40Y OLD WITH CAP with Z positive

 2024  JAN

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Patient and his/her attenders have been informed and their consent has been taken.

40 Y M WITH CAP

HOPI :

Patient came with complaints of cough since 10 days non productive 

Complaint of  SOB  since 10 days MMRC grade 2, not associated with wheeze, aggravated in exertion and relieved on rest 

No complaint of fever, chest pain,palpitations, orthopnea, hemoptysis

PAST HISTORY

Not a k/c/o DM, HTN, ASTHMA, TB, Epilepsy, CAD, CVA

PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Sleep - Normal

Bowel and bladder movements -regular

No known allergies 

Addictions Alcoholic occasional  toddy 90ml

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy

Temp: 98.6°F

PR- 78bpm    

RR- 17cpm

BP- 100/70 mmHg

Spo2 -97%at RA

Grbs- 103mg/dl

SYSTEMIC EXAMINATION

CVS S1 S2heard no murmurs

RS -  BAE, NVBS heard, Crepts over bilateral IAA, ISA

P/A - Soft, non tender

CNS- NFND

INVESTIGATION

Retroviral positive 

Sputum for AFB negative, no pathogenic organism isolated on culture. 

Mantoux test

DIAGNOSIS

Retroviral positive denovo with Community Acquired Pneumonia ? TB

Anaemia (Microcytic Hypochromic) with Bicytopenia