1801006129 short case

A 30 year old female completed her degree final year came with complaints of fever since 2 month’s and cough with sputum since 15 days.
HOPI:
Patient was apparently asymptomatic 2 months back and then she developed fever which was insidious in onset,,high grade and not associated with chills and rigors and relieved on taking medication and again after one week she again developed fever which is of high grade and 15days back patient developed cough associated with sputum.And her sputum is scanty in amount, white in colour,no blood in sputum and non foul smelling sputum.And patient developed shortness of breath which is present only at nights not disturbing her sleep and she had known about it after her attenders noticed it.SOB at nights only since15 days which is on and off and 15days.
No loss of Apetite,No weight loss in last 2 months.
Not a known case of DM,HTN ,TB, ASTHMA, CAD and CVA.
Attendend a  weight loss programme for which she lost 7kgs in last 7 mnths.
Her weight now 66kgs.
GENERAL EXAMINATION:
No pallor,Icterus,Cyanosis,Clubbing,Koilonychia,Lymphadenopathy and edema.









JVP:No raise

Systematic examination:
Bp:130/80mmHg in right arm in sitting posture on day 1
100/60mmhg in right arm in sitting posture on day 6
PR:120bpm,regular rhythm,normal volume
CVS:S1 and S2 are heard 
Decreased heart sounds
CNS:NAD
RS:18cpm 
BAE present
Air entry decreased in right side
Right infrascapular wheeze and right infraaxillary wheeze and left Infrascapular crepts are present.
Temperature:Afebrile at time of presentation 
Mantoux test:Done outside shows positive reaction.



CB NAAT of sputum:Shows negative for AFB
INVESTIGATIONS:
Chest x ray and CT chest done on 17 june outside 



Chest x ray done on 23 june 2022


Renal Function Tests:

Test

Result

Urea

19 mg/dL

Creatinine

0.7 mg/dL

Uric acid

3.0 mg/dL

Calcium 

10.1 mg/dL

Phosphorous

4.1 g/dL

Sodium

134 mEq/L

Potassium

3.8 mEq/L

Chloride

100 mEq/L




Liver Function Tests:

Test

Result

Total Bilurubin

# 1 20 mg/dL

Direct Bilurubin

# 0 31 mg/dL

SGOT(AST)

# 45 IU/L

SGPT(ALT)

27 IU/L

ALKALINE PHOSPHATE

# 198 IU/L

TOTAL PROTEINS 

80 gm/dL

ALBUMIN

# 3.19 gm/dL

AIG RATIO

66




Hemogram:

Test

Result

Hemoglobin

8.5 gm/dL

Total Count

7100 cells/cu. mm

Neutrophils

66%

Lymphocytes

22%

Eosinophils

2%

Monocytes

10%

Basophils

0%

PCV

27.2 vol %

MCV

72.5 fl

MCH

22.5 pg

MCHC

31.3%

RBC Count

3.72 millions/ cu. mm

Platelet Count

3.64 lakhs/cu. mm




Complete Urine Examination:

Test

Result

Colour

Pale Yellow

Appearance

Clear

Reaction

Acidic

Sp. Gravity

1.010

Albumin

Nil

Sugar

Nil

Bile Salts

Nil

Bile Pigments

Nil

Pus Cells

2 - 3

Epithelial Cells

2 - 3

Red Blood Cells

Nil

Crystals

Nil

Casts

Nil

Amorphous Deposits

Absent

Others

Nil


Pericardial Fluid:

Test

Result

V

0.5 ml

APP

Clear

COI

Reddish

TC

1000 cells

DC

90% L + 10% N

RBC

6 lakhs

Others

Nil




Blood Sugar:

Test

Result

Random Blood Sugar

209 mg/dL

Post Lunch Blood Sugar

179 mg/dL


Glycated Hemoglobin:

Test

Result

HbA1c

6.6%














Pericardial fluid ADA levels raised :61
Pericardial fluid for CB NAAT:No AFB and no sensitivity for rifampicin,
PROVISIONAL DIAGNOSIS:
pericardial effusion secondary to TB.



Treatment Given:
1. NEB BUDECORT 1 RESPULE / 6TH HOURLY
2. TAB DOLO 650 MG / TID
3. TAB RIFAMPICIN 150 MG GIVEN FOR 2 DAYS
4. TAB ISONIAZID 75 MG
5. TAB PYRAZINAMIDE 400 MG
6. TAB ETHABUTOL 275 MG
7. TAB WYSOLONE 20 MG BD GIVEN FOR 2 DAYS
8. TAB BENADON OD
9. PROTEIN POWDER - 2 SCOOPS IN 1 GLASS OF MILK TID

Advice at Dishcharge:
1. NEB BUDECORT 1 RESPULE / 6TH HOURLY
2. TAB DOLO 650 MG / TID
3. TAB RIFAMPICIN 150 MG
4. TAB ISONIAZID 75 MG
5. TAB PYRAZINAMIDE 400 MG
6. TAB ETHABUTOL 275 MG
7. TAB WYSOLONE 20 MG BD FOR 1 DAY, OD FOR 3 DAYS
8. TAB BENADON OD
9. PROTEIN POWDER - 2 SCOOPS IN 1 GLASS OF MILK TID



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1801006129 long case