A 22-Year-Old Woman With

Fever & Weight Loss

Dr. Samim Reza

Phase-A, Haematology
Orange Unit, Department of Medicine
Particulars:
Mrs. Rubi
22 Years
Housewife
Mohammadpur, Dhaka

Date of Admission 01/4/17

Presenting Complaints
* Fever for 1 month

*Cough for same duration

*Loss Of appetite & Weight loss for 3 months

Course of Illness
*Fever
Low grade
Evening rise
Irregular
3-4 days per week
Temperature not recorded
Subsided spontaneously, sometimes with antipyretic
Course of Illness
*Cough
Nonproductive
No diurnal variation

*Loss of Appetite

*Weight loss over last 3 months

*No-
Hemoptysis
Orthopnea
Paroxysmal Nocturnal Dyspnea
Joint pain
Oral ulcer
Alteration of bowel movement
*Amenorrhoea for 3 months
*Mother of One Child(LUCS 10 months back, got 2 unit of blood)

*Low income family

*Lives in slum area

*Brother is on CAT-I anti TB for last 3 months due to intestinal TB

Medication Received
Tab Azithromycin 500mg daily for 7 days and steroid
Tab Paracetamol
Cap Omeprazole

But no improvement
General Examination
Toxic
Emaciated
Anaemic
Smooth shiny tongue

Pulse- 100/min
BP-90/60 mm Hg, No postural drop
Respiratory rate-30/min
Temperature-100*F

IV cannula in situ
General Examination
*No-
Jaundice
Oedema
Cyanosis
Clubbing
Koilonychia
Leuconychia
Lymphadenopathy
Thyromegaly
JVP not raised
Respiratory System Examination
Features suggestive of Right sided Consolidation in upper & mid zone
and Left sided Hydropneumothorax.

Chest movement restricted on left side

Trachea is shifted to right
Apex beat is in left 5th ICS medial to mid clavicular line
• In Right side-
Percussion note is dull in Right 2nd to 5th ICS
along paravertebral line.

Breath sound Bronchial from Right 2nd to 5th ICS

Vocal resonance is increased in above mentioned area
There is presence of coarse Crepitation
In left side-
Percussion note is resonant with obliteration of Cardiac
dullness
Breath sound is diminished from left 4th ICS to
downwards along midclavicular line
Vocal resonance is also diminished in above mentioned
area
There is Pleural rub and coarse Crepitation
Respiratory system examinations
• Dull percussion from left 8th ICS downward along midscapular line
• Breath sound absent
• Vocal resonance reduced in above mention area
Abdomen Examination
*Abdomen is not distended.
Flanks are not full.
*Tenderness over epigastrium and umbilical region.

*No organomegally.

*No ascites present.

Provisional Diagnosis
Bilateral Extensive Pulmonary TB with Left sided Hydropneumothorax
Investigation
CBC
1/4/17 8/4/17
Hb% 5.3 g/dl 15 g/dl (after 3 units of BT
& steroid)
ESR 35 mm in 1st hour 25 mm in 1st hour
WBC 5000/c mm 7000/ c mm
Platelet 100000/ c mm 150000/c mm
Neutrophil 90% 88%
Lymphocyte 7% 8%
PBF Microcytic Hypochromic
Anaemia with
Thrombocytopenia
Investigations
Electrolytes
9/4/17 13/4/17 16/4/17
Na+ 129mmol/l 131 mmol/l 135mmol/l
K+ 2.9 mmol/l 3.6 mmol/l 3.24 mmol/L
Cl- 93 mmol/l 79mmol/l 106 mmol/l
Investigations
S. Creatinine 0.36 mg/dl
S. Bilirubin 1.2 mg/dl(9/4/17) 0.6 mg/dl(16/4/17)
FT3 1.08 IU/l
FT4 12.5 IU/l
TSH 0.39 IU/l
MT 02 mm
S. ADA 57.9 U/l
ANA Negative
 Investigations

S. Cortisol 123 nmmol/l

SGPT 28 U/l
S.ALP 167 U/l
S. Albumin 18 g/l
RBS 4.5 mmol/l
S. LDH 731 U/L
Urine R/E Normal Findings
USG of Whole Abdomen Pelvic Collection
04/4/17
9/4/17
15/4/17
Chest X-ray
04.04 09.04 15.04
 Hospital course of Illness
Patient was treated with CAT-1 Anti TB medication & Steroids from
4/4/17

After 3-4 days days of Anti TB therapy

Fever-
Fever with chills and rigor,
mostly at night
highest recorded temperature 103◦F
relieved by antipyretic with sweating

Shortness of breath-Insidious onset not aggravated by lying flat

Pleuritic type of pain in the left lower chest
Hospital Course
She develops loose motion –
8-10times per day
Volume –moderate
Not blood mixed
Associated with central colicky abdominal pain
Hospital course of Treatment
Inj. Ceftriaxone 1gm daily start from 10.4.17
Inj. Amikacin 500mg BD 10.4.17
Tab. Metronidazole 500mg
3 units of blood transfusion
Our plan
• IT tube insertion
• Fleural fluid study including xene xpart
• Antibiotic coverage for atypical organism
Problem List

* Diagnosis?

*What can be done next?

Opinion from expart
1)Immediate waterseal drainage
2)Fleural fluid study during drainage(bacteriological,AFB, xene
xpart,fungal,pleural fluid ADA,biochemical)
3)Exclusion of adrenal TB
Diagnosis primary progressive TB until proved otherwise,other
diagnosis drug resistant TB,atypical pneuomonia,pneumonia caused by
fungui
THANK YOU ALL