52/F with cough and fever since 2 months
Admission on 17/5/2023
52 years old lady came to OPD with chief complaints of fever and cough since 4 months (i.e.,Jan 2023 last week onwards) generalised weakness since 15 days.
HOPI:
Patient was apparently asymptomatic 4 months back then she developed fever which is low grade not associated with chills and rigors, relieved with medication, no diurnal variation.
Cough since 4month, non productive cough, diurnal variation present i.e., more during night.
And also more in supine position and after eating food,no seasonal variation.
So for this they went to local hospital ,there they asked to take chest xray on 14/2/2023.
CT scan done on15/2/2023.
So they gave cough relievers, but her cough is relieving only when she is taking medication but not subsided completely.so they came to our OPD.
H/o weight loss since 2 months.
No H/o SOB,wheeze
No h/o vomitings,loose stools,pain abdomen
No h/o palpitations,pedal Edema
PAST HISTORY:
No similar complaints in the past.
K/c/o DM 2 since 10 years ( on Zoryl MV 1 )
N/k/c/o HTN, asthma, epilepsy,CAD,CVA
PERSONAL HISTORY:
Diet - mixed
Appetite - decreased
Sleep- inadequate (due to cough)
Bowel and bladder- regular
Addictions- No
FAMILY HISTORY:
Her husband had a h/o TB 10 years back.
GENERAL EXAMINATION:
-Patient is conscious, coherent,cooperative.
-moderatly built and nourished
pallor +
No icterus,cynosis,clubbing, generalised lymphadenopathy,pedal Edema.
VITALS:
Temp:96.8°F
BP:100/70 mmhg
PR:92 bpm
RR: 18 cpm
Spo2: 98
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Inspection:
Transverse diameter - 22 cms
AP diameter -30 cms.
Thoracic ratio is = 0.73
Shape- elliptical
Droopling of right shoulder ,
Supraclavicular and infraclavicular hollowing is present
Trachea appears to be deviated to right.
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
No visible apex beat.
Palpation:
Inspectory findings are confirmed
No local rise of temperature
No tenderness
Trachea slightly deviated to the right
Expansion of chest is symmetrical.
Percussion
Dull note heard on right infra clavicular region.
Rest of the regions are normal ,resonate note heard
Auscultation:
bilateral air entry present.
Normal vesicular sounds.
Crepts heard in the right infraclavicular region
ABDOMINAL EXAMINATION:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration. No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Pneumonia with Rt lung upper lobe cavity ? Pulmonary TB.
INVESTIGATIONS:
17/5/2023
2d echo:
Bronchoscopy was done today for BAL(Bronchalveolar lavage).
*Rifampicin Sensitive MTB Detected*
* ATT started from 20 /5/2023
Ophthalmology:
22/5/2023:
DIAGNOSIS:
PULMONARY KOCH'S ( CBNAAT OF SPUTUM AND BAL ARE POSITIVE)[ RIFAMPICIN SENSITIVE] with right upper lobe cavity with -type 2 DM since 10 yrs
TREATMENT:
1.1Tab.ISONIAZIDE 225 mg PO/OD
2)Tab.RIFAMPICIN 450 mg PO/OD
3)Tab.PYRAZINAMIDE 1125 mg PO/OD
4)Tab.ETHAMBUTOL 675 mg PO/OD
5)Tab.PYRIDOXINE 40 mg PO/OD
6)Tab.Zoryl -MV 1 PO/OD
7)Tab.PAN 40 mg PO/OD
8)Syp.Ascoril D 10 ml PO/TID
9)Tab.Dolo 650 mg PO/sos
10)2 egg whites /day
SUMMARY:
FINAL DIAGNOSIS:
PULMONARY KOCH'S ( CBNAAT OF SPUTUM AND BAL ARE POSITIVE)[ RIFAMPICIN SENSITIVE] with right upper lobe cavity with -type 2 DM since 10 yrs
HISTORY:
52 years old lady came to OPD with chief complaints of fever and cough since 4 months (i.e.,Jan 2023 last week onwards) generalised weakness since 15 days.
HOPI:
Patient was apparently asymptomatic 4 months back then she developed fever which is low grade not associated with chills and rigors, relieved with medication, no diurnal variation.
Cough since 4month, non productive cough, diurnal variation present i.e., more during night.
And also more in supine position and after eating food,no seasonal variation.
So for this they went to local hospital ,there they asked to take chest xray on 14/2/2023.ther is a right upper lobe cavity in the chest x ray.So they advised for CT scan due to there is a cavity in right upper lobe.
CT scan done on15/2/2023.
After the scan they adviced for sputum AFB test. The sputum AFB is done in the March and it is negative .
So they gave cough relievers, but her cough is relieving only when she is taking medication but not subsided completely.so they came to our OPD.
H/o weight loss since 2 months. About 5 -6 kgs.
No H/o SOB,wheeze
No h/o vomitings,loose stools,pain abdomen
No h/o palpitations,pedal Edema
PAST HISTORY:
No similar complaints in the past.
K/c/o DM 2 since 10 years ( on Zoryl MV 1 )
N/k/c/o HTN, asthma, epilepsy,CAD,CVA
PERSONAL HISTORY:
Diet - mixed
Appetite - decreased
Sleep- inadequate (due to cough)
Bowel and bladder- regular
Addictions- No
FAMILY HISTORY:
Her husband had a h/o TB 10 years back.
GENERAL EXAMINATION:
-Patient is conscious, coherent,cooperative.
-moderatly built and nourished
pallor +
No icterus,cynosis,clubbing, generalised lymphadenopathy,pedal Edema.
VITALS:
Temp:96.8°F
BP:100/70 mmhg
PR:92 bpm
RR: 18 cpm
Spo2: 98
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
Transverse diameter - 22 cms
AP diameter -30 cms.
Thoracic ratio is = 0.73
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Percussion - resonant
Auscultation:
bilateral air entry present.
Normal vesicular sounds.
Crepts in the right infraclavicular region
ABDOMINAL EXAMINATION:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration. No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
COURSE IN THE HOSPITAL :
Patient got admitted for cough and intermittent fever since 4 months , chest x ray shown cavity in the right upper lobe on 17/5/2023.
On 18/5/2023 sputum is sent for culture and sensitivity, gram staining, ZNstaining ,AFB by inducing sputum with NS in nebulizer.(but sputum is scanty)
Pulmonology referral was taken on 18/5/2023, they advised to induce sputum for testing.
Due to scanty sputum bronchoscopy was done for BAL on 19/5/23.
CBNAAT OF SPUTUM and BAL is positive and RIfampicin sensitive.
ATT was started from 20/5/2023
Ophthalmology refferal was done on 20/5/2023 I/v/o diabetic retinopathy.
Opinion - normal ant.chamber and fundus in both eyes. No features suggestive of diabetic retinopathy as of now.
Advise at discharge :
1Tab.ISONIAZIDE 225 mg PO/OD
2)Tab.RIFAMPICIN 450 mg PO/OD
3)Tab.PYRAZINAMIDE 1125 mg PO/OD
4)Tab.ETHAMBUTOL 675 mg PO/OD
5)Tab.PYRIDOXINE 40 mg PO/OD
6)Tab.Zoryl -MV 1 PO/OD
7)Tab.PAN 40 mg PO/OD
8)Syp.Ascoril D 10 ml PO/TID
9)Tab.Dolo 650 mg PO/sos
10)2 egg whites /day
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