Post TB sequale

 

 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.

Name :- Kattekola Sathwik
Roll no :-58
2017 batch

A 65 yr old farmer (man) hailing from Rural Nalgonda with a past history  of Tuberculosis  one year ago has presented  with the complaints of
1. SHORTNESS OF BREATH SINCE 4 MONTHS
2. COUGH WITH EXPECTORATION SINCE ONE MONTH
3. CHEST TIGHTNESS SINCE 15 DAYS

HISTORY OF PRESENTING ILLNESS
The patient was apparently  asymptomatic  one year ago. Then he developed  cough with expectoration with blood in sputum. He went to a local hospital and was diagnosed  as TB after evaluation. He took the treatment  for 5 months only .
Now from about 4 months he developed  Grade 1 Shortness of breath (NYHA) which relieves on rest. There were no complaints of cough ,chestpain ,Orthopnea pedal edema  that point of time
Then about from one month he is complained of cough with Greenish white expectoration.He says that the SOB was increasing after cough.
Then he has complained of chestpain  from 15 days. He says that the chest pain increases  after cough. He also says that the pain starts in the left side of the chest and then progresses to entire chest
No complaints  of Orthopnea, PND
He also complains of Burning micturition and loin pain occasionally. No other urinary complaints

Past history :- No History  of comorbidities

Personal history :-
Appetite :- Good
Diet :- Mixed
Bowel and bladder  :- regular, Occasional burning micturition.
Sleep :- Adequate
Addictions:-
1. He is a chronic smoker since he was about 16 yrs of age . Smokes one packet of beedis per day
2. He is an occasional alcoholic

Family History:- No history  of similar complaints

General examination 
Patient was examined  in a well lit room after obtaining valid informed  consent and Adequate exposure
He was conscious, coherent, cooperative
Well oriented to time place person
Moderately built and nourished 
Pallor :- Present
Icterus:- Absent 
Cyanosis:- Absent
Clubbing :- present 
Lymphadenopathy:-Absent
Pedal edema:- Absent

Vitals
Temperature:- Afebrile
RR:-13cycles/min
Pulse :-76 bpm,regular,normal volume,normal character,vessel wall :-firm
BP :-120/80mmHg

Clinical Images 

Incidental finding in the patient- A swelling in the back and also the posterior aspect of right side of the neck.

Both of then were soft with with a smooth surface and soft in consistency without any signs of oongoing inflammation

The patient doesnt have any problem with these swellings...

Systemic  examination  

Respiratory  system 

Inspection

Chest is bilaterally symmetrical

The trachea appears to be in centre
Apical impulse is not appreciated 
Chest moves equally with respiration on both sides
No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest diameters

• Anteroposterior diameter :-7 inches
• Transverse diamter:-12 inches 

Chest moves equally on both sides 
Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line
Tactile vocal fremitus- appreciated 
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.

Auscultation-
Normal vesicular breath sounds are heard
No adventitious sounds


CARDIOVASCULAR SYSTEM- 
Inspection- 
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated 
Palpation-
Apical impulse is felt in the fifth intercostal space, 1 cm lateral to  the midclavicular line
No parasternal heave felt
No thrill felt
Percussion- 
Right and left borders of the heart are percussed 

Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard 

PER ABDOMEN
Inspection
• The abdomen is scaphoid
• Umbilicus is central
• No distention 
• No engorged veins
• No visible pulsations
• No scars and sinuses
• Herinal orifices are free

Palpation
• No local rise of temperature and tenderness
• All Inspectory findings  are confirmed
• On deep Palpation, Liver and spleen are not palpable
Percussion :-Tympanic note heard
Auscultation:- Bowel sounds appreciated

CENTRAL NERVOUS SYSTEM-
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.


All cranial nerves - Intact

No signs of meningeal irritation


Motor system

                              Right.                  Left


BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N


TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N


POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5



Superficial reflexes and deep reflexes are present, normal

Gait- normal

No involuntary movements


Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated

Provisional  diagnosis 
Post TB sequale  with probable lung infection for further evaluation

Investigations

Hemogram 

• HB :-9.4

• Total WBC :- 8400 (N 77   L17 M5 E1)

• PCV :-31.5

• MCH :-21.2  MCHC :-29.8

• MCV :- 70.9

• RDW :-18

• Platelets :-3.33 lakh

LFT

• Total bilirubin:- 0.44

• Direct bilirubin :- 0.15

• AST :-11

• ALT :-10

• A/G  :- 0.63

Serum creatinine:-1.2

Blood urea:-31


Electrolytes 

• Sodium:-141

• Potassium:-4.2

• Chloride :98

CUE 

Chest X ray

2D echo 

USG abdomen 

ECG

Treatment
1. INJ AUGMENTIN 1.2G IV TID
2. INJ .PAN 40MG IV OD
3. T.MUCINAC AB TID
4. SYP. ASCOXIL TID 2 asp
5.NEB. with Duolin 6th hrly and BUDECORT 12TH HRLY
6. 4TH HOURLY VITALS MONITORING