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TikurAnbessa Hospital Addis Ababa

Name: TeshomeTesemaBedasoAge: 47 Sex: M Occupation: Teacher Religion: Orthodox Christian

Address: ShakisoWereda, BorenaDate of Admission: April 02 2012Ethnicity: Oromo

Department: Internal Medicine Ward: D-8 Bed No:807.1Marital Status: Divorced

Date of Clerking: April09 2012Source of History: The Patient

Previous Admission

None

Chief Complaint

Progressive worsening of back pain, 5 days duration

History of Present Illness

This is a known RVI patient for the past 3 months who has been taking Tenofovir, Lamivudine and
Nevirapine daily. He was in a relatively healthy condition until around two months ago at which time he
started experiencing a gradual onset of posterior neck and posterior right upper chest pain. The pain was
intermittent and was of throbbing and squeezing nature. It happened both day and night but was worst at
night sometimes awakening him form sleep. It was exacerbated by walking and bending over and it wasn’t
relived by taking painkillers. At the same time he also experienced intermittentfever which was worst at
night and accompanied by shivering.

Following this he went to a local health center where he was treated for typhoid. Through the following
days the fever and shivering disappeared but the pain increased in intensity and radiated to the posterior
left upper chest and to the midline of the back.

Showing no improvement he came to Addis Ababa 25 days ago to seek better medical care. Here he went
to Universal Clinic where he had a stool, urine and blood examination. The results aren’t available but the
patient was given unspecified oral medication and was told to go to Filwohafor massage. After one week of
massage he showed decreased in intensity of the back pain.

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Five days before present admission the patient experienced an acute onset of squeezing and pounding type
of headache involving the top of the head which was worst at night awakening him from sleep. It was
accompanied by avoidance of light, intermittent fever, chills, night sweats, vertigo, nausea and non-
projectile vomiting. He also experienced exacerbated back pain of the previously involved areas.

Due to this he went to Teklehimanot Hospital. There he had blood, urine, and chest x-ray. The results aren’t
available but the patient was referred to Black Lion Hospital.

The patient has history of malaria 20 years ago and asthma since he was a child. But he has no history of
hypertension,Diabetic Mellitus or cardiac illnesses. No history of head trauma,earache or discharge. No
history of forgetfulness, abnormal body movement, weakness, nervous breakdown, visual disturbances or
insomnia. Nodiarrhea, melena or hematemesis. No dysuria, red discoloration of urine, loss of hearing,
rashes, ulcers over the penis or any other area. No enlarged masses over the neck, axilla or groin. No
history of chest pain,chronic cough or contact with a chronic cougher.

In the past two months of his illness he has gained approximately 5 Kg. There is no color change noted by
the patient and he came to black lion hospital supported by his brother.

Past Illnesses

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

Nosurgery, trauma, psychiatry problems or drug allergy.

Functional Inquiry

H.E.E.N.T

Head:SEE HPI.

Ears:SEE HPI.No tinnitus

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

Nose: No epistaxis or discharge.

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

Glands: SEE HPI. No heat or cold intolerance.

Respiratory System:SEE HPI.Noexpectoration,hemoptysis, shortness of breath, wheezing or stridor.

Cardiovascular system:No dyspnea, palpitation, orthopnea, paroxysmal nocturnal dyspnea or syncope.

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Gastrointestinal system:SEE HPI. No loss of appetite, dysphagia, abdominal pain, tarry or clay colored stool.

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

Integumentary system:SEE HPI.Moist skin, no changes in hair distribution or pigmentation.

Allergy:SEE HPI.No drug sensitivity or food allergy.

Locomotory system: No bony deformities, no joint pain.

Central nervous system: SEE HPI.

Personal History

The patient was born in Addis Ababa. He had a healthy childhood. He learnt at Yekatit 23 until 6 th grade and
followed his secondary education at Medahnialem high school, Addis Ababa. Then he went to Bahr Dar
University where he had a degree in teaching geography. Then he was assigned to Borena to Work.He was
working as 8th grade geography teacher at ShakisoHigh School until about 3 weeks ago when he came to
Addis Ababa looking for better medical treatment.

He has no history of alcohol, tobacco or chat abuse.

He was married for 19 years but got divorced 4 years ago. He has two children. The older one is female and
is 12 years old and the younger one is male and is 8 years old. They are all alive and living well.

Family History

Father and mother:His father is alive and healthy, but his mother died about 20 years ago due to a chronic
liver disease. Further specifications couldn’t be assessed.

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

Family Diseases: SEE HPI.

Physical Examination
General Appearance

The patient appears to be alert and is fully cooperative. He is lying on his back on an inclined angle. He
appears to be slightly worried but doesn’t seem to be depressed. He isn’t malnourished and doesn’t seem
to be in respiratory distress.

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 Vital signs

BP:100/60mmHg, right arm, supine positionPulse:70/min., radial artery, regular, full volume

RR:27/min, deep, regular rhythm T0:36.70c, axillary, morning

Weight: 63 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 conjunctivaeare
pink. The scleraearenoticteric. 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 but they are dry. 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. The buccal mucosa is slightly dry. The tonsils are intact and inflamed.

Lymphatic and glandular system

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

The thyroid is not enlarged. No tremor or lid lag.

Respiratory System

Inspection: There is no cyanosis or clubbing or the finger nails.The palms arenot pale. Breathing is deep
and is of regular rate. The chest is symmetrical. There are no deformities, surgical scars, visible
pulsation or dilated vessels.

Palpation: Thetrachea is central. There is no tenderness over theentire chest. The total circumferential
chest expansion is 3 cm along the nipple line on deep inspiration. Tactile fremitus is normalover the
entire lung field. Chest expansion is symmetrical.

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Percussion:Both the rightand left chest are resonant. Diaphragmatic excursion is 3 cm.

Auscultation:The breath sounds are vesicular over the entire 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 no distended veins over the neck, chest wall, or leg.

JVP observed at an inclination of 450 is 2 cm above the angle of Louis.

No Hepato-jugular reflex.

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

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Inspection:The abdomen is flat, symmetrical and moves with respiration.The flanks arenot full. There are
no surgical scars, massesor dilated veinsover abdomen. 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 was no muscle spasm, or superficially palpable mass. There was also
no direct or rebound tenderness.
 Deeppalpation:The liver wasnot palpable below the right costal margin. The spleen isalso not
palpable.

Percussion: There is no shifting dullness, fluid thrillorflank dullness. The total vertical span of the liver along
the right mid-clavicular line is7 cm.

Genitourinary System

There is no costo-vertebral angle tenderness. Kidneys are not palpable. 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 no abnormal hair distribution. The nails don’t show
spooning or clubbing.

Locomotory 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 doesn’t seems to be depression.

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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 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. 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: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 fasciculation or atrophy.

Motor:

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  Musclebulk: There is no muscle bulk reduction in all extremities and there is also no bulk difference
between the left and the right sides. There is no spontaneous as well as induced fasciculation.
 Muscle toneand 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: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

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)

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  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:

 There isneck stiffness.

 Kernig's Sign is negative.
 Brudzinski's Sign is negative.

Summary of problems
 Subjective summary:

A 47 year old know RVI male patient for the past 3 months on ART. He presented with posterior neck and
back pain of two month duration. He also had headache associated with photophobia, fever, chills, night
sweats, fatigue, vertigo, nausea and non-projectile vomiting.

 Objective summary:

On physical examination it was found that his lips and buccal mucosa were dry. He also had neck stiffness.

Differential Diagnosis
 Cryptococal meningitis
 Aseptic meningitis
 Tuberculos meningitis
 Neuro-syphilis

Discussion of Differential Diagnosis

 Neuro-syphilis
Neurosyphilis is a complication of late syphilis and can be asymptomatic or may present as acute
meningitis, with headache, nausea, vomiting and neck stiffness which are in accordance with the findings in
this patient. But lack of cranial nerve involvement, neuroretinitis, deafness, seizures, changes in mental
status and lack of history of penile ulcer aren’t supportive of the diagnosis.

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  Tuberculos Meningitis
It results from the hematogenous spread of primary or postprimary pulmonary TB or from the rupture of a
subependymal tubercle into the subarachnoid space. The disease often presents with severe headache,
lethargy, neck rigidity low grade fever which are consistent with the findings in this patient but lack of
anorexia, irritability and/or paresis of cranial nerves (ocular nerves in particular),which area frequent
finding in people suffering from tuberculos meningitis, make this diagnosis less likely. Plus the patient has
no history of previous TB disease, chronic cough or contact with a chronic cougher

 Aseptic meningitis
It is an immune mediated disease which can occur at any time in the course of HIV infection, most
commonly at the time of acute HIV infection. Most of the symptoms like headache, photophobia, nuchal
rigidity are present in this patient but other minor symptoms such as cranial nerve involvement (commonly
VII but occasionally V or/and VII) and acute encephalitis aren’t present but still it is a suitable diagnosis.

 Cryptococcal Meningitis
It is caused by Cryptococcus neoformans, which is a yeast like fungi. It is the leading cause of meningitis in
patients with AIDS and is particularly common in patients with AIDS in Africa. It usually presents with low
grade fever, nausea, vomiting, headache, neck stiffness and photophobia, which are presented in this
patient and make this diagnosis very likely.

Diagnostic Workup
 Complete Blood Count with differential – to assess if there is inflammatory state.
 ESR – to assess if there is inflammatory state
 Lumbar Puncture with CSF analysis - to assess the WBC with differential, protein, glucose and LDH
in order to identify which type of meningitis it is. Indian ink – for identification of cryptococcal
meningitis. Dark field microscopy – neurosyphilis.
 Brain Imaging such as CT and MRI – to evaluate if there are complications such as hydrocephalus,
brisk meningeal enhancement and/or intracranial tuberculoma.
 Venereal Diseases Research Laboratory (VDRL) test and Fluorescent treponemal antibody-absorbed
(FTA-ABS) Test - Serological Tests for syphilis

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