A 50 yr old female with pulmonary TB
17 March 2022
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CHIEF COMPLAINT:
A 50 yr old female came to OPD with chief complaint of shortness of breath since 20 days , difficulty in swallowing since 3 days and not able to open mouth since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 months ago
2 months back patient had cough and expect oration,pain in the chest region and went to local hospital and she was diagnosed with pulmonary miliary tuberculosis
After 1 month of usage of antitubercular drugs she developed redness and itching all over the body which is a ATT induced erythroderma.
She stopped ATT for 20 days and then again started using 20 days back.
Patient was apparently alright 20 days back
Patient have Pedal edema, palpitations,chest pain since 3 days
She is having difficulty in Swallowing And since 1 day Patient is not able to open mouth wide because of pain.
Daily routine:
Before
She used to wake up at 5am and complete her morning household chores till 7am. She takes a nap in afternoon. Till 9 pm she completes her dinner and sleeps by 10pm. She feel normal tiredness as she's completely engrossed in household work.
After
Unfortunately after diagnosis, she's facing difficulty in her daily routine work. Intially, she can't stand and cook for a longer period of time. Now she's totally avoiding work from past 2 months.
HISTORY OF PAST ILLNESS:
Known case of rheumatoid arthritis,hypothyroidism, Diabetes and Hypertension
Not a k/c/o Asthama
PERSONAL HISTORY:
Appetite - Normal
Diet- mixed
Bowel movement- regular
Sleep- Adequate
Not alcoholic
GENERAL EXAMINATION:
- patient is Conscious,coherent and cooperative
-pallor is present
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of finger
VITALS:
Temperature-afebrile
Pulse rate -98bpm
Respiration rate -27bpm
Bp-130/80 mm Hg
Spo -95%
SYSTEMIC EXAMINATION:
◾CVS
- S1 &S2 sounds are heard
- No thrills
- No cardiac murmurs
◾ Respiratory system
Dyspnoea is present
◾CNS
Sensory and motor system is normal
INVESTIGATIONS:
Tab. FLUCONAZOLE 150 mg PO/OD
Tab. NODOSIS 500 mg PO/TID
Tab. THYRONORM 5 mg PO/OD
