left FIBRO CAVITARY DISEASE SECONDARY to TB WITH HbsAg +

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

FOLLOWING IS THE VIEW OF MY CASE

CHIEF COMPLAINTS:

c/o cough since 20 days

c/0 SOB since 20 days

c/o fever since 7 days

HISTORY OF PRESENT ILLNESS

Pt was apparently asymptomatic 20 days back then

 1.he developed cough with sputum, mucopurulent, non blood stained ,non foul Smelling, more cough during night, 

  • no seasonal variation, not associated with chills.
  • no aggrevating & relieving factors

 2.c/o SOB since 20 dats 
  • Grade II (MMRC), 
  • not associated wheeze, 
  • no aggravating no seasonal variation,
  •  more during Early mornings.
  • no aggravating & relieving factors, no orthopnea, no PND. 
3.c/o fever since  7 days
  •  intermittent type, Low grade fever 
  • relieved of medication. & rigors,
  •  no Evening rise of temperature 
 4.clo wt loss and loss of appetite from 4 months no c/i Chest Pain Chest fightness, hemoptysis, palpitations 

5.h/0 Similar complaints 4 months back.
h/o of TB 4 months back (detected in sputum CBNAAT) H/O TB AAT (3 tabs/day) for 2 months, then stopped

PAST HISTORY 

not a known case of CAD,CVD, thyroid disorders epilepsy
No history of surgeries


PERSONAL HISTORY :

  1. Diet: mixed
  2. Appetite: increased
  3. Bowel habits: normal
  4. Bladder habits: normal
  5. Sleep: normal
  6. Addictions: 
                                    (i) alcohol consumption - daily 180ml
                                                                            stopped from 6months
 
                                    (ii) smoker since 30 years - 2 pack of beedi/day 
                                                                                stopped from 6months
             
FAMILY HISTORY :

not significant

                                   
GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.
Examined after taking valid informed consent in a well enlightened room.
  • Pallor          - absent
  • Icterus        - absent
  • Clubbing    -absent
  • Lymphadenopathy    - absent
  • Cyanosis     - absent
  • Pedal edema  -absent

VITALS :
  • Temperature: 101F
  • Pulse : 130 bpm
  • Respiratory rate : 20 per minute 
  • Bp 110/70
  • Spo2 96%
  • GRBS 105 mg%
CVS EXAMINATION 

 S1 S2 heard
no murmurs

RESPIRATORY SYSTEM
Bilateral air entrty present
NVBS

PER ABDOMEN 

soft, non tender

URT
  • Nose - No DNS, No nasal polyps.
  •  Oral cavity - normal oral hygeine
  •                       Dental Carier +
  • Posterior pharyngeal wall - normal
LRT 

1.inspection
  • Shape of chest - Elliptical
  • B/L symmetrical
  • Trachea appears to be central (Trail's sign - Absent)
  • Chest Expansion - Equal on BS.
  • usage of accessory muscles of respiration
  • left supra clavicular hollowness > right supraclavicular hollowness
  •  crowding of ribs + left side > R 
  • NO drooping of Shoulders. 
  • Spino scapular distance L>R 
  • Apical impulse not seen
  •  wasting of muscles +
  •  No kyphosis & scoliosis
  •  Skin over chest - no sinuses, scars, engorged veins
2. palpation
  • All inspectory finding conformed
  • No local rise
  • No tenderness
  • Trachea slightly deviated to left
  • chest morte slightly decreased left-side
  • Ape beat - left 5th ICS medial to MCL
  • TVF- equal on BS
  • AP diameter -20cms
  • Transverse - 24cm
  • CC - inspiration : 80 cm
  •          expiration : 79cm
  • right hemi - 42cm
  • left hemi - 40 cm
3. percussion 
  • direct - resonant
  • indirect - resonant in all areas
  • liver dullness : from right 5th ICS
  • cardiac dullness : within normal limits

4. auscultation
  • BAE +
  • decreased BS in left ICA, infra SA, IAA
  • crepts + left ISA
  • VR - equal on BS

INVESTIGATIONS :

                                                 












PROVISIONAL DIAGNOSIS:
left FIBRO CAVITARY DISEASE SECONDARY to TB WITH HbsAg +

TREATMENT GIVEN 

1) INJ. CEFTRIAXONE 1 GM IV BD FOR 5DAYS
2) INJ PAN 40 MG IV ODFOR 5DAYS
3) TAB PCM 650 MG PO TID IF TEMP >99 F
4) TAB MVT PO/ OD
5) SYP. ASCORIL LS 2TSP PO /TID
6) TAB MUCINAC 600MG PO BD(MIX IN 1 GLASS OF WATER)
7) PROTEIN POWDER 2 TSP IN 1 GLASS OF WATER BD
8) 2 EGG WHITES PER DAY
9) ATT (3TABS/DAY) BBF PO UNDER NTEP (IP) DAY 1

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