32 M PTB

 PT C/O CHEST PAIN ON LEFT SIDE SINCE 2-3MONTHS WITH SOB SINCE 2-3 MONTHS WITH COUGH WITH EXPECTORATION

 HOPI: PT WAS APPARENTLY ALRIGHT 2-3MONTHS AGO THEN HE DEVELOPED SOB(GRADE II)WITH COUGH WITH EXPECTORATION ,GREEN COLOURED WITH PALPITATIONS,COUGH INCREASES AFTER FOOD INTAKE AT NIGHT NIGHT TIME RISE OF TEMPERATURE PRESENT ASSOCIATED WITH SWAETING AND WEIGHT LOSS SINCE 3 MONTHS(15-20KGS) LOSS OF APPETITE,NAUSEA PRESENT NO C/O ABDOMINAL PAIN,VOMITINGS,DIARRHEA NO ORTHOPNEA,PND 

PAST HISTORY: N/K/C/O DMII, HYPERTENSION,TB,EPILEPSY,CVA,CAD,ASTHAMA,THYROID DISORDERS. 

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE, WELL ORIENTED TO TIME,PLACE AND PERSON.

 MODERATELY BUILT AND NOURISHED. 

NO SIGNS OF PALLOR,ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

 VITALS: TEMP: AFEBRILE BP: 120/80 MM HG RR: 76 BPM RR: 18 CPM 

CVS: S1, S2 HEARD ,NO MURMURS RS: BAE +, NVBS CNS: NFND P/A: SOFT, NON TENDER, BOWEL SOUNDS HEARD

 Investigation HEMOGRAM: HB: 9.6 GM/DL TOTAL COUNT: 11600 CELLS/CUMM N/L/E/M/B: 75/20/3/7/0 % PCV: 32.8 VOL% MCV: 80.1 FL MCH: 25.8 PG MCHC: 32.3 % RBC:4.0 MILLIONS/CUMM PLATLET COUNT: 6.1 LAKHS/CUMM

 SEROLOGY: NEGATIVE

 LIVER FUNCTION TEST: TOTAL BILURUBIN: 0.83 MG/DL DIRECT BILRUBIN: 0.27 MG/DL AST: 11 IU/L ALT: 12 IU/L ALP: 157 IU/L TOTAL PROTIENS: 6.1 GM/DL A/G RATIO: 0.87

 RENAL FUNCTION TEST: UREA: 35 MG/DL 

CREATININE: 1.4 MG/DL 

SODIUM: 138 MEQ/L POTTASIUM: 4.4 MEQ/L CHLORIDE: 99 MEQ/L

 ECG: NORMAL SINUS RHYTHM. 

Treatment Given

 INJ AMOXYCLAV 1.2MG IV/BD INJ PANTOP 40MG IV/OD TAB AZYTHROMYCIN 50 MG PO/OD SYP.GRYLLINCTILIS PO/TID ADEQUATE FLUID INTAKE ORALLY SYP.LACTULOSE 10ML PO/TID 4TH HRLY IN 1 GLASS OF WATER

AFB POSITIVE 

SPUTUM CBNAAT POSITIVE 

CHEST X RAY SUGGESTIVE OF TUBERCULOSIS


ATT STARTED 4 TABS/DAY

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