50 YEAR OLD MALE WITH TUBERCULOSIS AND RETROVIRAL DISEASE

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Name: Sreshta J

Roll no: 48

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