TikurAnbessa Hospital Addis Ababa

Name: TeferaWoldeAlemuAge: 50 Sex: M Occupation: Farmer Religion: Orthodox Christian

Address: BerehWereda, Sendafa, OromiaZoneDate of Admission: April 04 2012Ethnicity: Oromo

Department: Internal Medicine Ward: B-8 Bed No:816.3Marital Status: Married

Date of Clerking: April05 2012Source of History: The Patient

Previous Admission

None

Chief Complaint

Bilateral flank pain and abdominal distension, 3 months

History of Present Illness

The patient was perfectly well 3 months ago at which time he started experiencing a gradual onset of right
flank pain of stabbing nature. The pain lasted for about thirty minutes with approximately three hour gap
between intervals. It happened both day and night but mainly at night usually awakening him from sleep.
There were no precipitating factors but it was eased by standing or walking.

After three or four days the pain was also felt at the left flank and right upper part of the abdomen. It was
accompanied by night sweats and intermittent fever which was worst at night. Furthermore, he started to
noticeabdominal distension which first involved only the right upper part of the abdomen but in the
following days it encompassed the whole abdomen. This resulted in difficulty in breathing mainly in the
supine position and as a result he uses two pillows to sleep. Even though the patient has good appetite
there was decreased intake of food and water because it exacerbated the distension. At the same time he
also noticed red discoloration of urine which was light at first but through the course of the disease it
started to become bright red. It occurred throughout the course of urination and had a pungent smell.
There was anincrease in the volume and frequency of urination which was accompanied by difficulty in
starting urine and supra-pubic burning sensation while urinating. He also started awakening from bed
three to five times a night to urinate and experienced urinary urgency, hesitancy but no dribbling.

Following these symptoms he went to National Hospital in Addis Ababa (2 months ago) where he was given
2 unspecified oral drugs to be taken through the course of two weeks. Afterwards, he went back to his
home town but he still showed no improvements even though he was taking his medication as he was told.
One month ago he started experiencing a squeezing pain over both shoulders occurring simultaneously
with the flank and right upped abdomen pain. At the same time he experienced a throbbing headache
involving the left side of the head accompanied by dizziness and blurring of vision. He also started to notice
slight yellowish discoloration of the sclerae, appearance of clay colored stoolofnormal consistency and
feeling of excessive thirst and dry mouth.

Following this he went to a local clinic (3 weeks ago) where he was given IV fluids, unspecified gluteal
injection and was immediately referred to Paulos Hospital. Upon reaching Addis Ababa he noticed a
gradual swelling of both ankles. The swellings didn’t decrease when he elevated his legs and it wasn’t
painful when touched or when walking. He stayed at Paulos Hospital for two week and had an abdominal
ultrasound, chest x-ray, urine and blood examination. The results are not known by the patient but he was
referred to Black Lion Hospital.

There is no history of abdominal or flank trauma. No history of epistaxis, hemoptysis, hematemesis, melena
or hematochezia.He hasn’t been exercising strenuously around or after the onset of the symptoms. No
previous history of similar illness before. No previous drug history. No eyelid or facial swelling, pruritus or
skin lesions. No nausea, vomiting, heart burn or diarrhea. No Paroxysmal nocturnal dyspnea, chest pain,
palpitation,syncopeor cough.

He has no history of tobacco or chat abuse but drinks around 12-15small glasses of ‘habeshaareqe’ and 2-4
glasses of ‘tela’ 2-3 times a week for the past twenty five years.

There is yellowish discoloration of the skin over the face and hand which the patient first noticed 2 weeks
ago. He never weighed himself but he has showed marked reduction in his weight. He is in pain and easily
tired and as a result it is almost two and half months since he stopped working. He came to this hospital
supported by his cousin.

Past Illnesses

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

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

Functional Inquiry

H.E.E.N.T

Head:SEE HPI. No trauma

Ears:SEEHPI.No loss of hearing, discharge, earache, or tinnitus

Eyes:SEE HPI. No strain, lacrimation, or itching

Nose:SEE HPI. No discharge

 Mouse and throat:Nodental pain, bleeding from the gums, sore throat or tonsillectomy.

Glands:No enlarged masses over the neck, axilla or groin. No heat or cold intolerance.

Respiratory System:SEEHPI.Noexpectoration, wheezing or stridor.

Cardiovascularsystem:SEE HPI.

Gastrointestinal system:SEE HPI.

Genitourinary system:SEE HPI.

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

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

Locomotory system: No bony deformities, no joint pain.

Central nervous system:Noforgetfulness,seizures, nervous breakdown or insomnia.

Personal History

He was born and raised in a small village in Berehworeda, Sendafa, Oromia zone where he lived all his life.
He had a healthy childhood and was an active boy who liked helping his father around the farm. There is no
school near his village and like his parents, he never went to school.But he is able to read and write
numbers.

He is a farmer and also raises cattle, sheep and goat. He eats bread made from barely and ‘tef’.

He is currently married and has ten children. All are healthy and living well.

He denies of any history of extramarital activities.

Habits- SEE HPI.

Family History

Father and mother:Both his father and mother are dead. His father died around 30 years ago due to
unknown cause while his mother died two years ago at age 86 to natural causes.

Siblings: He has two sisters and four 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 appears to be weak and moderately malnourished. He is lying on his back on an inclined angle
with his knees bent. He appears to be slightly worried and depressed but is fully cooperative. He has
shallow breathingand occasionally moans during respiration.

Vital signs

BP:105/75mmHg, right arm, supine positionPulse:95/min., radial artery, regular, full volume

RR:42/min, shallow, normal rhythm T0:37.00c, axillary, morning

Weight: ?

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 conjunctivaeare
pink.The scleraearemoderatelyicteric. 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 areintact and show no
ulceration. There are no carious teeth, extractions, dentures or filling. The tongue is pink, doesn’t show any
atrophy but is slightly dry. The buccal mucosa is slightly dry. The tonsils are intact and inflamed.

Lymphatic and glandular system

There are no enlarged lymph nodes over the anterior and posterior cervical, sub-mandibular, sub-mental,
posterior and pre auricular, occipital, axillary,epithrochlear, supra-clavicular and inguinal areas.

The thyroid is not enlarged. No tremor or lid lag. Both Testicles are descended.
 Respiratory System

Inspection: There is no cyanosis or clubbing or the finger nails.Thepalms arepale. Breathing is shallow and
is of higher rate. The chest is symmetrical. No deformities, surgical scars or visible pulsations but
there are visible vertical dilated vessels over the lower part of the anterior chest.

Palpation: Thetrachea is central. There is slight tenderness overtheentireanterior chest. The total
circumferential chest expansion is 1 cm along the nipple line on deep inspiration. Tactile fremitus is
normalon the right side but slightly decreased over the left lower lung field. Chest expansion is
symmetrical.

Percussion:Therightchest is resonant but there is slight dullness over the leftlower lung field.
Diaphragmatic excursion couldn’t be assessed because the patient is unable to sit due to marked weakness
and distended abdomen.

Auscultation: There is slightlydecreased air entryover the leftlowerlung field. The breath sounds are
vesicular over other parts of the lung field. No wheezing, crepitations, stridor or pleural friction rub.

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 lower part of theanteriorchest. The direction of flow is upwards.

JVP observed at an inclination of 450 is not raised above the angle of Louis.
 No Hepato-jugular reflex.

Precordium

Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse isnotvisible.

Palpation: The point of maximum impulse could not be felt. 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:There is mild leukonychia. No palmar erythema, liver flap or dupuytren’s contracture. But the
hypothenar muscles are atrophied. The sclerae are mildly icteric. There is no parotid enlargement,
peripheral or central cyanosis. There is no spider angioma over the chest or abdomen. No gynacomastia
but there is mild loss of axillary hair.

The abdomen is distended, symmetrical and moves with respiration.Theflanks are full. There are no
surgical scars or massesbutthere are dilated veinsover the upper left and rightquadrants. The umbilicus is
inverted. Hernia sites are free. No visible pulsation or peristalsis. No caputmedusae.

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

Palpation:

 Superficial palpation: There is tenderness over all four quadrants of the abdomen.No rebound
tenderness. There was no muscle spasm.
 Deeppalpation:The liver is palpable up to7 cm below the right costal marginand it is tender. The
spleen isalso palpable 10 cm below the left costal margin along the line of growth. It is tender.
Percussion: There is shifting dullness,fluid thrill and flank dullness. The total vertical span of the liver along
the right mid-clavicular line is15 cm.

Genitourinary System

There is costo-vertebral angle tenderness. Kidney palpation was not performed because the patient was
complaining of severe pain.

There is no hydro-cele, penile ulcer or urethral discharge. Both testicles are descended and without mass.

Integumentary System

The skin is warm with no rash, scars or ulcers.There is patchy distribution of hair over the anterior chest
and abdomen. The nails don’t show spooning orclubbing.There is yellowish discoloration of the skin
markedly visible over the face.

Locomotory System

There is no muscle tenderness or spasm. There is no bone deformity or tenderness. There is no stiffness of
the joint but there is pitting pedal edema.

Nervous system

Mental Status:

The patient is conscious, fully cooperative seems to in painany 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 6 meters. (Visual Acuity)

He sees waggling of finger approximately 1000 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. They react to light directly and consensually.

N-V:Heidentifies 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:TheSternocleidomastoid 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 fasciculation or atrophy.

Motor:

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

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:Abdominal reflex is absent 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

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 upto 4 mm apart over the finger tips (2 pt discrimination).
 He is able to recognizedifferent movements of the toes with his eyes closed.(Position sense)
 Vibration sense was not assessed due to lack of Tuning Fork.

Meningeal Sign:

 No neck stiffness.
 Kernig's Sign is negative.
 Brudzinski's Sign is negative.
Summary of problems
 Subjective summary:
o Bilateral flank and right upper abdomen pain
o Abdominal distension
o Dyspnea
o Orthopnea of two pillows
o Red discoloration of urine throughout the course of urination with pungent smell
o Increase in the volume and frequency of urination
o Difficulty in starting urine and supra-pubic burning sensation while urinating
o Nocturia,urinaryurgency and hesitancy
o Fever
o Night sweat
o Headache with aura and dizziness
o Yellowish discoloration of the sclerae
o Clay colored stool
o Excessive thirst and dry mouth
o Swelling of both ankles
o Fatigue
o Weight loss

 Objective summary:
o Tachypnea
o Shallow Breathing
o Decreased Chest expansion
o Decreased tactile fremitus,dullness on percussion and reduced air entry over the anterior
left lower lung field
o Dilated vessels over the lower area of the chest and the upper left and right quadrants of
the abdomen
o Distended abdomen with full flanks
o Fluid thrill, Shifting dullness, and flank dullness
 o Tender Hepatomegaly
o Tender Splenomegaly
o Costo-vertebral angle tenderness
o Jaundice (moderate), mild leukonychia and atrophy of hypothenar muscles
o Patchy distribution of hair over the anterior chest and abdomen with mild loss of axillary
hair
o Palmar paleness
o Dryness of buccal mucosa
o Pitting pedal edema
o Absent abdominal reflex

Differential diagnosis

 Hepatocellular carcinoma
 Budd- chiari syndrome
 Cirrhosis of liver secondary to chronic alcoholism
 Nephrotic syndrome
 Acute viral hepatitis
 Polycystic kidney disease
 Pyelonephritis
 Heart failure

Discussion of the differential diagnosis

 Heart Failure

Generalized abdominal distention due to ascites typically accompanies severe cardiovascular

impairment and is confirmed by shifting dullness and a fluid wave, which is the case here. The pedal
edema, the hepatomegaly associated with the right upper quadrant pain,dyspnea, orthopnea, fatigue
and nocturia also support this diagnosis.

But the lack of jugular vein distention, tachycardia, cyanosis, paroxysmal nocturnal dyspnea, anorexia,
nausea, vomiting, productive cough, crackles and its inability to explain the flank pain and hematuria,
which are the primary symptoms of this case, makes this diagnosis unlikely.Plus the patient has no
history of ischemic heart disease, cigarette smoking, hypertension, obesity or diabetes.
  Pyelonephritis

Gross hematuria, fever,bilateral flank andabdominal pain, CVA tenderness, weakness, fatigue, urinary
frequency, urgency, nocturia, and difficulty in starting urine are all consistent in findings of
pyelonephritis.Plus signs of paralytic ileus, such as hypoactive bowel sounds and abdominal distention
is also absent.

But absence of dysuria,chills,anorexia,myalgia, nausea and vomitingaren’t in accordance with

pyelonephritis. In addition the hepato and splenomegaly aren’t explained.

 Polycystic kidney disease

Dull, aching, bilateral flank and supra pubic pain,hematuria, polyuria, swollen tender abdomen pain
consistent with hepatomegaly,signs and symptoms of UTI, such as urinary frequency and urgency are
present in this patient and are common findings in patients with this disease.

The age of the patient at the onset of the symptoms is also consistent with this disease.

But the absence of colicky type of pain, increased blood pressure, perineal and lower back painaren’t in
accordance with findings of polycystic kidney disease.

The aggravating and relieving factors of this disease (aggravated by exertion and relieved bylying down)
aren’t consistent with the findings in this patient.

Laboratory Workup
 Echocardiography
 CXR
 Electrocardiogram
 Blood Tests (electrolytes, renal function test, liver function test, thyroid function test, complete
blood count and differential)
 Abdominal ultrasound
 Ultrasonography of the kidneys
 Voiding cytourethrography
 Renal biopsy
 Urine analysis
 Urineculture
 Blood culture
 Antibiotic sensitivity test