48 year old female with Multi system involvement.

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48 year old female , resident of Hyderabad and home -maker by occupation, presented to casualty on 14/3/22 with complaints of ,

shortness of breath  2 week back - initially grade -2 later progressed to grade 4 .

pedal edema and chest tightness 
generalised weakness and fatigue and frequent falls 
difficulty opening mouth and oral ulcers  2week back.

difficulty in swallowing both solids and liquids since 10 days .

H/O skin peeling all over body 35 DAYS ago .

 



PT HUSBAND - AUTO-DRIVER .

HOPI: 

TIMELINE :





















25-01-2022







SPUTUM CBNAAT REPORT - OUTSIDE HOSPITAL.






REPEAT SPUTUM AFB OUT HOSPITAL REPORT :
( 19/03/22) 

 

PERSONAL HISTORY :

loss of appetite 

weight loss present

sleep adequate

bowel and bladder movements regular

C/O burning micturation since 1 week 



GENERAL EXAMINATION :

PT C/C/C

PALLOR - PRESENT

NO ICTERUS ,CYANOSIS ,CLUBBING ,LYMPHADENOPATHY

MILD EDEMA - NON PITTING EXTENDING UPTO FEET .



VITALS ON ADMISSION :

Vitals at the time of admission: 

Temperature:100F



PR: 98bpm

BP:130/80mm Hg

RR:27cpm

Spo2: 95%

GRBS:105gm%


HEAD TO TOE EXAMINATION :
ALOPECIA- PRESENT.

EYES - Proptosis Seen . NO conjunctival suffusion

EOM- intact

MICROSTOMIA PRESENT 

BALD TONGUE NOTED , RED COLOR 

no ulcers .

THYROID- no goitre noted

SKIN - 
MULTIPLE HYPER- PIGMENTED MACULES SEEN ALL OVER FACE, UPPER LIMBS , NECK ,THIGH , ABDOMEN AND UPPER BACK .
DRY SKIN PRESENT 

THICKENING OF SKIN over fore arms , dorsum of hand and fingers and on around mouth.

absent hair 

SLIGHT PEELING still over arms and legs .



SYSTEMIC EXAMINATION :


RESPIRATORY SYSTEM :

Inspection :
Movements of chest appears to be Equal on both sides .

Palpation vocal fremitus decreased in left mamary , ISA area 



Percussion

 Dull note in left mamary area and ISA .

Auscultation :

- Decreased air entry on left ISA,IMA .
RIGHT side - normal air entry .

-BILATERAL VESICULAR BREATHING NOTED . 

-Tubular breathing heard on right inter-scapular area .

-Coarse crepitations - end inspiratory - no variation with cough - heard on left ISA >>right ISA .





CARDIO VASCULAR SYSTEM :

S1S2 heard.
No murmurs. No palpable heart sounds.




PER ABDOMEN - 

SOFT , NO ORGANOMEGALY.
NO GUARDING AND RIGIDITY.
BOWEL SOUNDS PRESENT .




CNS : 
NO FOCAL NEUROLOGICAL DEFICITS .
GAIT - NORMAL
RHOMBERGS NEGATIVE .


PROVISIONAL DIAGNOSIS :

Miliary tuberculosis , ATT induced scleroderma  
K/c/o HTN , HYPOTHYROIDISM 

ON PRESENTATION :

21/3/22




















RBS: 70mg/dl
HbA1c : 6.8%

RFT
Blood Urea: 136mg/dl 
S. Creatinine: 4.8mg/dl
Na 139
K 3.0
Cl 102

Hemogram
HB 7.2
TC 15,000
MCV 80.4
PCV 21.5
MCH 27.0
MCHC 33.6
PLT 3.67
RDW 62
P.S NORMOCYTIC, NORMOCHROMIC
Serum iron : 45ug/dl

ABG
pH 7.34
PCo2 18.8
PaO2 92.4
HCO3 12.2
SpO2 96

LFT
TB 2.8
DB 0.74
AST 14
ALT 10
ALP 673
TP 7.4
ALB 2.23

CUE
ALB ++
Sugars nil
Pus cells plenty
Epithelial cells 1-2

COVID-19 RAT - NEGATIVE

ESR - 180
CRP - POSITIVE (1.2 mg/dl)

RA FACTOR - NEGATIVE .

LDH - 326 IU/L

Chest X-ray



ECG


USG ABDOMEN



HRCT





Few small volume mediastinal lymph nodes noted

Both lungs are studded with tiny nodular densities - miliary TB or ILD?
 
Small air filled cyst noted left lower lobe.

No evidence of effusion.

Non-obstructive left renal calculus. 







Treatment
Stop  ATT
IVF NS/RL/DNS @ 75 ml/hr
NEB. Ipravent 1resp inH TID
NEB. BUDICORT 1RESP INH TID
INJ. HUMAN ATRAPID according to sliding scale
Inj. PIPTAZ 2.25 gm IV TID
T. Thyronorm 50 mg PO OD
INJ. PAN 40 MG IV OD
T. AMLONG 5 MG PO OD
MUCOPAIN JEL L/A 40 MINS BEFORE MEAL
Betadine mouth wash TID
Liquid paraffin all over body TID