45 yr old patient with pulmonary tb

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CASE:

A 45 year old female patient came to OPD with chief c/o fever since 10days, cough and breathlessness since 5 days,no palpitations,no chest pain o up by Drr chest tightness,no h/o hemoptysis,complains of weightloss 5kgs during 2 months.Had 1 episode of vomiting and 4 episodes of loose stools yesterday 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back from when she had fever which is associated with chills and rigors,high grade ,intermittent and with diurnal variation,increasing during night and subsided by day.Cough is not productive and occasional.Breathlessness insidious onset and MMRC grade 3 associated with wheeze 

No complaints of chest pain,palpitations,giddiness,hemoptysis,

1 episode of vomiting since yesterday-non projectile non bilious had food particles

4 episodes of loose stools since yesterday 

PAST HISTORY:

No similar complaints in the past.Not a known case of DM,Htn,epilepsy,TB,CAV,CAD

PERSONAL HISTORY:

Mixed diet

Sleep and apettite normal 

Bowel and bladder movements are regular

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION:

 On examination patient is conscious,coherent and cooperative.

PR:- 83 bpm

BP:- 130/90 mm hg

RR:- 16 bpm

Temp:- aferbrile

RS :- .BAE +

           B/l crepts +

CVS :- S1 S2 +

CNS.:- NFND

P/A: - Soft,Nt 

SYSTEMIC EXAMINATION:-

Patient was moderately built and nourished 

No pallor,icterus,cyanosis,clubbing,koilonychia,lymphadenopathy,Edema 

RESPIRATORY SYSTEM:-

Inspection:-

Upper respiratory tract:-

No sinus tenderness,no flaring of alar nasi,no nasal septal deviation,Throat and tonsils normal,no good oral hygiene

Lower respiratory tract:-

On inspection 

Elliptical shaped chest,

Trachea- appears to be in midline

No supraclavicular hollowing 

Infraclavicular flattening

No shoulder drooping

No kyphoscoliosis,no lordosis

Chest movements appears to be b/l symmetrical

No visible scars/sinuses/dilated veins,no intercostal retractions or swellings 

On palpation :-

Trachea confirmed to be central in position

Apex beat- 1 cm medial to mid clavicular line in lt 5th intercostal space 

Chest movements- b/l symmetrical 

Vocal fermitus-b/l normal 

No rib crowding/bony tenderness

Measurements:-

Ap diametre :- 7.5 inches 

Transverse diametre:- 8 inches 

Chest expansion 2 cm

Percussion

Decreased resonance on mammary and infrascapular areas 

On auscultation

Breath sounds:- nrml vesicular breath sounds 

Crepts in mammary and infra scapular areas of both lungs

Wheeze (-)

Rhonchi(-)

Decreased breath sounds on mammary area of rt lung

INVESTIGATIONS

Chest x ray 

Usg abdomen 

Hb-8.2

TLC- 29000

PLT-3.2

N-92

L-03

M-04

E-01

PCV-24.6

MCV-68.3

MCH-20.0

MCHC-29.3

RDW-18.7

RBC-3.60

Color doppler:-

HRCT chest:-

ECG

Sputum culture- tested negative for AFB

CBNAAT:- tested positive for AFB

Provisional diagnosis:-

Septic shock secondary to pneumonia

? Tuberculosis infection