52/F PTB

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.

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.
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


18/5/2023

Pulmonology refferal: i/v/o pneumonia with rt upper lobe cavity?PTB 

19/5/2023 
2d echo:

Bronchoscopy was done today for BAL(Bronchalveolar lavage).


Smear picture with acid fast bacilli:

*CBNAAT:
BAL and Sputum sample 
*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

PATIENT WAS CONTACTED THROUGH PHONE CALL - COMPLETED TREATMENT  ON 09-12-2023 AND WAS FOUND TO BE SPUTUM NEGATIVE.NOW PATIENT IS DOING FINE.

OUTCOME - COMPLETELY RECOVERED


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