A 52 yr old male with pleural effusion secondary to TB
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I have 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 diagnosis and treatment plan.
TELECASE HISTORY TAKING
A 52 yr old male patient resident of Siliguri, of West Bengal, a computer technician by occupation presented with complains of
Chief complaints:
Fever since 2 months
Cough since 1 month
Right sided Chest pain since 1 month
History of presenting illness:
Patient was apparently asymptomatic 2 months back then he developed fever which is insidious in onset and gradually progressive in nature and of moderate grade associated with chills and rigor, aggravated during night time and temporarily relieved on medication.
He also has cough since 1 month which is insidious in onset , dry cough had no diurnal variation and had a postural variation of more cough on lying down and had no releiving factors even on use of cough syrup and bouts of cough was around 10-15 times a day
He also had pain in the chest region and lumbar region which was insidious in onset gradually progressive which was of pricking type of pain was also radiating to lower back ,aggravated on taking deep inspiration and had no relieving factors.
H/o severe weight loss in last 2 months (62 kgs to 49 kgs) and was also associated with Night sweats.
No H/o dyspnea, wheeze,hemoptysis,hoarseness of voice
No h/o palpitations,orthopnea, pnd.
No h/o nausea, vomiting,loose stools,constipation,abdominal distension.
No h/o burning micturition, decreased urination.
Past history:
SEQUENCE OF EVENTS
16.12.21
He had history of weakness of Lt sided upper limb and lower limb associated with intermittent fever for 1 month one and half year ago and was taken to hospital
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29.12.21
There he was diagnosed as Right fronti temporal convexity extra Sol (Meningioma?) and Right fronti temporo parietal craniotomy with durotomy with gross excision of right fronti temporal SOL done
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Then on advice of doctor he was on bed rest for 2 months and after that started going to work occasionally when ever he feels like going
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April 2023
Started having fever which was intermittent and used paracetamol for a few days and then consulted a doctor and was tested for malaria and dengue and was negative and was given antibiotic medication? For 5 days
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Then had 2 episodes of seizures
Then visited the doctor who had done his craniotomy surgery and ct was done again was said as clear and was referred to visit other doctor for the complaints of recurrent fever
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May 2023
Fever was recurring and also was associated with dry cough and right sided chest pain and also had a severe weight loss for which he again visited hospital and was investigated with x ray of chest and ct thorax
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Was diagnosed as a case of Bilateral pleural effusion with large effusion on left side and moderate effusion on right side.
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June 2023
He was also associated with Night sweats and chills and severe weight loss which made the doctor suspicious of TB
Usg guided pleural fluid aspiration was done sent for cytology and Ada on suspection of TB. Referred to TB hospital
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After visiting TB hospital was diagnosed as case of TB and was adviced on starting Tb medication.
Not a k/c/o Htn, Dm, asthma, epilepsy,cad,thyroid disorders.
DAILY ROUTINE
Before illness:
He used to wake up at 8 to 9 am and after getting freshup then has tea and snacks and has a habit of taking tiffin only occasionally 1hr after getting up and some times doesn’t have the habit of taking tiffin and goes to work of computer repair (hardware) work and sits there in the shop and work for upto 3pm and then has his lunch at shop and then works upto 7 pm at the shop and then goes to his home and freshen up and watch tv for an hour and has his dinner around 8 to 9 pm and has habit of watching movies for around 2 hrs and then goes to sleep around 11 to 11:30 pm .
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After UL and LL weakness:
After having surgery of brain he was advised for the bed rest and stopped working for 2 months and his daily activity were altered in terms of work which was shifted to rest . After 2 months he started working at shop only occasionally whenever he feels like going and couldn’t do work compared as previously
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After Fever ,Cough,Chest pain
He wakes up at around 5 am and freshen up and around 7 am has almonds tea and snacks and has breakfast sometimes and then just takes rest and watch tv and stopped going to work completely and has his lunch at 1pm and has snacks in between at around 5 pm and has dinner at 9pm and then struggles for sleep because of the fever associated with chills and cough which becomes more prominent on lying down and sleep at around 1 am for 3.5to 4hrs and then wakes up around 5 am again.
Family history: No significant family history
Personal history:
He was educated upto class 10 and married in the year 2004 and had his first boy child in 2005 currently studying inter 2nd year and had his second girl child in 2007 currently studying 10th class. He works as a computer technician. Stopped working completely since last 2 months because of fever cough and chest pain .
Diet - Pure vegetarian
Sleep - Reduced since last 2 months
Appetite- Normal
B&B - Regular
Addictions -
Has a habit of taking pan masala since 30 yrs
No smoking or alcohol habits
No allergic history.
Treatment history :
Dec 2021
Tab.Torleva xr 500 BD for 4 days
Tab. Pantocid D OD for 4 days
Under gone excision of Right fronto temporal SOL .
After discharge was on medication of :
Tab. levexx 500mg 1tab twice daily continuous
Tab. Pan 40 1 tab OD for 7 days
Tab. Dolo 650 mg TID for 3 days
Tab. linid 600 mg 1 tab BD for 10 days
Tab. cetil CV 1tab BD for 2 weeks
April 2023
Was on Antibiotics ? for 1 and half month.
Then on
May 2023
Inj Xone 1gm BD for 5 days
Tab. Pan 40 mg Od for 20 days
Tab. Levipil 500 mg
Tab. Becosules OD
June 2023
Investigations:
ADA
Pleural fluid sugar protein
X ray
Urine analysis
Serology
Haematology
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