47 year female with abdominal distention
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FNAC was done on 25/06/2022 which showed findings s/o - Chronic granulomatous lymphadenitis - possible TB.
Exicisonal biospy was done on 05/07/2022. she was started on ATT from 21/07/2022. She had complaints of Grade IV SOB and generalized itching and admitted in a local hospital, she underwent pleural tap under asceptic conditions and adviced to started on leukotriene receptor antagonist for 6 days; ADA 1.80 U/L; Glucose 170mg/dl; protein 0.5 mg/dl; LDH 35 U/L. She has discharged after stabilization but her generalized itching was still present.
2D Echo:
PRESENTING COMPLAINTS:
C/O Generalized Itching since a month.
C/O Shortness of breath since 10 days.
C/O Abdominal pain since 7 days.
C/O Lower back pain since 7 days.
HOPI:
A 47 year female who was a known case of Extrapulmonary TB with Ascites on ATT 21/07/2022; Now presented to the OPD with complaints of Generalized Itching 7- 10 days after starting the ATT regimen. History of shortness of breath not associated with Orthopnea and PND since 10 days. History of gradual painless abdominal distention associated with lower back pain since a week. No history of chest pain, palpitations, bleeding manifestations, fever and cough. Now admitted for further management and workup.
PAST ILLNESS:
A 47 year female who was apparently asymptomatic 6 years ago had complaints of giddiness and soughted for consultation and diagnosed with Diabetes Mellitus; she was started on oral hypoglycemic agents for initial 4 years and shifted to Insulin. 5 months ago she had complaints of pedal edema, she sought for consultation at a local hospital and got discharged after reduction in pedal edema. After a month of discharge she had complaints of painless gradual abdominal distention and grade II NYHA SOB, she soughted for consultation and admitted. Therapeutic and Diagnostic ascitic tap was done under aseptic condition and reports were found to be Low SAAG Low protein. Shewas diagnosed with HTN and Hypothyroidism and started on treatment. Upon examination she had cervical lymphadenopathy; for which USG Neck was done which showed B/L discrete lymphnodes at level I B/ II/ III/ IV.
Ascitic fluid culture and sensitivity showed growth of E. Coli.
SURGICAL HISTORY:
S/P - Tubectomy done under LA 20 years ago.
PERSONAL HISTORY:
A 47 year married female, home maker.
Normal Appetite
Decreased food intake because of SOB d/t abdominal distention.
Irregular Bowel - hard stools.
Decreased Micturition.
No addictions.
FAMILY HISTORY:
Mother was Diabetic.
MENSTRUAL HISTORY:
Age at Menarche: 13 years.
Cycles are regular 3-4/28 day cycle.
Attained menopause at the age of 44.
OBSTETRIC HISTORY:
Age at Marriage: 18 years
P2A2
Daughter - Spontaneous NFTVD (Age: 28)
Son - Spontaneous NFTVD ( Age: 21)
GENERAL EXAMINATION:
Patient was conscious and coherent.
Afebrile.
Pallor +; clubbing+; lymphadenopathy+; pedal edema +; cyanosis -; Icterus -.
VITALS:
Temp: 98.6°F; PR: 84 bpm; BP: 140/90 mmHg;
RR: 19 cpm; SpO2: 97% @RA; GRBS: 499 mg/dl.
CVS: S1,S2+; R/S: BAE+, Clear; P/A : Soft, non tender, BS+, Distended.
CNS: HMF +; GCS: 15/15;
COURSE IN THE HOSPITAL:
A 47 year female presented to the OPD with the above mentioned complaints. Upon admission necessary investigations were done and Therapeutic and Diagnostic ascitic tap was done under aseptic condition and samples were sent for study. 800 ml of ascitic fluid has been removed by tap. Dermatologist cross consultation was done and orders followed. Liquid parafin and Atarax were added to her treatment.
Ascitic fluid analysis showed TC 100 Cells which are 100%L; CRP 1.2mg/dl; Hb 7.2, TLC 5000, pcv 22.4, rbc 2.48, platelet 2.51 at the time of presentation; SAAG 1.06; Sr. Albumin 1.28 gr/dl, Ascitic albumin 0.22 gr/dl; ascitic TG 142 mg/dl; CUE : albumin 3+, sugars 3+; lipid profile: Total Cholesterol 273, TG 131, HDL 50, LDL 123, VLDL 26.2. Urine for ketones was negative. Ascitic fluid LDH 118, SUGAR 103, PROTEIN 0.7. Spot urine protein 726, creatinine 284.2, ratio 2.55. Thyroid profile: T3 0.62, T4 7.35 , TSH 13.73 micro IU/ml. She had bouts of pruritis so we have withhold the ATT completely on 03/09/2022. She had complaints of bilateral loin pain and had pitting type of edema over the sacral and bilateral loin to the ankles, which was reduced on taking opioid medications. Ascitic tap of 500ml was done on 3/09/2022 , ascitic fluid cells count was 42 with 40%N & 60% L, occasional mesothelial cells. 24 hour urinary volume 800ml, protein 2160 mg/day, 0.9 g/day.
Usg abdomen with renal study was done which showed findings of :
1. liver 15.2 cms, heterogenous echotexture , 13×10mm hypoechoic lesion seen in segment 8 of liver - s/o ?calcified granulomas; PV 9mm, CBD normal.
2. Distended gall BLADDER with increased wall thickness.
3. Spleen 8.6 cms.
4. Rt kidney 8.7×4cms & lt kidney 9.9×3.8 cms withbnormal size and echotexture, CMD partially maintained, PCS normal. S/o B/L Grade II RPD Changes.
5. Gross Ascites.
2D ECHO showed Trivial TR; NO MR/AR; Good LV Systolic function; NO RWMA; Sclerotic AV; NO MS/AS; Diastolic dysfunction, Minimal Pericardial effusion 0.8 cms; IVC Sizze 1.3 cms; EF 63%.
Ascitic fluid culture sensitivity showed no growth and no malignant cells in cytology. On 06/09/2022 we have done therapeutic ascitic tap of 1 liter to relieve her discomfort. Her weight was 48.2kg. Her blood sugar levels were under control on 6U of Human Actrapid Insulin which was given as fixed dose.
Her Hb 8.0, pcv 24.4, TLC 6500, RBC 2.75, Platelet 2.97; she was started on loop Diuretic dose of 120mg/day on 06/09/2022. She has been discharged in a hemodynamically stable condition.
ECG AT PRESENTATION:
CHEST X RAY PA VIEW:
PREVIOUS:-
PRESENT :-
FEVER CHART:
USG ABDOMEN:
17/08/2022
30/08/2022
Previous admission:
Present admission:
GRBS CHARTING:
Clinical Images:
Pallor
edema pitting type:
Clubbing
1. TAB. LASIX 40MG 1TABLET THRICE DAILY AFTER FOOD AT 8AM- 3PM- 8PM.
2. TAB. TELMA 40 MG 1 TABLET ONCE DAILY BEFORE FOOD AT 7AM.
3. TAB. METOLAZONE 10MG 1 TABLET TWICE DAILY AFTER FOOD AT 8AM - 8PM.
4. TAB. OROFER XT 1 TABLET ONCE DAILY AFTER FOOD AT 2PM.
5. TAB. THYRONORM 100mcg 1 TABLET ONCE DAILY BEFORE FOOD AT 7AM.
6. CAP. BIO D3/PO/ONCE WEEKLY.
7. INJ. HUMAN ACTRAPID INSULIN / S/C / THRICE DAILY 6U AT 8AM - 6U AT 2PM - 6U AT 8PM.
8. TAB. RIFAMPICIN 450MG
9. TAB. ISONIAZID 225MG
10. TAB. PYRAZINAMIDE 1200MG
11. TAB. ETHAMBUTOL 825MG
12. GRBS MONITORING.
13. VITAL AND TEMP CHARTING 4TH HOURLY.
DISCHARGE TREATMENT:
1. TAB. LASIX 40MG 1TABLET THRICE DAILY AFTER FOOD AT 8AM- 3PM- 8PM.
2. TAB. TELMA 40 MG 1 TABLET ONCE DAILY BEFORE FOOD AT 7AM.
3. TAB. METOLAZONE 10MG 1 TABLET TWICE DAILY AFTER FOOD AT 8AM - 8PM.
4. TAB. OROFER XT 1 TABLET ONCE DAILY AFTER FOOD AT 2PM.
5. TAB. THYRONORM 100mcg 1 TABLET ONCE DAILY BEFORE FOOD AT 7AM.
6. CAP. BIO D3/PO/ONCE WEEKLY.
7. INJ. HUMAN ACTRAPID INSULIN / S/C / THRICE DAILY 6U AT 8AM - 6U AT 2PM - 6U AT 8PM.
8. TAB. BENADONE 40 MG 1 TABLET AFTER FOOD AT 8AM - 8PM.
9. TAB. PREGABA M 75MG 1 TABLET AFTER FOOD AT 2PM.
10. TAB. ULTRACET ½TABLET FOUR TIMES DAILY AFTER FOOD AT 8AM- 2PM- 8PM- 2AM.
11. HIGH PROTEIN DIET.
12. HOME MONITORING OF BLOOD PRESSURE AND BLOOD SUGAR (GRBS).
REVIEW:
REVIEW ON SATURDAY (10/09/2022) IN GENERAL MEDICINE OPD.
Patient was started with TAB. ISONIAZID 150mg 1 tablet orally as a single dose for 3 days; from day 4; TAB. ISONIAZID 300mg and TAB. RIFAMPACIN 150 mg once orally for 3 days; from day 7; she was started on TAB. ISONIAZID 300 mg and TAB. RIFAMPACIN 450 mg orally for another 3 days; later on from day 10 TAB. PYRAZINAMIDE 250mg was added to regimen.
PROVISIONAL DIAGNOSIS:
EXTRAPULMONARY TB AT CERVICAL LYMPHADENOPATHY;
LOW SAAG LOW PROTEIN ASCITES;
DIABETIC NEPHROPATHY;
K/C/O DM, HTN & HYPOTHYROIDISM.
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