Case 3

This is a patient I saw last week in the male ward.

Mr A, a 60-year-old Chinese man, previously diagnosed with nasopharyngeal carcinoma 10 years ago and currently in remission for 5 years now, was admitted for chronic cough for 5 years. The cough started insidiously 5 years ago and at that time the sputum was greenish-whitish in colour. However, 2 years ago, he started having hemoptysis as well. The sputum coughed up now is thick blood mixed with mucus and about half cup to one cup each time. He also complains of intermittent low grade fever for the past 2 years and night sweats as well. He also has dizziness and headache after a bout of hemoptysis. However, he does not have any palpitations or fainting spells. He contracted nasopharyngeal cancer 10 years ago as he was working in a glue factory then. He had a growth in left nostril and completed radio and chemotherapy for it. He was told that his cancer was cured after completing therapy. He is under follow-up at Hospital Melaka for it. He currently has anosmia, reduced hearing but his sense of taste is still present. He does not have any TB contact and no other person staying with him has any similar signs and symptoms. He stays with his wife and his sister now. He is fully dependant on his wife and sister for income and housing as he lost his job at the glue factory as the factory closed down.

On examination, Mr A is alert, comfortable and cooperative. He cannot lie supine on his bed as he claims it will irritate his throat and cause him to cough. There is clubbing over all his fingers and toes. Capillary refill time is less than 2 seconds. However, he has pallor over his hands and conjunctiva. He does not have any jaundice. There is no signs of Horner's syndrome. Trachea was not deviated. On examination of his lungs, there is equal chest expansion of both lung fields. On tactile fremitus, there was increased resonance over the right middle and lower lobes of the lungs. On percussion, there was dullness over the right middle and lower lobes. On auscultation, there were normal vesicular breath sounds heard with no added sounds. On vocal fremitus, there was increased resonance over the right middle and lower lobes of the right lung as well.

Mr A had undergone many chest X-rays and CT scans over the past 5 years. The latest chest X-ray found a dense well-defined nodule in the right lower zone measuring about 3.5x2.5cm. CT scan in 2007 found consolidation of the right middle and lower lobe. Small bullae were seen within consolidation. AFB sputum was done in 2008 for one sample and was negative. ESR was also raised at 77. Full blood count showed hemoglobin 8.8 but other parameters were normal.

From the case, my differential diagnoses would be either a TB infection or a lung carcinoma, either primary or secondary from his previous nasopharyngeal carcinoma. Either way his symptoms are sinister and should not be allowed to drag on further. However, he was only admitted for less than 12 hours. He was treated with antibiotics for pneumonia and discharged with a follow-up visit to the MOPC 2 weeks later. The MO-in-charge thought of the above differential diagnoses but did not bother to take further action to investigate further. The official diagnosis written in the case notes was also pneumonia. The other symptoms were made light of. I feel that it is very unethical to just push the patient off and not bother about what will happen to him when he has already gone through so many prior investigations. Mr A was very desperate for someone to just listen to him and diagnose and treat him properly. Hopefully whoever who will see Mr A in the MOPC will attend to his symptoms properly and treat him as soon as possible.

Yilin