrist. No swelling, redness, nodules, deformities, or muscle atrophy. Nails are
pinkish, convex, clean, no clubbing or nail plate abnormalities. DIP and PIP no swelling,
bogginess, bone enlargement or tenderness. Full ROM (pronation, supination,
extension, abduction, adduction, handgrip, opposition of thumb). With IV line at left
hand.
• Forearm. Symmetrical(23cm). No gross deformities, swelling, tenderness, mass,
nodules. No visible lesion, abnormal pigmentation, muscle atrophy. Full ROM
(pronation & supination)
• Elbow joint. No gross deformities, swelling, tenderness, mass, nodules. No visible
lesion or abnormal pigmentation. Full ROM (flexion, extension, pronation, supination)
• Upper arm. Symmetrical (24cm). No gross deformities, swelling, tenderness, mass,
nodules. No visible lesion, abnormal pigmentation, muscle atrophy. Biceps and triceps:
no tendernss, swelling. With good muscle strength
• Shoulder. No muscle atrophy, swelling, deformities, mass, nodules, tenderness. Full
ROM on the shoulders (flexion, extension, abduction, adduction, internal and external
rotation)
• Hip. No swelling, tenderness, misalignment, deformities,
mass, nodules. No visible lesion or abnormal pigmentation.
• Thigh. Symmetrical (35cm). No muscle atrophy, swelling,
tenderness, deformities, mass, nodules. No visible lesion or
abnormal pigmentation
• Knee. No swelling, tenderness, mass, nodules. No visible
lesion or abnormal pigmentation. No cyst (anterior &
posterior). Full ROM (extension, flexion)
• Lower leg. Symmetrical (30cm). No muscle atrophy, swelling,
tenderness, gross deformities, mass, nodules. No visible
lesions or abnormal pigmentation.
• Ankle joint and foot. No gross deformities, swelling,
tenderness, mass, or nodules. No visible lesions or abnormal
pigmentation. No pedal, toes, or cutaneous abnormality. Full
ROM (dorsiflexion, plantar flexion, inversion, eversion)
NEUROLOGICAL EXAMINATION
Cerebral Function
• Patient is conscious, coherent, reactive to verbal stimuli,
good memory, can recall remote, recent, immediate
events, speak with ease and fluently, oriented to time,
place and person, show good judgment and calculation
ability.

Cerebellar
• Patient is able to perform finger to nose test, alternating
supination and pronation with accuracy and speed. Normal
base gait and normal stance seen in tandem walking.
• C.N. 1 (olfactory): able to identify odorant on both nostrils with both eyes closed.
• C.N. 2 (optic): able to read at distant of 1 foot, both eyes tested separately
• C.N. 2(optic), 3(occulomotor): reactive direct and consensual pupillary light reflex
• C.N. 3 (occulomotor),4 (trochlear),6 (abducens): intact EOM
• C.N 5 (trigeminal): can clench teeth; can move jaw side to side; can feel light
touch on both sides of the ophthalmic, maxillary, and mandibular portion of face
• C.N. 5 (trigeminal) & 7 (facial): (+) corneal reflex
• C.N. 7 (facial): can smile, frown and elevate the eyebrows equally; can wrinkle
forehead and able to feel pain sensation on the face
• C.N. 8 (vestibulocochlear): can hear whispered commands both ears tested
separately, tuning fork sound is heard equally in both ears (Weber test) and air
conduction is greater than bone conduction (Rinne Test)
• C.N. 9 (glossopharyngeal): positive gag reflex
• C.N 10 (vagus): (+) gag reflex, uvula at midline, intact voice production, no
hoarseness
• C.N. 11 (spinal accessory): able to shrug shoulders against resistance; able to turn
head side to side against resistance
• C.N. 12 (hypoglossal): tongue is midline on protrusion; negative fasciculation of
the tongue; able to push out using the tongue against resistance
• Motor Examination
• No atrophy, hypertrophy, involuntary movements nor fasciculations
were observed. Muscles are normotonic. Muscle strength in bicep,
tricep, quadriceps and ankles is 5/5 with good tone bilaterally.

• Sensory Examination
• The patient has normal pain sensation of symmetrical dermatomal
areas. The patient can also identify position by testing the
proprioception of the big toe. The vibration sense is intact on upper
and lower distal extremities. Patient can recognize objects placed in
her hand.

Deep Tendon Reflexes

• Joint reflex is intact, symmetrical, normoflexive with (-) Babinski sign

• Meningeal Signs
• Negative for nuchal rigidity, Brudzinski’s sign, Kernig’s sign.
 ADMITTING IMPRESSION

• Pneumothorax secondary to
ruptured bleb, Left;
Pulmonary Tuberculosis;
Cardiomegaly
BASIS FOR DIAGNOSIS
SPONTANEOUS PNEUMOTHORAX SECONDARY TO
RUPTURED BLEB, LEFT
POSITIVE PERTINENT NEGATIVE PERTINENT
Dyspnea Hemoptysis

Chest pain radiating to the back Pleural Friction Rub

Decreased Breath Sounds on the left lung Orthopnea

Hyperresonance of the left upper and PND

middle lobe, Decreased tactile fremitus
Trachea deviated towards the left side

Cigarette Smoking (25 pack years)

History of PTB
• SECONDARY PNEUMOTHORAX
• Secondary to a lung disease (Pulmonary Tuberculosis)
• More life threatening than it is in normal individuals
because of the lack of pulmonary reserve in these
patients.
BASIS FOR DIAGNOSIS
PULMONARY TUBERCULOSIS
POSITIVE PERTINENT NEGATIVE PERTINENT

Chills
Easy Fatigability
Weight Loss
Cough
Cigarette Smoking (25 pack
years)
History of PTB diagnosed last
June 2015 and recurred last 2016
 CLASSIFICATION OF TB
• BACTERIOLOGICAL STATUS: BACTERIOLOGICALLY
CONFIRMED
• ANATOMICAL SITE: PULMONARY TB
• PREVIOUS TREATMENT: CHRONIC CASE
• NEW CLASSIFICATION OF TB: RETREATMENT
• DRUG SUSCEPTIBILITY: MULTIDRUG RESISTANT
BASIS FOR DIAGNOSIS
CARDIOMEGALY
POSITIVE PERTINENT NEGATIVE PERTINENT

Apical beat at 6th Intercostal

Space, Left Midclavicular Line
Distended Jugular Vein with
Jugular Venous Pressure of 7.5
cm H2O.
DIFFERENTIAL DIAGNOSIS
PLEURAL EFFUSION
RULE IN RULE OUT
CHEST PAIN (-)PLEURAL FRICTION RUB

DYSPNEA (-) RALES

TRACHEA DEVIATED TOWARDS THE (-) DULLNESS UPON PERCUSSION

OPPOSITE SIDE
DECREASED BREATH SOUNDS

DECREASED TACTILE FREMITUS

DIFFERENTIAL DIAGNOSIS
PULMONARY EMBOLISM
RULE IN RULE OUT

CHEST PAIN ASSOCIATED SYMPTOMS OFTEN

NONE
DYSPNEA HEMOPTYSIS
COUGH SYNCOPE
APPREHENSION
DIAPHORESIS
FEVER
ABDOMINAL PAIN
DIFFERENTIAL DIAGNOSIS
PNEUMONIA
RULE IN RULE OUT
CHEST PAIN NAUSEA AND VOMITING

DYSPNEA DIARRHEA

FEVER HEMOPTYSIS

COUGH RUSTY COLORED SPUTUM

HEADACHE

CHILLS

SWEATING

EASY FATIGABILITY
DIFFERENTIAL DIAGNOSIS
(EARLY) LEFT SIDED HEART FAILURE
RULE IN RULE OUT
DYSPNEA RESONANT UPON PERCUSSION

Distended Jugular Vein with Jugular TRACHEA IS IN MIDLINE

Venous Pressure of 7.5 cm H2O.
CARDIOMEGALY PND

CONFUSION

ORTHOPNEA

VESICULAR BREATH SOUNDS

TACHYCARDIA

LATE INSPIRATORY CRACKLES

PATHOGENESIS
CARDIOMEGALY MECHANISM

1. EFFECT OF ANTI-TUBERCULOSIS THERAPY

• Anti-tubercular drugs are associated some
common and uncommon adverse effects. We
report the association between cardiomyopathy
and the use of anti-tubercular drugs. In the two
cases described in the case report the different
causes of cardiomyopathy are ruled out leading to
the diagnosis of drug induced cardiomyopathy. The
report also throws light on the various aspects of
this association and the clinical implications.
2. TUBERCULOUS DILATED CARDIOMYOPATHY
• Tuberculosis (TB) is generally believed to spare these
four organs-heart, thyroid, pancreas and skeletal
muscle. Involvement of myocardium by TB is rare,
and generally occurs in conjunction with pericardial
involvement. Isolated myocardial TB is a rare finding,
and definitive diagnosis during life requires a
myocardial biopsy. it should be suspected as a cause
of congestive heart failure in any patient with
features suggestive of TB, as cases of myocardial TB
almost always show evidence of TB at other sites 
• SOURCES:
• Recurrent heart failure in pulmonary tuberculosis patients on antitubercular therapy: A case of protector turning predator.
Animesh Ray MD, DNB, MRCP, DM 1,  Vivek Nangia2,  RS Chatterji3,  Navin Dalal1,  Ruchismita Satpathy Ray4. THE EGYPTIAN
JOURNAL OF BRONCHOLOGY. CASE REPORT, 2017, VOLUME 11, ISSUE 3, PAGE 288-291

• Tuberculous dilated cardiomyopathy: an under-recognized entity?. Ritesh Agarwal, 1 Puneet Malhotra

,1 Anshu Awasthi,2 Nandita Kakkar,2 and  Dheeraj Gupta1. BMC Infect Dis. 2005; 5: 29. . Published online 2005 Apr

27. doi: 10.1186/1471-2334-5-29
 LABORATORY PROCEDURES
AND DIAGNOSTIC MODALITIES

• TUBERCULIN SKIN TESTING (MANTOUX SKIN TEST)

• DIRECT SPUTUM SMEAR MICROSCOPY (SPUTUM AFB)
• CHEST X-RAY
• TB CULTURE/DRUG SUSCEPTIBILITY TESTING
• RIFAMPICIN ASSAY
• LINE PROBE ASSAY
• FAMILY HISTORY OF DIABETES MELLITUS
• RBS
• HBA1C
• FBS
• TO EXCLUDE LEFT SIDED HEART FAILURE
• BLOOD TESTS
• CHEST X-RAY
• ECG
• ECHOCARDIOGRAM
• STRESS TEST
• CT SCAN
• MRI
• CORONARY ANGIOGRAM
• MYOCARDIAL BIOPSY
TREATMENT
• Tube thoracostomy or thoracoscopy or thoracotomy
with bleb stapling and pleural abrasion
• If patient refuses surgery, pleurodesis is an option
by intrapleural injection of a sclerosing agent such
as doxycycline
END