Internal medicine 1 rotation

Case write-up 1 (pulmonary disorder)

Reem Sadeq Alsuraihi- U18100852

2022-2023
History
Demographics
 Initials: T.M
 MRN: ZH00156226
 Room number: 235
 Age: 55-year-old
 Gender: male
 Nationality: Egyptian
 Marital status: married
 Occupation: employed (accountant)
 Source of history: patient

Chief complaint
55 years old Egyptian male patient with known type 2 diabetes mellitus for past 4 years
presents with Severe body pain since 3 days, fever, headache and cough since two days.

History of presenting illness

T.M, a 55-year-old male, presented to the emergency department with a complaint of a
severe body pain specially in the muscles that started 3 days before the presentation. The
pain started gradually and increased in severity. The pain It is not associated with trauma,
and it not aggravated by position or anything specific. Furthermore, nothing specific makes
the pain better he tries using Panadol and vitamin C but no improvement. Along with the
pain, the patient experienced fever with highest reading 38 and it’s presented all the time
and there are no chills, no sore throat, no runny nose, no discharge from the ear or ear pain,
there is burning sensation while urinating. Also, the patient describes the headache as
throbbing like pain and its 8 out of 10 with no blurred vision. The cough is productive of a
spoon amount of sputum and the sputum colour was white with no blood. The patient did
not experience any shortness of breath, chest pain or chest tightness, no palpitation no leg
swelling. Moreover, he did not notice any weight changes or changes in his appetite but
feels more fatigued and tired than usual. Patient thinks that he gets infected with COVID-19.

Review of systems
 Constitutional: Generalized fatigue, fever, no weight loss, insomnia
 Neurological: headache, hearing difficulty in the left side(old) , dizziness
 Cardiovascular: No palpitations, chest pain or chest tightness
 Respiratory: No shortness of breath, no Hemoptysis, no Chest pain, cough
 Gastrointestinal: No nausea and vomiting, no diarrhea, no constipation
 Genitourinary: urinary frequency, urgency, dysuria
 Musculoskeletal: No Muscle wasting, no Morning stiffness, normal gait
 Endocrinological: Polyuria , Polydipsia, Dry mouth
Past medical and surgical history
 Patient was diagnosed with type 2 diabetes mellitus since 4 years and he is on oral
hypoglycaemic medication and the patient is non-compliant with medications, Hence
diabetic status was uncontrolled when he was admitted in the hospital.
 Cataract surgery was done in the right eye in February 2022.
 Patient have dyslipidaemia and he’s on statins

Family history
 No family history of similar complaint
 Family history is non-contributory

Social history
 He is living with his family
 Patient does not smoke or consume alcohol
 His diet is home cooked meals.
 Patient does not exercise

Physical examination
Vitals signs
 Temperature: 38 ̊C
 Pulse: 102bpm
 BP: 122/69
 RR: 20 breaths/min
 spO2: 96% on room air

Measurements
 Weight: 84 kg
 Height: 175 cm
 BMI: 27.43 kg/m2

General examination
 Patient was lying in bed and not in distress. Patient looks fatigue. No cyanosis,
muscle wasting, speech abnormalities, nail clubbing, tar stain, asterixis and signs of
dehydration noted. He was connected to an IV line and was conscious, alert and
oriented.
Focused examination
On examination:
Respiratory:
- Equal air entry bilaterally with normal vesicular breath sounds and no wheezing
bilaterally
- Normal abdominothoracic respiration pattern
- All lung fields resonant on percussion with normal tactile fremitus
Abdominal:
- The abdomen was soft and nontender 
- No masses felt on light and deep palpation 
- no hepatomegaly or splenomegaly
- negative rebound test and negative Murphey’s punch test
- no abdominal bruit detected
Cardio:
- chest looks symmetrical no scars and no deformities or abnormal shape.
- Normal location of apex beat with normal character.
- Normal heart sounds (S1 and S2) no murmurs or add sounds.
Neuro:
- Normal gait and there is no neurological deficits.
- Normal tone, power, and reflexes.
- No loss of sensation in periphery and normal cranial nerves examination.

Differential diagnosis
 Acute pharyngitis
 acute bronchitis
 pneumonia. 
 Allergic rhinitis

Investigations
Lab investigations
CBC
 Investigation Value
WBC  14520/cumm ( high)
RBC  5.88 million/cm (high)
Hgb  16.6
Hct  49.1%
MCV 83.5%
RDW  12.4%
Platelet  187000/cumm
Neutrophils%  76.4% (high)
Lymphocytes%  12.4%

Monocytes%  10.1% (high)

Basophils% 0.3%
Eosinphils% 0.3%

ABG:

Investigation Value
PH 7.443
PCO2 37.6mmHg
PO2 41.4mmHg
HCO3 25.2mmol/L

Influenza A and B rapid test

Investigation Findings
Influenza A antigen Negative
Influenza B Negative
antigen

COVID-19 BY RT-PCR : NEGATIVE

HbA1c : 10.7%

Infection markers
- CRP : 79.90 mg/L

Urinalysis

Investigation Value
Urine color Pale Yellow
 Urine appearance Clear
Urine PH 5.0
Glucose urine 1000mg/dl
Bilirubin urine Negative
Ketones urine 150mg/dl
Blood urine Negative
Protein urine Negative
Nitrite Urine Negative
Leukocytes urine Negative
Electrolytes 
Investigation Value
Sodium 136.0mmol/L
Potassium 4.38mmoL/L
Calcium 2.41 mmol/L
Chloride  99.1mmol/L
Chloride:Sodium Ratio 0.729mmol/L

No sputum culture : negative for any bacteria

Throat swab culture: negative for any bacteria

Imaging
Chest x-ray
- Prominent bronchovascular markings bilaterally
- Left lower lung zone showing consolidation
- Normal thoracic cage
- Clear costophrenic angles
CT scan of the chest
- Subtle patchy areas of ground glass attenuation.

Interpretation
- Elevated WBCs (neutrophilis specifically) along with the increased CRP, the
Prominent bronchovascular markings bilaterally and consolidation in the left lower
lung zone indicates an infective/inflammatory state in the lung.
 The ketone bodies and high glucose level seen in urine analysis is due to uncontrolled
type 2 diabetes mellitus and it suggest Diabetic ketosis without acidosis.

 Negative sputum and throat swab culture maybe because they started the antibiotic
course before taking the swab.
  Influenza A and B rapid test result was negative because the clinical presentation and
the imaging suggest atypical pneumonia.

Provisional diagnosis
- atypical pneumonia with CURB-65 score of 0
- Diabetic ketosis without acidosis due to uncontrolled type 2 diabetes mellitus.

Management plan
My plan
- Give normal saline IV because the patient looks dehydrated.

 Order blood workup (CBC, CRP, PCT, and ABG), urinalysis, HbA1c, sputum culture ,
chest x-ray, urine culture, urinary Legionella antigen , molecular diagnosis of
Mycoplasma pneumoniae or Chlamydophila pneumoniae, serology for atypical
pathogens

- Give the patient IV paracetamol to relieve the body pain, headache and fever.
- Pneumonia:
o Amoxicillin-clavulanate + azithromycin

- dysuria:
o advice the patient to drink more water
o uristat oral

- Diabetic ketosis without acidosis:

- Enforce sugar-free fluids
- Administer insulin ketone dose or correction bolus, whichever is greater
- Reassess every 2 hours until Blood β-hydroxybutyrate < 1 or
Urine Ketones < small (trace or negative):
o Check POC Glucose
o Check POC Blood β-hydroxybutyrate or urine ketones
o Dose insulin if blood glucose > 70
- If ketones not decreasing after 2 insulin doses
o consult Endocrinology
- If acidosis is present
o Follow DKA Pathway

- Cough:
o Guaifenesin
 - Diabetes mellitus type 2:
o Consult endocrinologist to prescribe the needed medication.

- Discharge the patient

Hospital Plan
- Admit patient
- Treat the uncontrolled diabetes with insulin as blood sugar was very high and ketone
was positive in the urine, but the ABG was normal
- Antibiotic intravenous started
- Blood investigation was sent
- X-ray, CT scan was advised
- Intravenous fluid to maintain the hydration and correct the ketosis

Follow up
Subjective: Patient feels better, and the fever subsided after 3 days
Objective: Vitals are stable and afebrile. The patient looks well and not in pain. CRP
decreased to the normal range. Ketones in the urine reduced from 150 to 50.
Assessment: chest x-ray and CT-scan confirm that the patient has pneumonitis. Sputum
culture and throat swab results suggested that the given antibiotics works very well to treat
the infection.
Plan: repeat x ray chest will be done on OPD once the patient come for follow up,
discharged the patient on antibiotics and insulin.

Learning points

- Pneumonitis frequently develops after inhaling an irritating chemical or bacteria. When

this occurs, the lungs' tiny air sacs become irritated, making breathing difficult and resulting
in various symptoms.

- The irritants that first induce pneumonitis are frequently never discovered.

- Many additional lung illnesses including pneumonitis share same symptoms. As a result, it
may take several tests before a definitive diagnosis is made because the doctor must first
rule out these other possibilities.
Literature review

The COVID-19 vaccine helps lower the risk of COVID-19 and offers protection against serious
illness, even in those who become infected after receiving the vaccine. ' Although extensive
research has revealed positive safety profiles for COVID-19 vaccinations, the long-term
safety and infrequent adverse responses are unknown. It has been documented that
interstitial pneumonitis is a rare side effect of vaccination against other bacteria. However,
the initial COVID-19 vaccine trial did not include it. Here, we present data on three cases of
interstitial pneumonitis following COVID-19 vaccination (Pfizer). All three patients met the
suggested criteria for drug-related pneumonitis, which also included the exclusion of other
possible causes and the presence of newly detected lung parenchymal opacities on chest CT
with a bilateral non-segmental distribution. After vaccination, all patients had an unusually
"prolonged" fever, tiredness, or dyspnea (4-15 days). Variable CT findings included air-space
consolidation with linear opacities, ground-glass opacities, and reticulation with subpleural
sparing or predominance.

Shimizu, T., Watanabe, S., Yoneda, T., Kinoshita, M., Terada, N., Kobayashi, T., Gohara, K.,
Tsuji, T., Nakatsumi, H., Tambo, Y., Ohkura, N., Abo, M., Hara, J., Sone, T., Kimura,
H., & Kasahara, K. (2022). Interstitial pneumonitis after COVID-19 vaccination: A
report of three cases. Allergology International, 71(2), 251–253.
https://doi.org/10.1016/j.alit.2021.10.003