50/M PTB HBSAG

50/M CAME WITH 

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
Sputum afb seen , sputum cbnaat positive 
 Att started on 14-2-2023 AND HE COMPLETED TREATMENT IN AUG 2023 AND WAS FOUND TO BE SPUTUM NEGATIVE. CONTACTED HIM IN SEPT 2023

OUTCOME- COMPLETELY RECOVERED

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