1701006039- SHORT CASE

 This E-blog also reflects my patient's centred online learning portfolio. 

A 30 year old female completed her degree final year came with 
Cheif complaints of :
 fever since 2 month’s and 
cough with sputum since 15 days.

HOPI:
Patient was apparantly assymptomatic 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 back diagonosed to be having pericardial effusion.
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
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.














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:

1)Anti tuberculosis drugs 4pills/day
2)Tab  Wysolone 20mg PO BD for 3 days followed by Tab Wysolone 20mg PO OD for 2 weeks
3)Neb.Budecort 1 respule 6th hourly.

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