final practical short case

A 56 year old male with fever and generalized lymphadenopathy.


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 comments on comment box is welcome.

Hall ticket number : 1701006191

I've been given this case to for my final practical examination to showcase my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

CASE:-
HISTORY :

CHIEF COMPLAINTS :

1. Pain abdomen since 20 days.
2. Multiple abdominal swellings since 7 days.
3. Fever since 7 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 5 months back, then he developed cough which was insidious in onset, gradually progressive and there was no sputum. 

Later, he developed fever which was high grade, associated with chills and rigors. He went to the hospital with above complaints and medications were prescribed and the symptoms subsided.

After 2 months, patient observed loss of appetite and loss of weight for which he went to the doctor. Upon, his advice, the patient got tested for Tuberculosis and HIV. He tested positive for both TB and HIV. The patient was given ART and ATT.

20 days back, patient started experiencing pain around the umbilicus which was insidious in onset, gradually progressive associated with abdominal discomfort. He complains of small multiple round swellings in the abdomen since 7 days which have gradually increased to present size. He had fever since 7 days which was high grade associated with chills and rigors.

PAST HISTORY :

Patient is a known case of Tuberculosis and HIV-AIDS and is on regular treatment.

Patient is not a known case of Diabetes mellitus, Hypertension, Asthma, Epilepsy, Thyroid disorders.

There is no surgical history, no history of blood transfusions.

FAMILY HISTORY:- Not significant

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased 

Sleep : Adequate 

Bowel and Bladder movements : Regular

Addictions : None

FAMILY HISTORY :

No history of similar complaints in the family.

HISTORY OF ALLERGIES :

No known drug or food allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well oriented to time, place and person.

Moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, edema

Lymphadenopathy is present. There are multiple enlarged lymph nodes in abdomen and neck. 

Cervical lymph nodes : Palpable on both sides of neck which are about 2x2 cm in size and soft to firm in consistency. 

Inguinal lymph nodes : Multiple palpable lymph nodes on both sides of size about 1x1 cm which are soft to firm in consistency are palpable.
Axillary and supraclavicular lymph nodes are not palpable.

Vitals :

Temperature : Febrile

Pulse Rate : 86 bpm

Blood Pressure : 120/80 mm Hg

Respiratory rate : 16 cpm

GRBS : 106 mg/dl


SYSTEMIC EXAMINATION :

Cardiovascular System : S1, S2 heard. No murmurs.

Respiratory System : Normal Vesicular Breath Sounds heard.

Central Nervous System : Conscious, Alert, Speech normal, Motor and Sensory examination normal.

Per Abdomen : Soft, No hepatomegaly. No splenomegaly. 

INVESTIGATIONS :-

1. Hemogram:-

Hemoglobin : 7.3 g/dl

TLC : 4000 cells/mm3

Neutrophils : 78%

Lymphocytes : 13%

Eosinophils : 2%

Basophils : 0%

PCV : 20.7 vol%

MCV : 85.2 fl

MCH : 30 pg

MCHC : 35.3%

RDW-CV : 17.2%

RDW-SD : 53.7 fl

RBC count : 2.43 million/mm3

Platelet count : 2.61 lakhs/mm3

Smear : Normocytic Normochromic anemia

2. Blood sugar : -97 mg/dl

3. ESR : 45 mm/1st hour

4. CRP : Positive (2.4 mg/dl)

5. LDH : 261 IU/L

6. HIV : Reactive

7. LFT :-

Total Bilirubin : 1.22 mg/dl

Direct Bilirubin : 0.24 mg/dl

AST : 43 IU/L

ALT : 22IU/L

ALP: 375IU/L

Total protein : 6.4 g/dl

Albumin : 3g/dl

A/G : 0.88

8.RFT:-

Urea : 20 mg/dl

Creatinine : 0.8 mg/dl

Uric acid : 4.0 mg/dl

Calcium : 9.3 mg/dl

Phosphorus : 3.3 mg/dl

Sodium : 139 mEq/L

Potassium : 4.1 mEq/L

Chloride : 102 mEq/L

9. CUE:-

Albumin:- positive

10. Chest x-ray:-
12. 2D Echo:-
13. FNAC : From right cervical lymph node - acid fast bacilli positive

PROVISIONAL DIAGNOSIS :-

Fever with generalized lymphadenopathy secondary to HIV/TB

TREATMENT :-

1. Tab. Dolo 650 PO TID

2. Tab. MVT OD

3. Inj. Neomol 1g IV/SOS

4. Tab. Dolutegravir, Lamivudine, Tenofovir Disoproxil Funerate (50 mg,300 mg,300 mg) PO OD

5. Tab. Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (150 mg,75 mg,400 mg,275 mg) PO OD

6. Tab. Septran-DS PO BD

7. Tab. Pan 40 mg PO BD

8. Syrup Aristozyme PO 10 ml TID

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