Case of a 41 year old male with chief complains of shortness of breath , chest pain and cough with expectoration .

CHIEF COMPLAINTS- A 41 year old male came to the opd with chief complaints of 
  • Shortness of breath (past 4 months )
  • Cough with expectoration (past 4 months)
  • Chest pain (past 1 month ) 


HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 3 years back 

3 years ago , the patient was found to be positive for retroviral disease and is on ART therapy since . 

From the past 4 months , 
The patient is experiencing, Shortness of Breath . 
from the past 10 days , the SOB has converted into grade 2 

The patient also complains of Cough with expectoration (non -foul smelling and non- blood stained ) from the past 4 months

 The patient mentions that he has had a weight loss of 4 Kgs in the past 4 months with loss of appetite .  

 From the past one month , the patient complains of chest pain associated with difficulty of swallowing both solids and liquids 

From the past 15 days the patient is experiencing Pain in the abdominal region- which is dull aching type , continuous , non radiating in the periumbilical region .  

No complains of Paroxysmal Nocturnal Dyspnea , burning micturition , decreased urine output . 


HISTORY OF PAST ILLNESS 

No History of 

  • DM, HTN , Ischemic Heart Disease 
DRUG HISTORY 
  • ART(anti retroviral theray ) from the past 3 years 
PERSONAL HISTORY 
  • Diet - mixed 
  • appetite reduced 
  • sleep adequate 
  • bowel and bladder movement regular 
  • The patient is a chronic alcoholic from the past 20 years  , he stopped consuming alcohol 3 months back 
  • No history of Smoking 
FAMILY HISTORY 

The wife's sister was seropositive for retrovirus and passed away recently after being diagnosed with pulmonary TB 
GENERAL EXAMINATION 
  • The patient is concious , coherent and cooperative , oriented to time place and person 
  • NO  pallor , icterus , cyanosis , clubbing lymphadenopathy 
  • Presence of swelling on the right half of the neck - 4 swollen matted Lymphnodes 







VITALS AT ADMISSION 
  1. Temperature - Afebrile 
  2. Blood Pressure - 100/70mm of Hg 
  3. Pulse Rate - 90 beats per minute 
  4. Respiratory rate - 12 cycles per minute 
  5. SPO2 at RA- 95 percent 
CVS EXAMINATION -
  • S1,S2 heard 
  • No murmurs 

RESPIRATORY SYSTEM EXAMINATION 
  • BAE present 
  • Decreased breath sounds in all areas 
  • Bronchial Breath sounds in the left ISA, IAA , AA

CNS EXAMINATION 
  • Higher Mental Functions normal 
  • No Focal Neurological Deficits 

PER ABDOMEN 
  • Soft , Non tender 

INVESTIGATIONS - day 1 

1. Complete Blood Picture 
  • HB - 5.7 g/dl  (normal - 13-17)
  • TLC- 5,500 cells / cubic mm (normal - 4000-10000)
  • Neutrophils - 72 percent (normal - 40-80)
  • Leucocytes - 18 percent (normal - 20 -40 )
  • Eosinophils - 2 percent  (normal -1-6)
  • Monocytes - 8 percent (normal 2-10)
  • Platelet- 2.72 lakhs per cubic millimeter (normal - 1.5 to 4.1) 
  • smear - Normocytic , Normochromic 
2. Serum Creatinine - 1mg/dl  (normal - 0.9 to 1.3 mg /dl ) 

3. Blood urea - 41 mg per dl ( normal - 12-42 mg/dl ) 

4. Serum electrolytes - 
  • Sodium- 133 m Eq per L ( normal - 136 to 145 mEq per L ) 
  • Potassium- 3.5 m Eq per L (normal - 3.5 to 5.1 mEq per L)
  • Chloride - 94 m Eq/liter (normal - 98 to 107 m Eq per L )
5. Liver Function test - 
  • Total bilirubin - 0.73 mg/ dl(normal 0 to 1 mg per dl)
  • Direct bilirubin - 0.20 mg / dl (normal 0.0 to 0.2 mg per dl ) 
  • SGOT - 11 IU/L  (normal  0 - 35 IU per L )
  • SGPT- 10 IU/L  (normal  0 -45 IU per L ) 
  • ALP - 120 IU/L  (normal  56 to 119 IU per L ) 
  • Total proteins - 6.1 g /dl (normal 6.4 to 8.3 g/ dl )
  • Albumin - 3.8 g /dl                        (normal - 3.2 to 4.6 g/dl )
  • A/G ratio - 1.65 
6. Pleural Fluid 
  • LDH- 510 IU/L                            
  • sugar - 47 mg/dl 
  • protein - 3.8 g/dl 
7. Chest Xray 



                            
8. FNAC - RIGHT CERVICAL LYMPHNODE - Day 3







9. SERUM LDH - 389 IU/ L 

10 . PLEURAL PROTEIN / SERUM PROTEIN - 3.8/6.1= 0.62

11. PLEURAL LDH / SERUM LDH - 510/389= 1.31

12. BACTERIAL CULTURE AND SENSTIVITY REPORT DAY 3 







PROVISIONAL DIAGNOSIS - 

? PLEURAL EFFUSION secondary to ?Koch's
RVD + 

DIAGNOSIS - 

Right sided loculated excudative pleural effusion , secondary to ?Pulmonary Koch's 
ATT started on Day 2 
RVD positive since 3 years on ART regimen associated with Nutritional Anemia . 

TREATMENT DAY 1 

  1. INJ . OPTINEURON 1 MO IN 100 ML NS SLOW IV/OD
  2. SYRUP LACTUOSE 15 ML , PO/HS 
  3. SYRUP ASCORIL - D PO/TID 10 ML 
  4. PROTEIN POWDER 2 SCOOPS IN 100 ML MILK TID 

TREATMENT DAY 2

  1. TAB. PANTOP - 40 MG PO/BD FOR 10 DAYS 
  2. INJ . OPTINEURON 1 MO IN 100 ML NS SLOW IV/OD
  3. SYRUP LACTUOSE 15 ML , PO/HS
  4. SYRUP ASCORIL - D PO/TID 10 ML
  5. PROTEIN POWDER 2 SCOOPS IN 100 ML MILK TID

 

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