A 66 yr old male with chest pain and difficulty in breathing

CBBLE UDHC SIMILAR CASES


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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box
A 66yr old male farmer by occupation who is a chronic smoker and alcoholic came to hospital with chief complaints of breathlessness since 6months
Chest pain since 4 months
Cough since 10ys
HOPI : Patient was apparently asymptomatic 1yr back. Then he had chronic cough and chest pain for which he went to hospital and diagnosed with Tuberculosis. Patient was started on ATT. He continued taking medication for some days after which he developed body pains and joint weakness. Then he stopped one of the 4 ATT medication on which his symptoms resolved. So he continued taking ATT except that one medication throughout its course which completed on October.
Patient again developed breathlessness and chest pain since 4 months.
cough since 15 days. Mucopurelent, no hemoptysis. 
Chest tightness +, increased during cough. 
Not a k/c/o DM, HTN, thyroid epilepsy, BA, CAD, CVA
General Examination :
Patient is c/c/c thin built and moderately nourished. 
Vitals :
Temp g afebrile 
PR - 78bpm
BP - 120/70 mmHg
Spo2 - 95%
CVS - S1 S2 +
RS - BAE +, Ronchi present. 
CNS - NAD. 
P/A - soft, non tender. 

Investigations :
ON 15/03/22
CBP:
HB- 9.4 gm%
TLC-8,400
PLT- 3.31 lakhs
PCV - 31.5
Microcytic hypochromic anaemia

BGT - AB +
RBS - 70mg/dl

RFT :
Urea - 31
Creatinine.-1.2
Na - 141
K - 4.2
Cl - 98

LFT :
TB - 0.44
DB - 0.15
AST - 11
ALT-10
ALP - 370
TP - 7.4
ALB - 2.85
A/G - 0.63

 USG - Left renal caliculi and Focal calyceal dilatation at upper and middle pole of right kidney with multiple caliculi within. 

Diagnosis :? Pulmonary Kochs ( irregular ATT) 

Plan:
1.AFB, sputum culture and CBNAAT reports awaited
2. Plan for ATT


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