Respiratory system:

To complete the examination, I would like to check for:

1. Sputum pot
2. Pulse oximetry of oxygen saturation
3. Arterial blood gas
4. Chest x-ray

Today, I examine this young Malay gentleman. On general inspection, he was lying in 45
degrees, he was alert and conscious. He had mild tachypnea with a respiratory breath of 22
breaths per minute. Otherwise, no other supporting devices were attached to him.
On peripheral examination, his hands were warm and pink with capillary refill time of
less than 2 seconds. There were fingers clubbing bilaterally with grade 3. Otherwises, there
was no tar staining, fine or flapping tremor, thinning or bruising of skin, stigmata of infective
endocarditis, stigmata of chronic liver disease and peripheral signs of aortic regurgitation. BCG
scar was present on his left deltoid.
Upon face examination, there were no conjunctival pallor or scleral jaundice. The overall
mouth hygiene was good with no central cyanosis. There was no temporal muscle wasting and
parotid swelling.
Upon neck examination, his JVP was not raised and there were no palpable lymph
nodes. Tracheal was centrally located.
Upon inspection of the chest anteriorly, there was no scar or chest deformity. Apex beat
was palpable at the left 5th ICS midclavicular line.
Upon respiratory examination on the back, there were no scars or spinal deformities
such as scoliosis or kyphosis. There was reduced chest expansion over the right lung.
Otherwise, tactile fremitus was normal bilaterally. There was resonance on percussion. Upon
auscultation, there was coarse crepitation which was best heard over the right lung and
resolved with coughing. Vocal resonance was normal bilaterally.
In summary, my finding is consistent with bronchiectasis as evidence of reduced chest
expansion and presence of coarse crepitation which was resolved with coughing.
Other differentials would be lung fibrosis, pneumonia and pulmonary edema.
I would like to further investigate this gentleman by doing full blood count to look for
white cell count which may be elevated in presence of infection, inflammatory markers to look
for inflammation, sputum culture to look for microorganism causing the disease, chest x-ray to
look for dilated bronchi and cystic shadows, and CT thorax to look for signet ring and tramtrack
line.
Causes of bronchiectasis are divided into inherited and congenital. Inherited causes of
bronchiectasis are primary ciliary dyskinesia, Kartagene’s syndrome, dextrocardia, situs
inversus and cystic fibrosis while acquired causes of bronchiectasis are pneumonia and
tuberculosis
Complications of bronchiectasis are infective exacerbation, haemoptysis, cor pulmonale
and pulmonary hypertension.
Abdominal system:

I would like to complete the examination by checking the external genitalia, external
hernia orifices and perform digital rectal examination.
Today, I examine this young gentleman. On general inspection, he was lying on supine
position, he was alert, conscious and not in respiratory distress. His respiratory breath is 16
breaths per minute. Otherwise, no other supporting devices were attached to him.
On peripheral examination, his hands were pale with capillary refill time of less than 2
seconds. Otherwise, there was no finger clubbing, fine or flapping tremor, tar staining, thinning
or bruising of skin, stigmata of chronic liver disease, stigmata of infective endocarditis and
peripheral signs of aortic regurgitation. There were no tattoos or needle marks on his arms.
Upon face examination, there were conjunctival pallor, mild scleral jaundice and frontal
bossing. Otherwise, overall mouth hygiene was good with no central cyanosis, angular
stomatitis and parotid swelling.
Upon neck examination, his JVP was not raised and there were no palpable lymph
nodes.
Upon inspection of the chest, there were no scars, spider naevi, gynaecomastia or chest
deformity. There was also no axillary hair loss.
Upon inspection of the abdomen, there were no scars or visible veins. The abdomen
was not distended and the umbilicus was centrally located. Upon soft palpation, the abdomen
was soft and non tender. On deep palpation, the liver was enlarged with a liver span of 15 cm.
The spleen was enlarged, 5 cm below the costal margin. There was no ballotable kidney and
evidence of ascites. Upon percussion, there was negative shifting dullness. The traube space
was obliterated on percussion. Upon auscultation, bowel sound was present and no bruits
heard.
In summary, this patient has thalassemia as evidence of frontal bossing, conjunctival
pallor, scleral jaundice, hepatomegaly and splenomegaly.
Other differentials would be chronic liver disease with portal hypertension, chronic
myeloid leukaemia, myelofibrosis and lymphoma.
I would like to further investigate this gentleman by doing Hb electrophoresis and DNA
analysis to confirm the diagnosis, full blood count to look for haemoglobin, MCH and MCV, full
blood picture to look for microcytic red blood cell, target cell and basophilic stippling, iron studies
to look for serum ferritin, serum transferrin and total iron binding capacity, and echocardiography
to look for left ventricular hypertrophy.
Complications of thalassemia would be iron overload complications which are
skin pigmentation, joint pain, cardiomyopathy, diabetes mellitus and chronic liver disease,
and blood-borne infection.