50 YEAR OLD MALE WITH TUBERCULOSIS AND RETROVIRAL DISEASE

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: B Jai Abhiram 

Roll no: 13

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

Following is the view of my case :

CASE PRESENTATION

A 50-year-old male has presented to the casualty on 15 September 2021 with the chief complaints of

  • fever and diarrhoea for 1 month
  • cough since 10 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 30 days ago when he developed a fever

FEVER: 

  • It was an intermittent and low-grade fever associated with chills and rigours.
  • no other associated symptoms like nausea, vomiting and headache.
DIARRHOEA:

  • multiple episodes per day following food intake
  • watery in consistency
  • greenish yellow color
  • not associated with abdominal pain 
COUGH:
  • cough with sputum since 10 days
  • more in the nights
WEIGHT LOSS:
-lost 5-6kgs in one month

PAST HISTORY :

  • not a known case of hypertension, diabetes, asthma, epilepsy.
  • suffered from TB 20 years ago, used medication for 9 months.
PERSONAL HISTORY :
  • married
  • lost appetite
  • takes mixed diet
  • bowel movements: loose stools
  • micturition is normal
  • no known allergies
  • addictions: has been addicted to playing cards since 15 years
No similar complaints in the family.

TREATMENT HISTORY:
TB treatment for 9 months 20 years ago

GENERAL EXAMINATION:

Done after obtaining consent, in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person.

  • No icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy, Pedal oedema and clubbing
  • pallor is seen

VITALS at the time of admission:

  • Temperature - afebrile
  • Pulse rate- 110 bpm
  • BP- 70/60 mm Hg
  • Respiratory rate- 40/min
  • Height- 170cm
  • Weight- 38kg
SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: 

  • Crepitations in the right infraclavicular region
3. Abdomen: Soft and non-tender

4. CNS: No focal deficit

INVESTIGATIONS:

HBsAg- rapid- negative 

Anti HCV Antibodies- non-reactive

Retroviral disease- positive

CBP



ECG



LFT



HBsAg- rapid- negative 

Anti HCV Antibodies- non-reactive

Chest X-ray 



Serum Electrolytes


Serum Creatinine


Serum urea-



PROVISIONAL DIAGNOSIS:

?Pulmonary tuberculosis 

TREATMENT PLAN  (given on 15 September 2021):

  1. IVF - NS 75ml/hr
  2. Inj metrogyl 100ml iv tid
  3. pantop 40mg iv od
  4. tab ciprofloxacin 400mg po bd
  5.  vitals monitoring


17 September 2021

VOMITINGS: 

  • 5 episodes during night
  • watery in consistency
  • greenish yellow in color

18 September 2021

VOMITINGS: 

    • 1 episode following food intake
    • contents: food

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