Case Discussion

Cough

Group E
Marcella Burhan 1006804773
Nabila Aljufri 1006718126

Internal Medicine Clinical Practice Module

Faculty of Medicine Universitas Indonesia
January 2016
Table of Contents
Chapter I ................................................................................................................................. 4
Introduction ........................................................................................................................... 4
Chapter II ............................................................................................................................... 5
Case Illustration .................................................................................................................... 5
2.1. Identity...................................................................................................................................... 5
2.2. Anamnesis ................................................................................................................................ 5
2.3. Physical Examination ............................................................................................................ 6
2.4. Supporting Examination ...................................................................................................... 8
2.5. Summary .................................................................................................................................. 8
2.6. List of Problems...................................................................................................................... 9
Chapter III .......................................................................................................................... 10
Problem Analysis ............................................................................................................... 10
1. Haemoptysis ..............................................................................................................................10
2. Lung tuberculosis ....................................................................................................................11
3. Diabetes Mellitus Type II ......................................................................................................12
Chapter IV........................................................................................................................... 14
Discussion ............................................................................................................................ 14
1. Hemoptysis ............................................................................................................................14
2. Lung Tuberculosis ...............................................................................................................17
3. Diabetes Melitus Type II ....................................................................................................20
Chapter V ............................................................................................................................ 21
Holistic and Comprehensive Management Scheme of the Case ............................. 21
Chapter VI........................................................................................................................... 22
Conclusion ........................................................................................................................... 22
References ............................................................................................................................ 23
 Chapter I
Introduction
Hemoptysis is one of the respiratory emergency situations that can make someone
immediately come to seek help. Hemoptysis is expectoration of blood, ranging from
blood streak to gross blood that originates from the lower respiratory tract. In most
cases, hemoptysis is self-limiting event, but fewer than 5% may be severe or massive.
Hemoptysis may cause asphyxia due to the flooding of the airways rather than
exsanguination is usually the cause of death, and it is commonly accompanied by
cardiovascular collapse. The mortality rate of untreated massive hemoptysis (>200-
600 ml/ 24-48 hours) is more than 50%. This is the reason why physicians should
assess the etiology of hemoptysis, which is to exclude the severe cases.

S. Depari et al, 2009, found that the main causes of hemoptysis in Persahabatan
Hospital was pulmonary tuberculosis (52%) and the recurrent hemoptysis of
tuberculosis in a month was 22%. While Retno et al found that the underlying cause
of hemoptysis was pulmonary tuberculosis (64,43%), followed by bronchiectasis
(16,71%) and lung cancer (3,4%).1 Pulmonary tuberculosis is the most common cause
of hemoptysis worldwide.2

The case below is one of the examples of hemoptysis case in the emergency
department. The patient already had productive cough months before the hemoptysis.
As it is known, tuberculosis is the most prevalence cause of hemoptysis in Indonesia.
This case is the example of lung tuberculosis hemoptysis. Unfortunately, there is no
specific guideline made for the management of hemoptysis. So the management of
hemoptysis should be individualized based on the condition of the patient, available
treatment and modalities.
 Chapter II
Case Illustration

2.1. Identity
Name : Mr. S
Gender : Male
Birth date : 18 January 1983
Age : 37 year old
Address : Senopati
Religion : Islam
Date of administration: 21 January 2016
Date of examination : 21 January 2016

2.2. Anamnesis
Chief complaint
Cough with blood that was more intense in 2 hours prior to hospital admission.

Current ilness history

Patient came to the ER with the complaint of bloody cough that was getting more
intense 2 hours prior to hospital admission. The color of the cough was light red,
approximately 100 cc (1/2 of aqua glass). Patient started to cough three days prior to
hospital admission with only the amount of two tablespoons of blood cough. He
denied of having any trauma, history of malignancy, inhaled or aspiration of foreign
body, recent sinusitis, pharyngitis, blood from the nose, nausea, vomiting, abdominal
cramp or chest pain. He also denied diagnosed with maag before. Moreover, he stated
that he was having shortness of breath and was better when changing his position to
the left. The shortness of breath was not exacerbated by his activities, did not wake
him up during night sleep, and no trouble with sleeping (sleeps only with 1 pillow).
His urination and defecation activities were normal.

Since three months prior to hospital admission, he was having productive cough. The
sputum was greenish and viscous. He experience night sweating and weight loss up to
15 kg in a month. He denied having fever. He has not take any medicine before,
including 6 months medication.

Patient stated that a year ago he was diagnosed with diabetes mellitus type 2. At that
time, he was complaining of starving, frequent urination and thirst a lot. He was given
metformin once a day, but the blood glucose was not controlled so the doctor changed
the frequency to be two times daily. He admitted that he did not take his medicine on
a regular basis. However, he denied having complaint such as tinggling, long wound
healing process, or edema on his leg.

History of Past Illness

He was diagnosed with fatty liver when he was in college. He used to drink alcohol a
lot during that time but did not remember how much. Aside from that, he does not
have any complaint or illness such as hypertension, asthma, and allergy. He has never
been hospitalized before.

Family History
No one in the family has the same sign and symptoms or illness as the patient. History
of hypertension and diabetes mellitus in the family was denied.

Social History
He is a human resource employee at Psychiatric hospital and rarely has any contact
with the patient. Patient lives in a private home with his wife. He stated that his house
have some ventilations. On the other hand, he rarely opens windows at his house and
sunlight rarely go through.

2.3. Physical Examination

Physical Examination
General condition Appeared Moderately Ill
Consciousness Compos mentis, Looked moderately ill
Blood Pressure 90/60 mmHg
Heart Rate 100 x/min
Respiratory Rate 28 x/min
 Temperature 37.1oC
Body Weight: 78 kg
Antopometri
Body Height: 165 cm

System Physical Examination

 Skin : brown (sawo matang) skin, normal turgor, no
bruises, no jaundice and scars
 Head-Ear-Nose-Throat-Eye Examination
o Head : normochephal, no pain during palpation, no
deformity
o Hair : black, discretely distributed, not easy to be
pulled
o Eye : anemic conjunctiva, sclera not icteric, pupil
was round, isochor, diameter 3 mm/3mm, direct light reflex +/+,
indirect light reflex +/+,
o Face : no abnormal face features, no pain during sinus
palpation
o Ear :cerumen plug (-), external ear not hyperemic,
intact tympanic membrane, tympanic membrane light reflex (5 o’clock
/ 7 o’clock)
o Neck : trachea in the middle, no trakeal deviation no
thyroid enlargement, no lymph node enlargement, range of movement
was normal bruit not heard during auscultation. JVP 5 – 1 cmH20
o Mouth : good oral hygiene, symmetrical pharyngeal
arc, no tonsils enlargement, smooth mucose, not hyperemic.
 Pulmonary Examination :
o Inspection : symmetrical static or dynamic
o Palpation : symmetrical tactile fremitus
o Percussion : sonor at right and left lung
o Auscultation : vesicular (+/+), wheezing (-/-), crackles (-/+).
There was fine crackle on the left basal area of his lung.
 Cardiovascular system :
o Inspection : ictus cordis was not visible
 o Palpation : ictus cordis was not palpated. There was no
thrilling, heaving, lifting.
o Percussion : left heart border was located on fifth left
intercostal, one finger medial from midclavicula line right heart border
was located on second right intercostal on sternal line
o Auscultation : S1 S2 regular, murmur (-), gallop (-)
o Blood vessels : No carotid bruit, femoral artery was not
checked, dorsalis pedis artery both dextra and sinistra was palpated
(strong), tibialis posterior artery both dextra and sinistra pas palpated
(strong).
 Abdomen :
o Inspection : looked flat, no venectation, no spider navy, no
scar
o Palpation : abdominal wall was loose, no pain upon
pressure, and left liver was not palpable . Spleen was not palpated.
o Percussion : shifting dullness was negative
o Auscultation : normal bowel sound (4x/minute)
 Extremities : warm, no edema, no clubbing fingers, no
baggy pants, CRT < 2 s
 Musculoskeletal : No deformities, bone pain, no redness, no
swelling.

2.4. Supporting Examination

ECG: Sinus Rhythm, rate 100 bpm, normal axis, Normal P wave, PR interval 0.12 s,
QRS 0.10 s, No ST Changes, T inverted at lead II, III, AVF, V1, V2, V3.
X-ray: Presence of cavity at the left lung, infiltrate at the left lung parenchyma.
Random blood glucose: 183 mg/dl.
Other lab?

2.5. Summary
A 37 year old, male patient came with with a complaint of hemoptysis that is getting
more severe 2 hours prior to hospital admission while the hemoptysis actually started
3 days before. There was also dyspnea that was better in changing position, no PND,
DOE, or ortopnea. He was experiencing cough for three months, night sweat, no
fever, extreme body weight loss (15 kg in a month), never had any anti-tuberculosis
drugs. A year ago, he was diagnosed with DM and still uncontrolled. Physical
examination revealed, fine crackles at his left lung, ECG: inferior ischemia, chest x-
ray showed cavity and infiltrate at his left lung.

2.6. List of Problems

1. Hemoptysis
2. Tuberculosis with unknown BTA
3. Diabetes Mellitus type II
 Chapter III
Problem Analysis

1. Haemoptysis
Diagnostic base:
 Anamnesis: He experienced bright red cough for 3 days and getting more
severe 2 hours prior to hospital admission. He did not have any gastritis
history. The color of the cough was light red, approximately 100 cc (1/2 of
aqua glass). Patient started to cough three days prior to hospital admission
with only the amount of two tablespoons of blood cough. He denied of
having any trauma, history of malignancy, inhaled or aspiration of foreign
body, recent sinusitis, pharyngitis, blood from the nose, nausea, vomiting,
abdominal cramp or chest pain. Moreover, he already had cough since 3
months prior to hospital admission. The sputum was greenish and viscous.
Other symptoms include night sweating and weight loss up to 15 kg in a
month. He denied having fever.
 Physical Examination: Tachycardia (100x/min), hypotension (90/60
mmHg), fine crackle on the apex of the left lung, no clubbing finger, no
cyanosis.
 Supporting Examination:
X-ray: Presence of cavity at the left lung, infiltrate at the left lung
parenchyma.
Planning:
 Diagnostic workup:
o Complete blood count (to se both the hematocrit and platelet count)
o Coagulation studies
o Renal function and urinalysis
o CT Scan
 Medication:
o Secure airway, breathing and circulation.
o Give oxygen through nasal cannule 2lpm.
 o Give IV fluid to help restoring the blood pressure (NaCl 0.9% 500
ml/ 8 hours).
o Seek for the cause and put patient in an isolation room.
o Put nasogastric tube to prevent aspiration.
Education:
o Hemoptysis and its causes. Explain the possible causes in this
patient.
o The emergency condition for this patient and possibility of
infectious disease, which include the reason why he needs to be
isolated.

2. Lung tuberculosis
Diagnostic base:
 Anamnesis: Patient has been coughing since the last 3 months and have
never been neither tested nor treated. The cough was productive, with
green sputum, thick sputum and mixed with blood over the last three days.
There was no fever, but night sweat was confirmed. Patient’s body weight
dropped 15 kilograms over the last month. Oftentimes patient felt short of
breath that is not affected by activities. All these symptoms are suggestive
of lung tuberculosis. Patient is also an active smoker for the last 22 years,
which increases the vulnerability of the lung.
 Physical Examination: Crackles were heard on the left apex of the lung
 Supporting Examination:
o Chest xray: cavity and infiltrate on apex of left lung
Planning:
 Diagnostic workup:
o Complete blood count
o Sputum examination
o Chest xray
o Gene Xpert
o HIV workup
 Medication:
o Waiting for sputum examination
  Education:
o Explaining the patient about lung tuberculosis; how it is
transmitted and that he should be using mask to prevent
transmitting to others, also to get his family tested because they are
on close contact with him.
o Explain that if it is tuberculosis, he should be compliant in taking
medications.

The patient has the classic symptoms of lung tuberculosis however differential
diagnosis are still considered;
1. Lung cancer; because of the warning signs which is 15 kilograms weight loss
with no effort over the past month, bloody cough, and shortness of breath.
2. Community acquired pneumonia; because the patient has productive cough
and shortness of breath, this diagnosis is still considered until the respiratory
problem is proven to be caused by tuberculosis.

3. Diabetes Mellitus Type II

Diagnostic base:
 Anamnesis: Patient knows that he has diabetes for the past one year from a
preop workup. He had the complaint of polyuria, polydipsia, and
polyphagia at that time. He is currently taking metformin 2 x 500 mg, but
is not taken regularly due to boredom. However he did not complaint of
disturbed vision, wound that are difficult to heal, or lesion on the feet.
 Physical Examination: -
 Supporting Examination: -
Planning:
 Diagnostic workup:
o Blood glucose
o HbA1c
o Lipid profile
o Urinalysis
 Medication:
o Metformin 2 x 500 mg
 Education:
o Lose weight; because the patient’s BMI is 28 kg/m2 (obesity gr I)
so he needs to lose weight.
o Low sugar diet
o Exercise
 Chapter IV
Discussion
1. Hemoptysis

Hemoptysis is the condition of expectoration of blood from the respiratory

tract that can arise at any location from the glottis to the alveoli. It is important
to distinguish hemoptysis from epitaxis and hematemesis. Usually the color of
hemoptysis is bright red blood, with the presence of sputum, associated with
asphyxia, without the presence of nausea/vomiting. Most common etiology of
hemoptysis worldwide is Mycobacterium tuberculosis infection from the
formation of cavity.2

Seeking the etiology of hemoptysis is needed to treat the patient. Diffuse

bleeding in the alveolar space is one of the causes. It can be inflammatory or
noninflammatory. Inflammatory is due to vasculitis/capillaritis of the vessels.
Another cause of hemoptysis is direct inhalational injury including thermal
injury from fires, inhalation of substances (cocaine), and inhalation of toxic
chemicals. 3

In this patient the most probable etiology is infection. Tuberculous infection,

which can lead to bronchiectasis or cavitary pneumonia, is a very common
cause of hemoptysis worldwide. Pneumonias of any sort can cause
hemoptysis. Patients may present with a chronic cough productive of blood-
streaked sputum or with larger volume bleeding. 2, 3

In patients with a history of chronic bronchitis, bacterial superinfection with

organisms such as Streptococcus pneumoniae, Haemophilus influenzae, or
Moraxella catarrhalis can also result in hemoptysis. Patients with
bronchiectasis (a permanent dilation of the airways with loss of mucosal
integrity) are particularly prone to hemoptysis due to chronic inflammation
and anatomic abnormalities that bring the bronchial arteries closer to the
2, 3
mucosal surface.
 Another cause of hemoptysis are cancers arising in the proximal airways are
much more likely to cause hemoptysis, but any malignancy in the chest can do
so. Because both squamous cell carcinomas and small-cell carcinomas are
more common in causing hemoptysis because of the large presentation and
more adjacent to the proximal airways. 2, 3

Tabel 1. Causes of hemoptysis from large vessels 3

2, 3
Diagnostic approaches
The standard evaluation of hemoptysis is chest xray. If the source of bleeding cannot
be identified by this method, then CT of the chest should be performed.
Bronchiectasis, alveolar filling, cavitary infiltrates are more visible for diagnosis
using CT Scan rather than chest xray.

Laboratory studies include complete blood count to assess both the hematocirit and
platelet count as well as coagulation studies. If the patient is producing sputum,
culture, gram’s and acid-fast staining are necessary to be conducted. If those studies
are still unrevieling, then bronchoscopy should be considered. Especially in smokers,
sometimes the endobronchial lesion are not visible through CT, then bronchoscopy
should be considered as part of the evaluation.

Figure 1. Evaluation approach for hemoptysis 2

2, 3
Management for hemoptysis

Management for hemoptysis include the emergency management regardless the cause
of hemoptysis. Patent airway, should be established. In condition that the airways is
obstructed, endotracheal intubation or even mechanical ventilation should be
considered. Volume of the hemoptysis should be known for further management. In
massive hemoptysis (200-600 ml/ 24-48 hours), the source of bleeding should be
known by either chest imaging or bronchoscopy. The goal is to isolate the bleeding in
only one lung so the gas exchange function on the other lung is not further impaired.
If the treatment does not stop the bleeding, severe hemoptysis from bronchial arteries
can be treated with angiographic embolization of the responsible bronchial artery.
Endobronchial lesions can be treated with a variety of bronchoscopically directed
interventions, including cauterization and laser therapy.
2. Lung Tuberculosis
Tuberculosis (TB) remains the world’s burdensome health issue regardless of the
strongly enforced programs by the WHO. According to WHO, it remains the top
infectious disease killer worldwide. In 2014, 9.6 million people fell ill with TB and
1.5 million died from the disease. WHO also states that TB is the leading killer of
HIV infected patients. The newly adopted Sustainable Development Goals by the
United Nations (UN) has replaced the Stop TB goal of 2015 and targeted the year of
2030 as the End of tuberculosis. Indonesia remain the 2nd country with the highest
prevalence in the world (10%), with one million new cases reported each year.
However, correct diagnosis and prompt treatment has proved to reduce the mortality
of TB by 47% since the adaptation of Millennium Development Goals era in 2000 –
2014. 4

Tuberculosis is caused by the bacteria Mycobacterium tuberculosis, a rod-shaped

bacteria that is resistant to acid. This bacteria can stay in dormant condition for years
in cold, dry condition. This bacteria is an intracellular parasite that lives inside
macrophages, making it difficult to eradicate by one’s immune system. Lung
tuberculosis is the most common site of infection because M.tuberculosis favors
highly oxygenated location such as the apex of the lung – making it the predilection
site.5

Lung tuberculosis is diagnosed by sputum examinations, and suspicions must be

raised in presence of the classic symptoms. Which includes:
 Fever – subfebrile is the most commonly found type.
 Cough / hemoptysis – due to the irritation to bronchus for the purpose of
expressing the inflammatory products. If blood present, there might be ulceration
or cavity inside the lung.
 Dyspnea – especially when the area infected are large
 Chest pain – if pleuritis is present, the characteristic is pain when inhaling
 Malaise – due to chronic nature of the disease that leads to loss of appetite,
weight loss, night sweats.
On physical examinations, lung tuberculosis inhibit the same feature as pneumonia.
The difference is usually the predilection site, which is on the apex of the lung. On
radiologic examinations, the early tuberculosis infection will appear cloudy spots with
no clear boundaries. However on later stage, tuberculoma might have formed and it
will appear as well demarcated radiopaque lesion.

The most important examinations is the sputum examination. It is done to three times
of sputum sampling; time – morning – time sputum. If any of the examinations reveal
positive result than the patient can be said to positively have active tuberculosis
infection. Chest xray and tuberculin test are not recommended to diagnose
tuberculosis.

The International Standard for Tuberculosis Care (ISTC) 2014 stated that anyone with
tuberculosis infection should undergo HIV testing and vice versa due to the high
number of comorbidities found. Therefore in this patient it is highly recommended to
test for HIV. Other than that, this patient has diabetes mellitus, which is also a
comorbidity commonly found in TB patients. Diabetes mellitus is known to triple the
risk of developing tuberculosis, and to increase the severity in tuberculosis patient,
along with worsening the blood glucose control in patients.6

The treatment of tuberculosis is aimed to:

 Cure and improve productivity and quality of life of the patients
 Prevent mortality
 Prevent relapsing
 Reduce transmission of both sensitive and resistant drug TB

The anti-tuberculosis drug is the one and only efficient effort can be done to achieve
the above aim. The drug used must be in combinations, with minimum 4 drugs for
active phase. It should be given in correct dosage and directly monitored by the care-
taker. The medication is given in two phase; the intensive phase, and the continuation
phase. First line regiments include isoniazid, rifampicin, pyrazinamide, streptomycin,
and ethambutol.7
 Table 1 - First line anti tuberculosis drugs

Medication Mode of Action Side Effects

Isoniazid (H) Bactericidal Peripheral neuropathy, toxic
psychosis, liver toxicity, seizure
Rifampicin (R) Bactericidal Flu-like syndrome, gastrointestinal
disturbances, red urine, liver toxicity,
thrombocytopenia, fever, skin rash,
shortness of breath, haemolytic
anemia
Pyrazinamide (Z) Bactericidal Gastrointestinal disturbances, liver
toxicity, gout arthritis
Ethambutol (E) Bactericidal Vision disturbances, peripheral
neuritis
Streptomycin (S) Bactericidal Balance and hearing disturbances,
anaphylactic shock, anemia,
agranulocytosis, thrombocytopenia

For category 1 patients, which are newly diagnosed TB patients, the regiment chosen
is 2RHZE/4RH. With the dosage listed on table 2.

Table 2 - Anti tuberculosis drug dosage

Medication Dosage (mg/kgBW) Maximum

Isoniazid (H) 5 (4 – 6) 300
Rifampicin (R) 10 (8 – 12) 600
Pyrazinamide (Z) 25 (20 – 30) -
Ethambutol (E) 15 (15 – 20) -
Streptomycin (S) 15 (12 – 18) -
3. Diabetes Melitus Type II
 Chapter V
Holistic and Comprehensive Management Scheme of the
Case
 Chapter VI
Conclusion

A 37 years old male with the chief complaint of hemoptysis and the medical problems
of lung tuberculosis and diabetes mellitus type II is admitted to hospital ward for
further workup and treatment.
 References
1 S. Depari RES, Swidarmoko B, Syahruddin E. Discharge criteria of patient with
hemoptysis and evaluation for a month in persahabatan hospital. J Respir Indo
2010; 30 (4): 197-205.
2 Kaspers et al. 19th ed. Harrison’s Principle of internal medicine. 2015; San

Francisco: Mc-Graw-Hill. P 245-7.

3 Larici AR, Franchi P, Occhipinti M, et al. Diagnosis and management of

hemoptysis. Diagn Interv Radiol 2014; 20:299-309.

4 World Health Organization. Tuberculosis Fact Sheet No. 104. Updated October

2015. Available from: http://www.who.int/mediacentre/factsheets/fs104/en/

5
6ISTC
7Kementrian Kesehatan Republik Indonesia. Pedoman Nasional Pengendalian
Tuberkulosis. 2014.