Name: Marital Status: Single

Age: 15 Ethnicity:

Sex: M Date of Clerking:

Occupation: Historian: The Patient

Address: Date of Admission:

Religion: Orthodox Ward:

Department: Internal Medicine Bed No:814.5

Previous Admission

Non

Chief Complaint

Bilateral neck swelling, 1 year Bilateral inguinal and arm pit swelling, 9 months

History of Present Illness

The patient was relatively healthy 1 year ago at which time he started to experience bilateral gradual
swelling of the lateral neck. The swellings at first were similar to the size of a bean but with time increased
in size. It was itching, non-movable and non-tender. After few weeks he started to develop fever which was
continuous for few weeks and interrupted for several days followed by periods of remission and was
accompanied by night sweats and gradual loss of appetite.

After 3 months the increasing swellings brought difficulty in eating solid foods and breathing. He also
started to experience gradual onset of fatigue, bilateral swellings of the arm pit and the inguinal area
which had the same properties as the primary swelling and intermittent productive cough of yellowish
sputum of about half Arabic coffee cup per 24 hours. The sputum didn’t give any odor. The cough was
worst ant night and was exacerbated by lying on supine position.

Following these symptoms, he first went to a local traditional healer who gave him a topical remedy to rub
on the swelling. After few days of applying the substance the swelling over later neck started to ulcerate
and bleed for few minutes.

Due to this he went to a local clinic which upon history and physical examination referred him to a health
center near town. There he had unspecified laboratory examination the result of which the source of
history doesn’t know but was again referred to Petros Hospital in Addis Ababa.
In Petros Hospital he had a chest x-ray, a series of laboratory examinations and a sample was taken from
the left lateral neck swelling the result of which the source of history doesn’t know. Following this he was
referred to Black Lion Hospital.

He had no chest pain, hemoptysis, bluish discoloration of the finer nails, palpitation, leg edema, orthopnea
or paroxysmal nocturnal dyspnea. There was no bone or joint pain. No red discoloration of urine. No skin
lesions, eye pain or photophobia. No History of contact with a chronic cougher or exposure to raw milk,
radiation or insecticides. No change in bowel habit. He is not from malaria endemic area. He was not tested
for RVI.

There was no obvious color change observed by the patient but he has lost around 7kg in the course of his
illness. He is very weak and easily tired and as a result it is almost four months since he stopped going to
school. He came to the hospital driven by a taxi and was carried to his bed by his father.

Past Illnesses

No chicken pox, mumps, small pox or any other childhood diseases.

No history of surgery, trauma, psychiatry problems or drug allergy.

Functional Inquiry

H.E.E.N.T

Head: No headache or trauma

Ears: No loss of hearing, discharge, earache, vertigo or tinnitus

Eyes: SEE HPI. No disturbance of vision, strain, lacrimation, or itching

Nose: No epistaxis or discharge

Mouse and throat: No dental pain, bleeding from the gums, sore throat or tonsillectomy.

Glands: SEE HPI and Chief Complaint. No heat or cold intolerance.

Respiratory System: SEE HPI. No wheezing.

Cardiovascular system: SEE HPI.

Gastrointestinal system: No nausea, vomiting, heart burn, abdominal pain, jaundice, bloody, tarry or clay-
colored stools.

Genitourinary system: No flank pain, dysuria, urgency, hesitancy, dribbling or pyuria.

Integumentary system: Moist skin, no rashes or ulcers, no changes in hair distribution or pigmentation.

Allergy: No asthma, drug sensitivity, or food allergy.

Locomotor system: No bony deformities, no joint pain.

Central nervous system: No forgetfulness, seizures, nervous breakdown or insomnia.

Personal History

He was born in a small village in QerisaWereda, Oromia Zone where he lived all his life. He has a healthy
childhood and is an active boy who likes playing with his friends. He is in the second grade and helps his
father with farming in his spare time.

He denies of alcohol, tobacco or chat use.

Family History

Father and mother:His father and mother are alive and living well. His father is a farmer and his mother is a
house wife.

Siblings: He has two sisters and two brothers. All are living well.

Family Diseases: There is no family history of tuberculosis, allergy, diabetes mellitus, hypertension, or
sudden deaths.

Physical Examination
General Appearance

The patient is alert and lying at about 40 0angle. He doesn’t seem to be depressed. He has swellings on the
lateral neck. He has difficulty in breathing and appears to be in respiratory distress.

Vital signs

BP:105/58mmHg, right arm, sitting positionPulse:102/min., regular, full volume

RR:45/min, shallow, normal rhythm T0:36.30c, axillary, mid-day

Weight: 35 Kg

H.E.E.N.T

Head: Normal size, shape and hair distribution, No scar.

Ears: Normal contour of pinna. Clear external ear canal.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. The conjunctiva is
pink. The sclera is not icteric. No funduscopic examination was done.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge

Mouse and throat: The lips show no fissure, ulceration or herpes. The gums are intact and show no
ulceration. There are no carious teeth, extractions, dentures or filling. The tongue is pink and doesn’t show
any atrophy. The tonsils are intact and moderately enlarged.

Lymphatic and glandular system

There are multiple large matted lymph nodes all over the anterior and posterior cervical, sub-mandibular,
sub-mental, posterior and pre auricular, occipital, axilla, supra-clavicular and inguinal area with ulceration
on the right and left anterior cervical. They are hard, fixed, warm, non-tender, and non-pulsatile. The size
varies between 15 cm by 11 cm (right lateral neck) to 3cm by 2 cm (inguinal Lymph Nodes).

The thyroid enlargement could not be assessed due to the massive enlargement of the lymph nodes. No
tremor or lid lag. Both Testicles are descended.

Respiratory System

Inspection: There is no cyanosis but there is clubbing of the fingers (Grade II). The palms are not pale.
Breathing is shallow and is of higher rate. The chest is symmetrical. No deformities, surgical scars or
visible pulsations but there are visible dilated vessels over the neck and upper chest.

Palpation: The position of trachea could not be assessed. There is no tenderness over the anterior or
posterior chest. The total circumferential chest expansion is 1 cm along the nipple line on deep
inspiration. Tactile fremitus is normal both in the right and left side. Chest expansion is
symmetrical.

Percussion: Both right and left anterior chest is resonant but posteriorly there is dullness over the right
lower lobe area while the left one is resonant. Diaphragmatic excursion is 2 cm.

Auscultation: There is decreased air entry, crepitation and pleural friction rub are heard over the posterior
right lower lobe area. Breath sounds over other lung areas vesicular. No wheezing.

Cardiovascular system
Arteries: BP and pulse (see under vital signs). There is no hardening of the vessel wall. Pulse volume can be
tabulated as follow:

Carotid Axillary Brachial Radial Femoral popliteal PT DP

Right +++ ++ ++ ++ +++ ++ ++ ++
Left +++ ++ ++ ++ +++ ++ ++ ++

No radio-femoral delay detected.

No bruit over the carotid or femoral artery.

Veins: There are distended veins over the neck and the upper area of the chest wall.

Hepato-jugular reflex and JVP was not assessed because of the mass over the neck.

Precordium

Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse is visible at the fourth intercostal space along the mid clavicular line (7cm from the sternum).

Palpation: The point of maximum impulse is felt where it is visible. It has a diameter of 2.5 cm and it is
tapping. There is no parasternal or apical heave. There is no thrill. The heart sounds aren’t palpable.

Auscultation: Both heart sounds are normal over the valvular areas. There are no added heart sounds
(split, gallop, ejection click, opening snap) or murmurs.

Gastrointestinal system

Inspection: The abdomen is flat, symmetrical and moves with respiration. There is no flank fullness. There
are no dilated veins, surgical scars or masses. The umbilicus is inverted. Hernia sites are free. No visible
pulsation or peristalsis.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or liver
areas.

Palpation:
  Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was also
no tenderness upon such palpation.
 Deep palpation: The liver is palpable up to 4 cm below the right costal margin but it wasn’t tender.
The spleen is not palpable.

Percussion: No shifting dullness or fluid thrill. No flank dullness. The total vertical span of the liver along the
right mid-clavicular line is13 cm.

Integumentary System

The skin is warm with no rash or ulcers. But there are scars all over the chest and abdomen consistent with
scratch marks. There is normal hair distribution. The nails don’t show spooning but clubbing (grade II) is
present.

Locomotor System

There is no muscle tenderness or spasm. There is no bone deformity or tenderness. There is no stiffness of
the joint.

Nervous system

Mental Status:

The patient is conscious, fully cooperative and doesn’t show any signs of depression.

He knows what day it is, where he is and what his name is. Orientation

He remembers what he ate for breakfast. He also remembers where he used to live. Memory

He speaks in a low voice but there is no hesitancy or gaps in the flow and rhythm of his words. Speech

He denies any hallucinations or delusions.

Cranial Nerves:

N-I: Smells alcohol via each nostril.

N-II: He can differentiate 2 fingers at about 4 meters. (Visual Acuity)

He sees waggling of finger approximately 100 0 from axis of eye. (Visual Fields)

He differentiates green and red colors. (Color Appreciation)

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are round,
regular in outline and equal in size. Pupillary reflex couldn’t be assessed due to absence of torch light.

N-V: He identifies light touch and pin prick over the mandibular, maxillary and ophthalmic areas of the face.
He closes his eyes at the touch of the cornea with a cotton swab. Contraction of the temporal and masseter
muscles is symmetrical and strong.

N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising the eye brows). He
can close both eyes equally and forcefully.

N-VIII: He hears rubbing of the fingers on both ears.

N-IX & X: The soft palate rises in the midline when saying ‘ah!’

N-XI: The Sternocleidomastoid and trapezius muscles contract on turning the head and on shrugging the
shoulder against resistance, respectively.

N-XII: The tongue protrudes in the midline and shows no fasiculation or atrophy.

Motor:

 Muscle bulk: There is no muscle bulk difference between the left and the right side. There is also
no spontaneous as well as induced fasciculation.
 Muscle tone and power.

TONE POWER
Upper Lower Upper Lower
Right Normo-tonic Normo-tonic 5 5
Left Normo-tonic Normo-tonic 5 5

0 – no active contraction 1 - flickering movements 2 - movement in horizontal axis

3 - movement against gravity only 4 - movement against gravity + mild resistance 5 - normal power
Coordination:

Finger to nose, heal to shin and rapid alternating movement of the arm were done without any
abnormalities.

Pronator Drift test was negative.

Reflexes:

 Superficial reflexes: All the plantar, abdominal, & corneal reflexes are intact.
 Deep tendon reflexes:

Biceps Triceps Supinator Patellar Ankle

Right ++ ++ + ++ +
Left ++ ++ + ++ +

 Clonus: No clonus

Sensory:

 He identifies light touch and pin prick over the extremities and trunk.
 He appreciates the form of a key by means of only touch (Stereognosis)
 He recognizes writings of different numbers on his palm (Graphesthesia)
 He is able to differentiate 2 pin pricks up to 4 mm apart over the finger tips (2 pt discrimination).

Meningeal Sign:

 No neck stiffness.
 Kernig's Sign is negative.
 Brudzinski's Sign is negative.
Summary of problems
 Subjective summary:
o Bilateral lateral neck, armpit and groin swelling
o Fever
o Night sweat
o Pruritus
o Productive cough of yellowish sputum
o Dysphagia
o Dyspnea
o Fatigue
o Anorexia
o Weight loss

 Objective summary:
o Hypotension
o Tachycardia
o Tachypnea
o Enlarged thyroid
o Shallow Breathing
o Decreased Chest expansion
o Crepitations, pleural friction rub, decreased tactile fremitus and air entry over the posterior
right lower lobe
o Multiple large matted lymph nodes over the cervical, submandibular, supraclavicular,
axillary and groin area
o Grade II Clubbing
o Dilated vessels over the neck and upper area of chest
o Hepatomegaly
Differential diagnosis
 Non- Hodgkin’s Lymphoma
 Hodgkin’s Disease
 Tuberculosis (Disseminated)
 Sarcoidosis

Discussion of the differential diagnosis

 Sarcoidosis

Initial findings of, fatigue, malaise, weight loss, pulmonary symptoms,generalized lymphadenopathy,
dyspnea, dysphagia (due to, bilateral hilarand right paratracheallymphadenopathy) are common in
sarcodiosis and are also pertinent in this patient.

But the age of the patient, absence ofsplenomegaly,arthralgia,substernal chest pain, muscle weakness
and pain, phalangeal and nasal mucosal lesions, subcutaneous skin nodules, eye pain, photophobia and
peripheral nerve palsies make this diagnosis unlikely.

 Tuberculosis (Disseminated)

Chronic cough, fever, chills, fatigue,clubbing, night sweatsand weight loss are in accordance with
tuberculosis. And the fact that there is generalized lymphadenopathy and hepatomegaly indicates
disseminated tuberculosis to these sites.

The dullness of the chest and decreased tactile fremitus also point to this direction.

But the fact that the patient had no previous history of chronic chough or contact with a chronic
cougher, the presence of pruritus and the absence of hemoptysis and pleuritic chest pain makes this
diagnosis less likely.

 Hodgkin’s Disease
Common early signs and symptoms include pruritus, fatigue, weakness, night sweats, malaise, weight
loss, and fever (pel-ebsteins) which are all consistent with the findings in this patient. The dysphagia,
dyspnea, the dilated veins over the upper area of chest (superior venacaval syndrome) and the
pulmonary findings on the physical examination can all be explained by pressure produced by
mediastinal lymph nodes enlargement which is a pertinent finding in Hodgkin’s disease.

The age of the patient is also in accordance with that of Hodgkin’s disease.

Even though the swellings are hard and non-tender the fact that it’s matted, the pattern of spread,
which in this case is centrifugal (from the center to periphery) and that there is no splenomegalyaren’t
consistent with findings in Hodgkin’s disease.
  Non- Hodgkin’s Lymphoma

Painless enlargement of one or more peripheral lymph nodes is the most common sign of this disease,
with generalized lymphadenopathy. Dyspnea, cough, superior venacaval syndrome,and hepatomegaly
occur, along with systemic complaints of fever, night sweats, fatigue, malaise, and weight loss which
are all found in this patient.

The pattern of spread which is centrifugal, the involvement of the oropharynx (enlarged tonsil –
waldeyer’s ring) and the pulmonary findings on the physical examination are in accordance with that of
non-Hodgkin’s lymphoma.

But the age of the patient and the absences of enlargement of the epitrochlear lymph nodes, bone pain
and splenomegaly aren’t consistent with the findings of non-Hodgkin’s lymphoma.

Diagnostic Workup
 Complete Blood Count
 ESR
 Chest X-Ray
 Acid Fast stains from the sputum
 Lymph node Fine Needle Aspiration
 Lymph node biopsy