A 50 Year Old Female with Tuberculosis? .

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M. K. Farhan

Roll No. 171

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

Acknowledgement:- 

http://venkata-phaneendra.blogspot.com/2022/03/a-50f-with-sob-since-20-days.html

I have taken some inputs from the elog about the same patient which have been mentioned in the above link

29th March, 2022.

Case Discussion:

A 50yr old female came with c/o shortness of breath (Grade 2) since 25 days.

Pedal oedema and chest tightness , generalized weakness and fatigue and frequent falls difficulty in opening mouth and ulcers 14 days back

C/o Difficulty in swallowing solids and liquids since 14 days.

C/o Difficulty in walking and movement since 14 days days

History of Presenting Illness : 

Pt was apparently alright 10 years ago then she got severe headaches, and was easily fatigued, and on a visit to hospital for it she was diagnosed with hypertension and started on medications since then.

6 years ago hospital in view of weight gain and easy fatigability, she visited hospital and was diagnosed with Hypothyroidism and started on medications for it since then.

Later she was diagnosed with Arthritis but is not on any medications.

2 months back Pt had C/o cough with expectoration, pain in chest region. was diagnosed as PULMONARY MILIARY TB based on Chest X Ray and started on ATT. After 1 month of use she started developing redness and itching all over the body ATT induced Erythroderma, stopped ATT on 1 Feb 2022 for 20 days.

She was then shifted to a Government Hospital. There she stopped her ATT and was treated for her cutaneous condition. She again started having SOB ( grade 2), not associated with any Orthopnea/ Paroxysmal Nocturnal Dyspnea, Pedal Edema, Chest Pain, or Palpitations.

From 5 days she has difficulty in swallowing solids and liquids and was had difficulty in swallowing solids and liquids and was having difficulty in opening of mouth because of pain and c/o reddish discoloration of the tongue but now it got reduced.

Past History:

 k/c/o De novo Diabetes since 3 months, (Not on Medication)

k/c/o Hypertension since 3 years (on Medication- Amlodipine 5mg)

k/c/o Pulmonary miliary TB on ATT using 3 Tablets/ day (H- Isoniazid, R- Rifampicin, Z- Pyranzinamide, E- Ethambutol)

k/c/o Hypothyroidism since 6 years on Thyronorm 50 mcg.

Personal History:

• Decreased appetite
• Mixed diet
• Sleep Normal
• Bowel and Bladder-
• Addictions-

On Examination:

Patient was examined in a well lit room after taking consent her consent. 

• The Patient was conscious, coherent and co operative. She was well oriented to time, place and person
• NO Cyanosis/ Clubbing/Lymphadenopathy 

• PALLOR +

• ICTERUS+

                        Vitals at the time of admission :-

• Temperature:100F
• PR: 98bpm
• BP:130/80mm Hg
• RR:27cpm
• Spo2: 95%
• GRBS:105gm%

Systemic Examination:-

• CVS: JVP NORMAL, Apex beat 5th IV space mid clavicular line; s1 s2 +

• RS: BAE + , B/L crepts + (ISA, IAA)

• P/A: soft, non tender , BS +
• RBS: 70mg/dl

• HbA1c : 6.8%

• RFT

        Blood Urea: 136mg/dl 

        S. Creatinine: 4.8mg/dl

        Na -139

        K - 3.0

        Cl - 102

• Hemogram

        Hb - 7.2

        TLC - 15,000

        MCV - 80.4

        PCV - 21.5

        MCH - 27.0

        MCHC - 33.6

        PLT - 3.67

        RDW - 62

        Peripheral Smear:  NORMOCYTIC, NORMOCHROMIC

        Serum iron : 45ug/dl

• ABG

        pH - 7.34

        PCo2 - 18.8

        PaO2 - 92.4

        HCO3 - 12.2

        SpO2 - 96

• LFT

        TB - 2.8

        DB - 0.74

        AST - 14

        ALT - 10

        ALP - 673

        TP - 7.4

        ALB - 2.23

• CUE

        ALB - ++

        Sugars - nil

        Pus cells - plenty

        Epithelial cells - 1-2

• COVID-19 Rapid Antigen Test - NEGATIVE

• ESR - 70

• CRP - POSITIVE

X-rays :-

• Chest X-Ray

• X- Ray Neck (Lateral view) 

ECG:-

USG:-

Abdomen

HRCT- Chest 

• Small air filled cyst noted left lower lobe.

• No evidence of effusion.

• Non-obstructive left renal culculus.

Diagnostic nacendoscopy

        https://youtu.be/eBKqDXlAd-8

Diagnosis: 

        Interstitial Lung Disease

        Metabolic Acidosis

        Plummer Vinson syndrome with

        Urosepsis with

        Milliary pulmonary tuberculosis

Credits :- Thanks to Dr. PHANEENDRA (INTERN) for Clinical images

Treatment:-

•         IVF NS/RL/DNS @ 75 ml/hr
•         Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins
•         NEB. Ipravent 1resp inH TID
•         NEB. BUDICORT 1RESP INH TID
•         INJ. HUMAN ATRAPID according to sliding scale
•         Amlodipine 5mg PO OD
•         Inj. PIPTAZ 2.25 gm IV TID
•         T. Thyronorm 50 mg PO OD
•         INJ. PAN 40 MG IV OD
•         T. AMLONG 5 MG PO OD
•         MUCOPAIN GEL L/A 40 MINS BEFORE MEAL
•         Betadine mouth wash TID
•         Liquid paraffin all over body TID

Reference:-

        https://swathi162.blogspot.com/2022/03/50-year-old-female-with-dysphagia-under.html?m=1

SOAP NOTES Day 2

    S: Reduced oral ulcer pain

        C/o Burning Micturition

O: O/E 

Pt is c/c/c 

Pallor +

Icterus +

Cyanosis, clubbing, lymphadenopathy not present

 

Vitals: 

PR: 110bpm

BP: 120/80mm Hg

RR: 24 cpm 

CVS: s1s2 +

RS: BAE +

P/A: soft, non tender    BS +

A:

AKI secondary to Urosepsis

Dysphagia under evaluation

? Secondary to ATT induced STEVEN JOHNSONS ( oral ulcers) with MILIARY TB ( on ATT from 3/1/22)

H/o ATT induced Erythroderma (stopped ATT on 1/2/22) restarted on 21/2/22

K/c/o HTN, Hypothyroidism since 10yrs and 

 K/c/o DM since 3-4 months

? Rheumatoid Arthritis 10 yrs ago 

HFPEF ( moderate LV dysfunction, LAD Akinesia, EF-58%)

P:

1.  IVF- NS,RL: urine output + 30ml/hr
2.  Inj. PIPTAZ 2.25gm IV TID 
3.  Neb IPRAVENT 1 resp INH TID
4.  Neb BUDECORT 1 resp INH TID
5.  Inj. HUMAN ACTRAPID acc to GRBS 
6.  GRBS monitoring 6 th hrly
7.  T. THYRONORM 50ug PO OD
8.  Inj. PANTOP 40mg IV OD
9.  T. Amlong 5mg PO OD
10.  MUCOPAIN GEL for L/A ( 10 mins before each meal in oral cavity)
11.  BETADINE mouth wash TID
12.  LIQUID PARAFFIN all over the body TID
13.  STOP ATT
14.  strict I/o charting, temperature charting every 4th hrly

SOAP NOTES Day 3

S: Reduced oral ulcer pain

    C/o Burning Micturition

O: O/E 

Pt is c/c/c 

Pallor +

Icterus +

Cyanosis, clubbing, lymphadenopathy not present

 

Vitals: 

PR: 110bpm

BP: 120/80mm Hg

RR: 24 cpm 

CVS: s1s2 +

RS: BAE +

P/A: soft, non tender

        BS +

A:

AKI secondary to Urosepsis

Dysphagia under evaluation

? Secondary to ATT induced STEVEN JOHNSONS ( oral ulcers) with MILIARY TB ( on ATT from 3/1/22)

H/o ATT induced Erythroderma (stopped ATT on 1/2/22) restarted on 21/2/22

K/c/o HTN, Hypothyroidism since 10yrs and 

 K/c/o DM since 3-4 months

? Rheumatoid Arthritis 10 yrs ago 

HFPEF ( moderate LV dysfunction, LAD Akinesia, EF-58%)

P:

1) IVF- NS,RL: urine output + 30ml/hr

2) Inj. PIPTAZ 2.25gm IV TID 

3) Neb IPRAVENT 1 resp INH    TID

             BUDECORT 1 resp INH TID

4) Inj. HUMAN ACTRAPID acc to GRBS 

5) GRBS monitoring 6 th hrly

6) T. THYRONORM 50ug PO OD

7) Inj. PANTOP 40mg IV OD

8) T. Amlong 5mg PO OD

9) MUCOPAIN GEL for L/A ( 10 mins before each meal in oral cavity)

10) BETADINE mouth wash TID

11) LIQUID PARAFFIN all over the body TID

12) STOP ATT

13) strict I/o charting, temperature charting 4th hrly