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164 J.SASI HARSHITH ELOG CASES

A 50 Year Old Female with Tuberculosis?

  This is an online E-log book to discuss our Patient's de- identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E-log Book also reflects my patient- centered online learning portfolio and your valuable inputs on the comment box.


J.SASI HARSHITH

Roll No. 164

I've been given this case to solve in an attempt to understand the topic of "Patients Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Acknowledgement:- 

http://venkata-phaneendra.blogspot.com/2022/03/a-50f-with-sob-since-20-days.html

I have taken some inputs from the elog about the same patient which have been mentioned in the above link


21st March, 2022.


Case Discussion:

A 50yr old female came with c/o shortness of breath (Grade 2) since 25 days.

C/o Difficulty in swallowing solids and liquids since 8 days.

C/o Difficulty in walking and movement since 8 days


History of Presenting Illness : 

Pt was apparently alright 10 years ago then she got severe headaches, and was easily fatigued, and on a visit to hospital for it she was diagnosed with hypertension and started on medications since then.

6 years ago hospital in view of weight gain and easy fatigability, she visited hospital and was diagnosed with Hypothyroidism and started on medications for it since then.

Later she was diagnosed with Arthritis but is not on any medications.

2 months back Pt had C/o cough with expectoration, pain in chest region. was diagnosed as PULMONARY MILIARY TB based on Chest X Ray and started on ATT. After 1 month of use she started developing redness and itching all over the body ATT induced Erythroderma, stopped ATT on 1 Feb 2022 for 20 days.







She was then shifted to a Government Hospital. There she stopped her ATT and was treated for her cutaneous condition. She again started having SOB ( grade 2), not associated with any Orthopnea/ Paroxysmal Nocturnal Dyspnea, Pedal Edema, Chest Pain, or Palpitations.

From 5 days she has difficulty in swallowing solids and liquids and was had difficulty in swallowing solids and liquids and was having difficulty in opening of mouth because of pain and c/o reddish discoloration of the tongue but now it got reduced.

Past History:

 k/c/o De novo Diabetes since 3 months, (Not on Medication)

k/c/o Hypertension since 3 years (on Medication- Amlodipine 5mg)

k/c/o Pulmonary miliary TB on ATT using 3 Tablets/ day (H- Isoniazid, R- Rifampicin, Z- Pyranzinamide, E- Ethambutol)

k/c/o Hypothyroidism since 6 years on Thyronorm 50 mcg.


Personal History:

  • Decreased appetite
  • Mixed diet
  • Sleep Normal
  • Bowel and Bladder-
  • Addictions-

On Examination:

Patient was examined in a well lit room after taking consent her consent. 

  • The Patient was conscious, coherent and co operative. She was well oriented to time, place and person
  • NO Cyanosis/ Clubbing/Lymphadenopathy 

  • PALLOR +

  • ICTERUS+






                        Vitals at the time of admission :-

  • Temperature:100F
  • PR: 98bpm
  • BP:130/80mm Hg
  • RR:27cpm
  • Spo2: 95%
  • GRBS:105gm%

Systemic Examination:-

  • CVS: JVP NORMAL, Apex beat 5th IV space mid clavicular line; s1 s2 +

  • RS: BAE + , B/L crepts + (ISA, IAA)

  • P/A: soft, non tender , BS +
  • RBS: 70mg/dl

  • HbA1c : 6.8%


  • RFT

        Blood Urea: 136mg/dl 

        S. Creatinine: 4.8mg/dl

        Na -139

        K - 3.0

        Cl - 102


  • Hemogram

        Hb - 7.2

        TLC - 15,000

        MCV - 80.4

        PCV - 21.5

        MCH - 27.0

        MCHC - 33.6

        PLT - 3.67

        RDW - 62

        Peripheral Smear:  NORMOCYTIC, NORMOCHROMIC

        Serum iron : 45ug/dl


  • ABG

        pH - 7.34

        PCo2 - 18.8

        PaO2 - 92.4

        HCO3 - 12.2

        SpO2 - 96


  • LFT

        TB - 2.8

        DB - 0.74

        AST - 14

        ALT - 10

        ALP - 673

        TP - 7.4

        ALB - 2.23


  • CUE

        ALB - ++

        Sugars - nil

        Pus cells - plenty

        Epithelial cells - 1-2


  • COVID-19 Rapid Antigen Test - NEGATIVE

  • ESR - 70

  • CRP - POSITIVE

X-rays :-

  • Chest X-Ray

  • X- Ray Neck (Lateral view) 

ECG:-



USG:-



Abdomen

HRCT- Chest 




  • Small air filled cyst noted left lower lobe.
  • No evidence of effusion.
  • Non-obstructive left renal culculus.

Diagnostic nacendoscopy

        https://youtu.be/eBKqDXlAd-8


Diagnosis

        Steven-johnson syndrome secondary to ATT with
        Urosepsis with
        Milliary pulmonary tuberculosis with
        ?nephrotic syndrome

Treatment:-

  •         IVF NS/RL/DNS @ 75 ml/hr
  •         Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins
  •         NEB. Ipravent 1resp inH TID
  •         NEB. BUDICORT 1RESP INH TID
  •         INJ. HUMAN ATRAPID according to sliding scale
  •         Amlodipine 5mg PO OD
  •         Inj. PIPTAZ 2.25 gm IV TID
  •         T. Thyronorm 50 mg PO OD
  •         INJ. PAN 40 MG IV OD
  •         T. AMLONG 5 MG PO OD
  •         MUCOPAIN GEL L/A 40 MINS BEFORE MEAL
  •         Betadine mouth wash TID
  •         Liquid paraffin all over body TID


Reference:-

        https://swathi162.blogspot.com/2022/03/50-year-old-female-with-dysphagia-under.html?m=1



SOAP NOTES Day 2

    S: Reduced oral ulcer pain
        C/o Burning Micturition

O: O/E 
Pt is c/c/c 
Pallor +
Icterus +
Cyanosis, clubbing, lymphadenopathy not present
 
Vitals: 
PR: 110bpm
BP: 120/80mm Hg
RR: 24 cpm 
CVS: s1s2 +
RS: BAE +
P/A: soft, non tender    BS +

A:
AKI secondary to Urosepsis
Dysphagia under evaluation
? Secondary to ATT induced STEVEN JOHNSONS ( oral ulcers) with MILIARY TB ( on ATT from 3/1/22)
H/o ATT induced Erythroderma (stopped ATT on 1/2/22) restarted on 21/2/22

K/c/o HTN, Hypothyroidism since 10yrs and 
 K/c/o DM since 3-4 months
? Rheumatoid Arthritis 10 yrs ago 
HFPEF ( moderate LV dysfunction, LAD Akinesia, EF-58%)

P:
  1.  IVF- NS,RL: urine output + 30ml/hr
  2.  Inj. PIPTAZ 2.25gm IV TID 
  3.  Neb IPRAVENT 1 resp INH TID
  4.  Neb BUDECORT 1 resp INH TID
  5.  Inj. HUMAN ACTRAPID acc to GRBS 
  6.  GRBS monitoring 6 th hrly
  7.  T. THYRONORM 50ug PO OD
  8.  Inj. PANTOP 40mg IV OD
  9.  T. Amlong 5mg PO OD
  10.  MUCOPAIN GEL for L/A ( 10 mins before each meal in oral cavity)
  11.  BETADINE mouth wash TID
  12.  LIQUID PARAFFIN all over the body TID
  13.  STOP ATT
  14.  strict I/o charting, temperature charting every 4th hrly

SOAP NOTES Day 3

S: Reduced oral ulcer pain
    C/o Burning Micturition

O: O/E 
Pt is c/c/c 
Pallor +
Icterus +
Cyanosis, clubbing, lymphadenopathy not present
 
Vitals: 
PR: 110bpm
BP: 120/80mm Hg
RR: 24 cpm 
CVS: s1s2 +
RS: BAE +
P/A: soft, non tender
        BS +

A:
AKI secondary to Urosepsis
Dysphagia under evaluation
? Secondary to ATT induced STEVEN JOHNSONS ( oral ulcers) with MILIARY TB ( on ATT from 3/1/22)
H/o ATT induced Erythroderma (stopped ATT on 1/2/22) restarted on 21/2/22

K/c/o HTN, Hypothyroidism since 10yrs and 
 K/c/o DM since 3-4 months
? Rheumatoid Arthritis 10 yrs ago 
HFPEF ( moderate LV dysfunction, LAD Akinesia, EF-58%)

P:
1) IVF- NS,RL: urine output + 30ml/hr
2) Inj. PIPTAZ 2.25gm IV TID 
3) Neb IPRAVENT 1 resp INH    TID
             BUDECORT 1 resp INH TID
4) Inj. HUMAN ACTRAPID acc to GRBS 
5) GRBS monitoring 6 th hrly
6) T. THYRONORM 50ug PO OD
7) Inj. PANTOP 40mg IV OD
8) T. Amlong 5mg PO OD
9) MUCOPAIN GEL for L/A ( 10 mins before each meal in oral cavity)
10) BETADINE mouth wash TID
11) LIQUID PARAFFIN all over the body TID
12) STOP ATT
13) strict I/o charting, temperature charting 4th hrly


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