Submitted to Dr Kindu
Submitted by Samuel Masresha
MDR 68/12/02
April 6, 2012
Case report
Identification:
Name: Mihretab Abriha Age: 9 years Sex: male
Educational status: 3rd grade
Mother: Alganesh Age: 35 years
Occupation: house maid
Educational status: no education
Religion: Christian, orthodox
Address: Gofa, A.A
Date of admission June 4, 2011 G.C
Date of clerking April 1, 2012 G.C
Department Of Pediatrics and Child Health
Casualty ward, Bed #13
Historian:
Mother, without language barrier
Previous admission:
Mentioned in HPI
Chief complaint:
Shortness of breath and easy fatigability of 2 months duration
HPI:
The patient is a 9 year old relatively healthy boy who experienced shortness of breath
and easy fatigability of two months duration. His symptoms started when he was on a trip,
traveling by bus in which the ambient temperature was high. One day after the onset of his
symptoms, he received medical attention at Mekele Hospital and was diagnosed with heart
failure. He was treated with an oral diuretic and discharged after 2 months with an order of
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nasal O2 to be available from his home. The mother brought him to Tikur Ambessa hospital
because she could not afford the O2 setup at home.
The onset of his symptoms was gradual. The shortness of breath is brought about by
activities like walking for more than 10 minutes or climbing stairs. His symptoms have worsened
progressively. Nasal O2 alleviates his shortness of breath. He experiences dizziness associated
with his symptom. He also has a history of PND and orthopnea of 3 pillows. He has taken
spironolactone but symptoms persisted. He arrived at the hospital walking supported by his
mother.
His father died 3 years ago from pulmonary TB. At the age of 5, the patient had
complained of persistent cough and was treated for pulmonary TB with oral antibiotics for 8
months. His symptom had subsided at the end of therapy.
o His house condition is poor in ventilation. He does not have a current history of night
sweats, fever or recent weight loss. He has received BCG vaccination at birth.
o He has mild, intermittent, bilateral pain in the elbow and knee joints. He does not have a
history of frequent tonsillitis. He has no history of involuntary limb movements. He does
not complain of subcutaneous skin lesions.
o He has no history of a recent infection like malaria, measles, or pertussis.
o He has no history of cough, chest pain, wheezing or allergies.
o He has no history of swelling over the legs or lower trunk.
o He has no family history of heart disease, DM, hypertension or asthma.
o No history of loss of appetite.
o He has no history of diarrhea and was found sero-negative for HIV at Mekele hospital.
History of past illness:
Mentioned in HPI
Family
The mother works as a cleaning lady to support the family. He has three brothers, aged 18, 6
and 4, and two sisters, aged 15 & 5. His eldest brother assists in generating income for the
family by working as a mechanic at a local garage. The boys sleep in the same room used for
cooking. They have adequate and clean water supply. The family shares a single latrine.
Immunization
The patient is immunized according to the EPI, inferred from age at immunization.
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Nutrition
He was exclusively breast fed until 6th week. He was breast fed until the age of 1 and a half
years. He received complementary feeds like cow milk and injera. He was exposed to adequate
direct sunlight. He has grown up eating injera his entire life.
Developmental
The mother does not recall the exact time of his developmental milestones like starting to walk
or starting to talk; but she claims he plays and socializes well with his peers.
Review of symptoms
General:
No history of fever, chills or weight loss. No changes in sleeping pattern.
H.E.E.N.T
Head: no history of headaches or trauma
Ears: no history of ear aches, hearing loss or ringing in the ears
Eyes: good vision, no history of discharge or double vision
Nose: no history of discharge, bleeding, sneezing or stuffiness
Mouth & throat: complains of pain in the palate, no history of bleeding gums, he has shed his
first premolar deciduous tooth and the permanent first premolars have not erupted yet, no
difficulty in swallowing or hoarseness of the voice
Respiratory: mentioned in HPI
CVS: mentioned in HPI
GIS: no history of nausea, vomiting, diarrhea or constipation. No loss of appetite
GUS: no history of painful urination, urination at night, urgency or discharge. No change in urine
color
Integumentary: no history of rash, itching, hair change or yellowish discoloration of the skin.
Locomotor: no weakness or limitation of movement.
CNS: no numbness, seizures or defect in speech. No urine or stool incontinence
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Physical exam
General appearance:
The patient is on nasal O2 supply and but looks malnourished. Otherwise, he does not appear
sick looking, no gross deformities. No discoloration. He is awake and alert.
Vital signs:
Blood pressure: 90/59 mmHg right arm, supine, both systolic & diastolic values are b/n
10th &25th percentiles
Respiratory rate: 40 breathes /min tachypnic
Pulse rate: 84 beats /min (right radial artery)
Temperature: 36⁰c, axillary mild hypothermia
O2 saturation: 84% with nasalO2 hypoxic
Anthropometery:
Weight: 26.8 kg b/n 25th and 50th centile [NCHS]
Height: 130 cm b/n 25th and 50th centile [NCHS]
Head circumference: 51cm b/n x̄ and -2SD
Mid upper arm circumference: 17 cm
Chest circumference: 59 cm
H.E.E.N.T
Head: no swelling, no indentation, no area of tenderness, normal shape and hair distribution,
closed fontanels.
Eyes: normally spaced eyes, no discharge, pink conjunctiva, non-icteric sclera, no nystagmus or
strabismus.
Ears: normal position, normally shaped pinnae, no discharge, no tenderness over the mastoid
process
Nose: no discharge, patent choana, central septum, no tenderness over the maxillary or frontal
sinuses
Mouth: cyanosis of the lip but pink tongue and buccal mucosa, no cleft lip, normal size and
position of the tongue. White coating over the upper surface of the tongue, erupted central
and lateral incisors. No carries. No swelling of the tonsils.
Lymphoglandular system
Bilaterally palpable posterior cervical lymph nodes of 1cm diameter. The nodes are non-tender,
mobile and firm in consistency. The overlying skin is not inflamed. Other lymph nodes are not
palpable. Thyroid is not enlarged. Breast tissue is not palpable.
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Respiratory system:
Inspection: tachypnic, no other signs of respiratory distress, no central or peripheral cyanosis,
no clubbing, symmetrical chest expansion
Palpation: chest expansion of 07mm. no area of tenderness or subcutaneous crepitation.
Centrally positioned trachea, comparable tactile fremitus.
Percussion: resonant bilaterally, diaphragmatic excursion is 4cm on both sides
Auscultation: normal air entry on both sides, no modified or additional breath sounds. No
wheezing. No stridor. No pleural friction rub
Vocal resonance: bronchophony is absent
Cardiovascular system
Arteries: pulse is palpable over the radial, carotid, femoral and dorsalis pedis arteries. The rate
is 84 with regular rhythm. The volume is full. There is no radio-femoral delay.
JVP: elevated JVP, 5 cm above the sternal angle.
Inspection: the precordium is active, no bulging of the chest. The hands have no janeway
lesions or splinter hemorrhages. There is no palmar pallor
Palpation: the PMI is diffuse, there is a parasternal heave, and a palpable valve sound over
the pulmonary area. There is no thrill
Auscultation: valve sounds are heard over the aortic, pulmonary, tricuspid & mitral areas. P2 is
accentuated. no murmurs or pericardial friction rubs.
Gastrointestinal system
Inspection: scaphoid shape, symmetrical, no flank fullness, moves with respiration, no
distended veins, no visible scars, inverted umbilicus, no hernia at the umbilical, epigastric,
femoral or inguinal sites.
Palpation: no superficial mass or tenderness. Liver is not palpable. No splenomegaly, no deep
mass.
Percussion: tympanic all over. Total vertical liver span = 6cm, along mid-clavicular line
Rectal exam: not done due to lack of patient cooperation
Auscultation: active bowel sounds of 10/min. no renal artery bruit
Genitourinary system
Inspection: no distension over the suprapubic area, no visible lesions, pendulous penis, ruggae
over scrotum present, no epispadias, no hypospadias,
Palpation: kidneys are not palpable, no tenderness over the genitalia, testes in scrotum, no
scrotal swelling.
Locomotor system
No gross deformity, no swelling over the limbs or joints. The patient has a normal gait. There is
no asymmetry in limb size or movement. No tenderness or limitation of movement
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Integumentary system:
Skin: Five dark-brown macules on the medial side of the right arm. No jaundice, pallor or
cyanosis of the skin. No areas of hyper or hypopigmentation. The skin is dry and warm. Skin
pinch goes back quickly.
Hair: thick curly black hair over the head.
Nails: normal shape, no cyanosis, no pallor, no inflammation
Central nervous system:
General: conscious and well oriented to person place and time, good short term and long term
memory. Pays attention and speaks coherently.
Scores 15/15 on the Glasgow coma scale. Normal posture.
Cranial nerves:CN I smells alcohol
CN II identifies colors red, green and blue, good acuity and field of
vision, direct and indirect pupillary light reflexes are present
CN III, IV &VI patient looks in all directions with both eyes symmetrically
CN V intact sensation over the face, normal bulk of masseter &
temporalis muscles, corneal reflex present
CN VII face is symmetrical at rest and upon voluntary movements like
smiling, nasolabial folds are present bilaterally
CN VIII good and equal hearing,
CN IX & X central uvula, no hoarseness of sound
CN XI patient shrugs and turns head against resistance
CN XII central position of tongue upon protrusion, no atrophy of the
tongue
Motor: bilaterally comparable muscle bulk of limbs, no spontaneous or induced fasciculation,
normal muscle tone,
Muscle power: upper limb left right
flexors of fingers 5/5 flexors of fingers 5/5
Finger abduction 5/5 Finger abduction 5/5
Abduction of thumb 5/5 Abduction of thumb 5/5
Wrist flexion 5/5 Wrist flexion 5/5
Wrist extension 5/5 Wrist extension 5/5
lower limb left right
dorsiflexion 5/5 dorsiflexion 5/5
plantar-flexion 5/5 plantar-flexion 5/5
knee extension 5/5 knee extension 5/5
knee flexion 5/5 knee flexion 5/5
hip extension 5/5 hip extension 5/5
thigh flexion 5/5 thigh flexion 5/5
adduction of thigh 5/5 adduction of thigh 5/5
abduction of thigh 5/5 abduction of thigh 5/5
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superficial reflexes: abdominal present cremasteric present
plantar down going corneal normal
deep tendon: biceps: 2/4 triceps: 2/4 brachioradialis 2/4
patellar: 2/4 ankle: 1/4
sensory: tactile sensation is intact throughout the surface of the body, vibration
sensation over bony prominences and position sense of joints are intact
cerebellar sensation: finger to nose, finger to finger, heel to sheen, rapid alternating movement
are intact
cortical sensation: one point determination, two point discrimination, graphesthesia,
steriognosis are intact
Meningeal signs: no nuchal rigidity, absent kernig’s and brudzinsky’s signs .
Summary:
Subjective findings:
shortness of breath, 2 months
easy fatigability, 2 months
joint pain
orthopnea and PND
history of treated pulmonary TB,
diagnosis of CHF at Mekele Hospital
Objective findings:
nasal O2 supply, decreased chest expansion,
malnourished cyanosed lips,
appearance, elevated JVP of 5 cm above
tachypnea of 40 sternal angle,
breathes/min, active precordium,
mild hypothermia of 36⁰c diffuse PMI,
hypoxia of O2sat 84% parasternal heave,
with oxygen, accentuated P2
Differential diagnosis:
Cor pulmonale secondary to TB
CHF secondary to anemia of chronic disease
Rheumatic valvular heart disease
Interstitial lung disease
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Discussion:
Interstitial lung disease: ILD is a set of diseases that includes Idiopathic pulmonary fibrosis,
Nonspecific interstitial pneumonia, pneumoconiosis, sarcoidosis, connective tissue diseases and
the like. These diseases may be precipitated by infection, prolonged exposure to irritants or any
inflammation of the lung parenchyma. It commonly affects adult age group and those exposed
to certain substances. The usual presentation is progressive dyspnea with physical finding of
tachypnea. Even though the prognosis for each type of ILD varies, Idiopathic pulmonary fibrosis,
the worst and most commonly diagnosed interstitial lung disease usually, eventually progresses
to cor pulmonale from pulmonary hypertension.
The reasons supporting this diagnosis are the presentation of dyspnea with tachypnea, a history
of prolonged inflammation during TB infection, history indoor air pollution. Hypoxia even under
nasal oxygen supply suggests fibrosis or some other parenchymal lung disease. The presence of
associated joint pain indicates connective tissue disease. However, the young age of the
patient, absence of cough, failure to thrive, clubbing, wheezing, cyanosis or hemoptysis are
non-indicative of the disease even though they do not rule it out.
Rheumatic heart disease:
Rheumatic fever is the most common cause of acquired heart disease in a developing country
like ours and commonly affects children between 5 and 15 years of age. The major risk factor is
a pharyngeal infection by group A streptococcus. This immune mediated disease commonly
affects the valves that close under high pressure (aortic and mitral.) Unless early prevention by
treating the pharyngitis is made, the disease is difficult to treat often requiring heart surgery. So
it has a generally poor prognosis in our setup.
In this case the mitral valve may have been affected resulting in left ventricular failure and
pulmonary hypertension. The history of arthralgia supports diagnosis. However, there is no
history of recurrent pharyngitis, rash or any physical findings of murmur from affected valves to
support the diagnosis.
CHF secondary to anemia of chronic disease:
Anemia of chronic disease results from release of inflammatory cytokines such as IL-1 and TNF,
which mediate the suppression of erythropoietin release and decrease bone marrow sensitivity
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to erythropoietin. In addition, chronic inflammation induces secretion of hepcidin from liver
that results in decreased iron absorption from the gastrointestinal tract and decreased release
from iron stores. This results in a normochromic type of anemia. Anemia may lead to the
tachycardia evident in our patient and eventual left heart failure. This will explain the
pulmonary hypertension. The chronic disease causing anemia is considered to be the
pulmonary tuberculosis that the patient was treated for. However, there are no physical
findings like palmar or conjunctival pallor and tachycardia. The absence of pallor does not
preclude diagnosis because there can be anemia without pallor.
With erythropoietin therapy and resolution of the pulmonary TB, the prognosis of this patient
depends on the extent of cardiorespiratory damage.
Cor pulmonle secondary to TB:
Pulmonary hypertension may result from a number of disorders but relevant to this case is the
history of pulmonary TB. This chronic inflammatory condition ultimately results in healing by
fibrosis of the lung parenchyma. The fibrosis leads to pulmonary hypertension, which leads to
right sided heart failure.
This is the most likely diagnosis as the patient has had a history of pulmonary TB with a
reasonable interval between the appearance of the current symptoms and TB disease. Elevated
JVP, P2 accentuation and a parasternal heave strongly suggest pulmonary hypertension.
However, the absence of other associated symptoms of right sided heart failure like
hepatomegaly and edema of the dependent body parts either indicate a wrong diagnosis or a
mild form of the disease.
The prognosis of the patient depends on nasal oxygen availability and development of
complications like infection that could worsen the lung fibrosis.
Investigation
Chest X-ray
Echocardiogram
Electrocardiogram
Pulmonary function test
CBC
Hematocrit