Name-Rajender Goeteme Nationality-Kenyan

Age-60 Date of Admission-15/12/21

Sex-M Mode of Admission-Wheel Chair
Marital Status –Married for 30 years Date of Clerking-15/12/21
Educational status-Doctorate degree Source of history-Patient
Occupation-General Manager at Private Reliability-Reliable
Business
Religion-None
Address-Addis Abeba, Ethiopia

Patient Identification

History of Previous Admission

1.2005, Canada, for bullet injury had surgery to take out the bullets, stayed for 15 days improved
and discharged.

2.2013 Canada, for cardiac stenting surgery, stayed for 10 days, improved and discharged.

Chief Complaint-“Fever and chills of one week Duration”

HPI-This is a 60 years old otherwise healthy male patient who presented with a chief
complaint of fever and chills of one week duration. The fever is subjectively high grade,
intermittent and with no regular paroxysm. Associated with the fever and chills, the patient also
has fatigue which has been worsening over the week and restricting him from doing his daily
activities. In addition to this the patient also has diarrhea of 4 days duration. The diarrhea is
watery and loose and occurs 3 times a day. The patient also has dry cough, shortness of breath,
yellowish discoloration of the urine, and decrease in urine output.

The patient recently travelled to Assosa and stayed there for one month and came back two
weeks ago. He travelled using private transport and while he was in Assosa he had access to
 clean water and toilet and did not use anti-malarial bed nets and anti-malarial prophylactic
medication.

Otherwise he denies having any abdominal pain, nose bleed or any discoloration of the
skin. He also doesn’t have profuse sweating, yellowish discoloration of the eye or skin,
discomfort during bright light, and dry, brown or furred tough. Patient has no history sore
throat, runny nose, headache, muscle ache, nasal congestion, facial pain or pressure, tooth
pain, pain during breathing, wheezing ,chest pain or coughing up of blood. He did not have
exposure to bird’s feces or to any farm land. He does not have loss of appetite, rash, itching,
flank pain, confusion, thirst, urinary urgency, and frequency, Pain during urination, blood in
the urine or dizziness. The patient has no history of body piercing, tattooing, IV drug use or
blood transfusion.

He has history of smoking with 25 pack year and drinks alcohol occasionally. But doesn’t
chew Khat and doesn’t use cocaine.

Past medical history

Childhood illness-None

Adulthood history

-Doesn’t have Diabetes, Hypertension, hepatitis, Asthma and HIV.

-Hospitalization-Mentioned in the history of admission.

-Has not taken any medication in recent weeks.

Functional inquiry

HEENT Head: see HPI. No head injury, Normal hair distribution

Eyes: See HPI. No blurring of vision, pain in the eyes or orbit, eye itching, lacrimation,

Ears: see HPI. No deafness, vertigo, tinnitus

 Nose: No nose bleeds, discharge

Mouth and throat: No gum bleeding, sore throat. Good dental hygiene.

Glands: No swellings in the neck, axillae and groin, testicular swelling or pain, enlargement of
thyroid.

Respiratory system: See HPI. No expectoration, hemoptysis, chest pain, wheezing, stridor.

Cardiovascular system: See HPI. No palpitation, orthopnea, paroxysmal nocturnal dyspnea,

syncope, intermittent claudication

Gastrointestinal system: See HPI. No loss of appetite, Dysphagia, odynophagia, heart burn,
jaundice, hematemesis, hematochezia.

Genitourinary system: See HPI. No suprapubic pain , polyuria, frequency, dysuria, urgency,
hesitancy, dribbling, incontinence

Integumentary system: See HPI. No dry or moist skin, ulcers, urticaria, nail changes.

Locomotor system: See HPI. No joint deformities, bony deformities, joint pain or swelling,
limping, loss of function of limbs or joints, muscle weakness or wasting

Central nervous system: See HPI. No speech disturbance, seizures, diplopia, dysarthria, urinary
incontinence or retention, fecal incontinence or stool impaction, disturbance in sensation,
insomnia, nervous breakdown.

Personal and social history-See HPI

Family History

Mother died 10 years ago of unknown cause.

Father died 2 years ago of unknown cause

His mother had a Type 2 Diabetes mellitus.

No family history of migraine, epilepsy, asthma, malignancy or any other hereditary disease.

Physical exam

General appearance
Patient appears healthy looking, not in respiratory distress, alert and well-nourished.
Vital signs
BP: 110/80 mmHg on right arm and 100/70 on the left arm, sitting position
Pulse rate: 87 beats/min, regular, full volume, right radial artery.
RR: 18 breaths/min.
T0: 36.3oC axilla.
SPO2 :93% on atmospheric air.
HEENT
Head: the skull is normocephalic, no deformities, no depressions, no tenderness.
Eyes: symmetrical, non- icteric sclera,pink conjunctiva.
Ears: no lesion, no deformity, no masses, no discharge.
Nose: symmetric, no swelling, septum midline, no nasal discharge, no sinus tenderness.
Throat and mouth -Lips-no cyanosis, no lumps, no ulcers, no cracking.
Pink oral mucosa, no cleft lip or palate.
Normal tongue.
Lymphogladular system:
Preauricular, postauricular, occipital, submental, submandibular, anterior cervical, posterior
cervical, supraclavicular, axillary, epitrochlear and inguinal lymph nodes were not palpable.
Thyroid gland is not enlarged.
Testes were not palpated because patient wasn’t willing.
Respiratory system
Inspection: no cyanosis over lips and nails, no clubbing of fingers, no retraction, chest in drawing
or use of accessory muscles. Chest is symmetrical, no deformities and scars.
Palpation: trachea is midline, symmetric expansion of the chest, tactile fremitus is normal
bilaterally.
Percussion: resonant bilaterally. Diaphragmatic excursion- 5cm
Auscultation: vesicular breath sounds bilaterally, good air entry.
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 no distended veins over the neck, chest wall, or leg.
.No Hepato-jugular reflux.
Precordium
Inspection: There is no precordial bulge. The precordium is Quiet. The apical impulse is visible
at the fifth intercostal space along the mid clavicular line.
Palpation: The point of maximum impulse is felt where it’s seen. The heart sounds aren’t
palpable. There is no parasternal or apical heave. There is no thrill.
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. The flanks are not
full. There are no surgical scars, masses or dilated veins over abdomen. The umbilicus is
inverted. Hernia sites are free. No visible pulsation or peristalsis. No caput medusae.
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 direct or rebound tenderness.
 Deep palpation: The liver was not palpable below the right costal margin. The spleen is
also not palpable.
Percussion: There is no shifting dullness, fluid thrill or flank dullness. The total vertical span of
the liver along the right mid-clavicular line is 6 cm.
Genitourinary
No costovertebral angle or suprapubic tenderness.
Musculoskeletal system
No peripheral edema. No joint pain, redness, swelling
Integumentary system
No yellowish discoloration, no suspicious nevi, no rash, no petechiae or ecchymoses. Nails
without clubbing or cyanosis
Central Nervous system
Mental status: patient is alert and recognizes family members, conscious, fully cooperative
doesn’t seem to be depressed.
CNI: can smell alcohol through both nostrils
CNII: Intact visual acuity and color differentiation.
CNIII, IV, VI: Symmetric ocular movements. Pupils are round and have regular outline, reactive
to direct and consensual light.
CNV: Pain, touch and temperature are intact at ophthalmic, maxillary and mandibular
distributions bilaterally.
CNVII: symmetrical face on smiling, frowning, and blowing air. Intact tasting ability.
CNVIII: intact hearing to a ticking watch.
CNIX and X: Soft palate rises in the midline; uvula is in the midline. Intact gag reflex.
CNXI:The Sternocleidomastoid and trapezius muscles contract on turning the head and on
shrugging the shoulder against resistance, respectively.
CNXII: tongue is midline on protrusion and shows no fasciculation or atrophy.
Motor
Bulk: normal and symmetric muscle bulk, no spontaneous or induced fasciculation.
Muscle tone - normotonic, all extremities.
Strength- 5/5 all extremities.
Sensory: intact to light touch, pain and temperature sensation.
Reflexes
 Superficial reflexes: Abdominal reflex is present both in upper and lower quadrants.
Corneal reflex is intact in both eyes. Plantar reflex is down going on both sides.
 Deep tendon reflexes:
 Biceps Triceps Supinator Patellar Ankle
Right ++ ++ + ++ +
Left ++ ++ + ++ +

 Clonus: No clonus
 Meningeal signs: -ve Kernig and Budzinski’s signs.
Subjective Case summary

This is a 60 year old male who came with a chief complaint of fever and chills of 1
week duration. The fever is high grade, intermittent and with no regular paroxysm.
Associated with the fever, the patient also has fatigue which has been worsening over the
week. In addition to this the patient also has loose, watery diarrhea of 4 days duration. The
patient also has dry cough, shortness of breath, yellowish discoloration of the urine, and
decrease in urine output. He has a recent travel history to malaria endemic area.

Differential diagnoses (Most likely Least likely)

 Malaria
 AFI secondary to relapsing fever
 Typhoid fever
 Typhus fever
 URTI
 Sinusitis
 Acute bronchitis
 Pneumonia
 Acute Kidney Injury
 Viral Hepatitis

Discussion of differentials
Malaria
Malaria is a mosquito-borne infectious disease that affects humans and other animals. Malaria
causes symptoms that typically include fever, tiredness, vomiting, and headaches. It should be
suspected in people who are from a place where malaria is considered to be endemic.
Complications of malaria include anemia, hypotension, hypoglycemia, metabolic acidosis, renal
failure, non-cardiogenic pulmonary edema.
In support of Malaria: Patient has most of the symptoms of malaria including paroxysmal fever,
chills, fatigue. In addition he has a recent travel to a malaria endemic region as well as the fact
that he did not use anti malarial nets and prophylaxis medications makes him susceptible to this
infection.
Relapsing Fever
In support of Relapsing fever: Sudden onset fever, irregular high fever and chills.
Against Relapsing fever: The patient doesn’t have scattered petechiae, over the trunk and mucus
membranes. Analysis of blood smear for the presence of spirochetes will aid in excluding the
diagnosis
Typhoid fever
In support of typhoid fever: The patient has high grade fever and diarrhea.
Against typhoid fever-can be ruled out by the absence of alternating diarrhea and constipation,
step-ladder pattern of rise in T0 or a sustained high grade fever and paradoxical bradycardia.
Typhus
In support of Typhus: The fact that the patient has stayed in remote area for one month might be
a risk factor as there might be lice and rodents.
Against Typhus: The patient doesn’t have rash that begins at the trunk, later becoming
generalized so it helps us exclude the diagnosis.

Upper respiratory tract infection

It is also known as common cold. It is commonly caused by viruses like Adeno virus, rhino
virus, influenza and par influenza virus, corona virus and cocsaki virus.
In support of URTI-Dry cough, fever and chills.
Against URTI-There is no sore throat or runny nose.
Sinusitis
It is inflammation of the par nasal sinuses due to infection, allergy or autoimmune problems.
In support of sinusitis - He has cough and fever
Against Sinusitis-There is no headache, nasal congestion, facial pain or pressure and tooth pain.
Acute bronchitis
It is Inflammation of mucus membrane of the bronchi which is generally self limiting.
In support of Acute bronchitis-cough, shortness of breath and fatigue.
Against Acute bronchitis- The fever is high grade which is not common in acute bronchitis,
doesn’t have wheezing, chest pain and runny nose.
Pneumonia
It is the inflammation of the lung parenchyma which can be caused by infectious, aspirational or
inhalational causes. It can be classified in to nosocomial and community acquired Pneumonia.
In support of Pneumonia-The patient has cough, high grade fever, chills, fatigue, shortness of
breath and diarrhea. The patient also have a smoking history which can be a risk factor for
developing pneumonia.
Against Pneumonia-The patient doesn’t have Pleuretic chest pain, nausea, vomiting, myalgia and
sweating.
Acute kidney injury (AKI)
AKI Is defined by the impairment of kidney filtration and excretory function over days to weeks,
resulting in the retention of nitrogenous and other waste products normally cleared by the
kidneys..
In support of AKI: Fever, decreased urine output and yellowish discoloration of the urine.
Against AKI: patient has no flank pain, CVA tenderness, increased urinary urgency and
frequency, pain during urination or bloody urine, thirst or
Acute Viral Hepatitis
In support of Acute Viral Hepatitis-Symptoms such as fatigue, diarrhea, cough can be attributed
to the pre-icteric or pro-dromal phase of Acute viral hepatitis
Against-He does not have exposure history such as needle pricking, unsafe sexual intercourse,
body piercing, tattooing or blood transfusion and he also doesn’t have anorexia, nausea and
vomiting and also no nasal discharge or pharynigits which are the main symptoms of Pre-icteric
phase of acute viral hepatitis.

Diagnostic workup
 CBC with differential (to assess if there is inflammatory state)
 RBS
 LP (to r/o cerebral malaria if required)
 ABG (to check for metabolic acidosis)
 LFT and RFT
 Urinalysis
 Thick and thin blood film (to check for presence of parasite)
 Chest x-ray (to check for potential complications of malaria such as pulmonary edema)
 Abdominal U/S
 Culture from blood, urine
 Stool exam

Myungsung medical college

Internal medicine Case Report-1

Prepared by-Abenezer Bogale (CI-MD/001/18)

Date-27/12/21