1801006005 SHORT CASE

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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.


CASE PRESENTATION:

A 55 year old male resident of narketpally mechanic by occupation, came with cheif complaints of abdominal tightness since 1 month, decreased appetite since 1 month

HOPI: 

Patient was apparently asymptomatic 1 month back, then he developed abdominal distension which is insidious in onset gradually progressive, fever since 10days high grade  associated with chills and rigors and increased on night time relieved by medication

h/o decreased appetite

No h/o pain abdomen ,vomiting, pedal edema ,dyspnea ,jaundice ,cough, hemoptysis,burning micturition

PAST HISTORY:

not a k/c/o dm ,htn,tb, asthma ,epilepsy

PERSONAL HISTORY:

DIET- mixed

APPETITE- decreased

SLEEP- adequate

BOWEL AND BLADDER MOVEMENTS- Regular

ADDICTIONS- 

chronic alcoholic drinks 90 ml for 20 years 

chronic smoker 9 beedis per days for past 30 years 

DAILY ROUTINE 1 month back: patient wakes up at 6 o clock , drinks chai , goes for work , works in a factory ( brick making ) at 1 O clock eats lunch usually rice with curry  at 5 o clock comes home watches tv and 8 oclock eats dinner rice with curry and sleeps adequately

present daily routine:

at 6 oclock drinks chai eats 2 idli for breakfast drinks maaza  , cannot go to work , appetite decreased .

ON EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

PALLOR- ABSENT

ICTERUS- ABSENT

CYANOSIS- ABSENT

CLUBBING- ABSENT

LYMPHADENOPATHY- ABSENT

EDEMA- ABSENT

VITALS :

TEMP. : 97.2
PR : 88 BPM in right arm radial pulse , all peripheral pulses are palpable ,no radioradial delay ,no radiofemoral delay
RR : 18 CPM
BP : 100/60 bpm in right arm sitting position.









SYSTEMIC EXAMINATION:

RS : RESPIRATORY SYSTEM- 
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type. 
Trachea central in position & Nipples are in 4th Intercoastal space
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS
, 1cm medial to mid clavicular line
Cricosternal distance is 3finger breadths. 
MEASUREMENTS-
chest circumference- 31 inches at expiration & 32 inches at full inspiration
Chest expansion- 2.5cm
                                         Right                   left
Hemithorax-              15.5 inches 15.5inches

Hemithorax expansion-  1/2inch     1/2inch

AP diameter-                  7 inch
Transverse diameter-    12 inches

AP/T ratio - 0.58

Tactile vocal phremitus- diminished in left Infraaxillary & infra scapular area. 

Percussion:-
                                       Right                     left

Supraclavicular- Resonant (R)                 (R) 

Infraclavicular-              (R)                        (R) 

Mammary-                     (R)                      Dull

Axillary-                          (R)                        (R) 

Infra axillary-                R                   dull

Suprascapular-             (R)                        (R) 

Interscapular-               (R)                        (R) 

Infrascapular-             R                       dull 

Auscultation:-

                                      Right                     Left

Supraclavicular- Normal vesicular        (NVBS)
                        Breath sounds (NVBS) 

Infraclavicular-          (NVBS)                 (NVBS)

Mammary-                 (NVBS)                 (NVBS)

Axillary-                      (NVBS)                 (NVBS)

Infra axillary-      NVBS                 diminished
                                                          

Suprascapular-          (NVBS)                (NVBS)

Interscapular-            (NVBS)                (NVBS)

Infrascapular-          nvbs      diminished 
 
        
P/A : soft, tenderness presnent in epigastric and  umbilical regions , no shifting dullness ,,no  fuild thrill
CVS :S1, S2 herad no murmurs

INVESTIGATIONS:



































exudative picture
lymlhocytes predominant , low saag high protein , ada levels are high

PROVISIONAL DIAGNOSIS:
TB PERITONITIS 
LEFT PLUERAL EFFUSION, CLD  secondary to chronic alcoholism

TREATMENT:
1) SALT RESTRICTION<2GM/DAY
2) FLUID RESTRICTION<1.2LIT/DAY
3) INJ CEFTOXIME 1GM IV/BD
4) INJ PAN 40MG  IV/BD
5) INJ LACILACTONE20/25 PO/OD@9AM
6) SYP LACTULOSE 10ML PO/BD
7) TAB DOLO 650MG PO/TID
8) STRICT INPUT /OUTPUT CHARTING

 Att
isoniazid-5mg /kg OD
RIFAMPICIN-10 MG /KGOD
ethambutol- 15mg /kg OD
pyrazinamide-40mg po 
FOLLOW UP: REVIEW after 2 weeks







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