A 38 year old with shortness of breath since 20 days

 A 38 year old female who is a resident of meerpet and shopkeeper by occupation came to the OPD with,

C/O  Shortness of breath since 20 days

         Fever since 15 days


HISTORY OF PRESENTING ILLNESS:

        Patient was apparently asymptomatic 2 months back, then she developed cough which is insidious in onset and gradually progressive, associated with sputum,mucoid type,non foul smelling and non blood stained and with one spoon full quantity sputum for each episode.cough worsens at night .cough associated with chest pain and chest tightening and during cough she was unable to catch her breath and after about 10-15 min she regains normal ,aggravated on cold exposure and relieved on mediaction

After 5-6 days she was unable to hold the symptoms ,for that she went for hospital ,they ran some tests according to her symptoms and they diagnosed her with starting stage of pulmonary tuberculosis and treated her with medication and she is on medication from that day to 20 days span .She felt that the symptoms are not relieving and went on check up for other hospital and is on medication for about 10 days and symptoms are subsided.And it is associated with fever and it is relieved on medication.

05/06/23,

she was admitted in other hospital for SOB ,fever and the symptoms are not subsided.So that she reached our hospital and admitted on Saturday night( 12am).

10/06/23,(12am)

came with the C/O SOB and fever 

              Shortness of breath since 20 days of grade 2  (acc.to MMRC classification) which is insidious in onset and progressed to grade 4 currently (acc. to MMRC classification) and aggravated on cool exposure and relieved on medication associated with orthopnea and paroxysmal nocturnal dyspnea,chest pain .

H/O fever since 15 days which is insidious in onset and intermittent in nature associated with chills and it is relieved on medication.

H/O nausea

No H/O haemoptysis and wheezing

No H/O palpitations


PAST HISTORY:

History of hypothyroidism 1 year back and on medication thyronorm 12.5 mcg and stopped 6 months back 

History of similar complaints since 2 months.

H/O TB since 1 month and on medication(ATT)

H/O hospitalisation 5 days back for similar complaints,no inhaler usage,no travel history.

No H/O diabetes mellitus ,hypertension,CAD,Epilepsy,Asthma.


PERSONAL HISTORY:

Diet -mixed

Appetite-low appetite

Sleep-inadequate

Bowel and bladder movements -regular

Addictions -none

Allergies-none


FAMILY HISTORY:

No significant family history


TREATMENT HISTORY:

Tab.Thyronorm 12.5mcg since 1year and stopped 6 months back.

Anti tubercular therapy since 1 month.


GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative and well oriented to time ,place and person

Temperature-afebrile

BP-120/80mmHg

PR-109bpm

RR-32cpm

Pallor present 

Pedal edema present

No cyanosis,clubbing lymphadenopathy,icterus.










RESPIRATORY EXAMINATION:

INSPECTION-
   
        Upper respiratory tract:

                   No polyps,DNS,turbinate hypertrophy,dental caries,halitosis,post nasal drip,normal pharyngeal wall and normal oral hygiene.

         Lower respiratory tract:

                    Shape of the chest-elliptical
                    Trachea-seems to be central
                    Chest movements appears to be equal                          on both sides
                    Apex beat not seen visually
                No drooping of shoulders,crowding of ribs,kyphosis,scoliosis,supraclavicular hallowing,intercoastal indrawing,no scars and sinuses over chest.

PALPATION-

No local rise of temperature and tenderness
Trachea-central
Chest movements are equal on both sides.
Chest expansion is normal
        On inspiration-99cm
        Onexpiration -97cm
Antero-posterior diameter-26cm
Transverse diameter-19cm
Apex beat -on left side ,1cm medial to the mid                             clavicular line
Vocal fremitus -normal on all areas.

PERCUSSION-

NORMAL-supra clavicular area,infra clavicular area,mammary area ,infra mammary area,axillary area ,infra axillary area,supra scapular area,infra scapular area,inter scapular area.

AUSCULTATION-

On auscultation-   B/L mild fine crepitations heard on infra axillary area ,infra scapular area and infra mammary area
NORMAL-supra clavicular area,infra clavicular,mammary area,inter scapular area area,axillary area,supra scapular area.


CVS EXAMINATION:

S1 and S2 heard ,no murmurs present
Apex beat heard on left side 1cm medial to the midclavicular line.

CNS EXAMINATION:

No neurological deficits present.

PER ABDOMEN EXAMINATION:
soft and non tender ,no organomegaly present.


PROVISIONAL DIAGNOSIS:

May be pneumonia or bilateral lower lobe consolidation secondary to pulmonary tuberculosis on anti tubercular drug therapy.



INVESTIGATIONS-








       


















 FINAL DIAGNOSIS:
 
B/L LEFT LOBE CONSOLIDATION SECONDARY TO PULMONARY TUBERCULOSIS ON ANTI TUBERCULAR DRUG THERAPY ASSOCIATED WITH TYPE 1 RESPIRATORY FAILURE WITH HYPOTHYROIDISM AND IRON DEFICIENCY ANEMIA.


TREATMENT:

Oxygenation by nebulisation and continuous positive airway pressure

Oxygen mask and nasal prongs usage for oxygenation.

Inj.CEFTRIAXONE 1gm IV BD
Inj.PANTOP 40mg IV OD
Tab.PARACETAMOL-650mg per oral BD
Tab.BENADON 40mg per oral OD
Syp.ASCORIL per oral TID
Syp.POTKLAR per oral TID
Tab.OROFER XT per oral OD
NEBULISER-IPRAVENT 6th hrly
                       BUDECORT 12th hrly
Inj.HYDROCORT 100mg IV.

Anti tubercular drug therapy (6 months) course.


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