FINAL PRACTICALS

 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

50 year old male, working as a mason for past 25 years, who is staying away from his family to fetch a livelihood  started to experience detoriation in his health from past 5 months, where in patient developed fever, which is continuous, aggravating in evenings  associated with chills and relieved with night sweats. Patient also started having complaints of cough, which was characteristically exhaustive to the tune that patient some times use to gasp for breath. Cough is productive with copious amount and mucoid consistency. Patient use to take symptomatic medications untill he had come for his daughters marriage 2 months back, after which the family members took him to hospital where he was treated with IV Antibiotics symptoms subsided only to recur with in a span of one to two weeks. 

The attenders observed  there was a marked decrease in appetite with comprehensive reduction in carbohydrate & protein content of his diet which was differing from his previous diet.  There was an association of weight loss also, to which objectively patient confirms he lost 14kgs in last three months. On persistence of symptoms with the backdrop of this clinical picture patient was tested for Retroviral disease which turns out to be positive. Patient was started on ART ( Triple drug regime ).

Later on from last 15 days patient experiencing pain abdomen localised to peri umbilical region with single swelling in the posterior triangle of neck which is rubbery in consistency freely mobile not fixed to underlying structures measuring about 2 X 1 cms in size.

Past History

No significant medical history.

Personal History

Although ITI Graduate couldn’t find a job persuaded him to take up the profession of construction worker & search for livelihood away from his hometown making him a occasional visitor to his family.

He has a habit of consuming alcohol regularly in the quantity of 180-360ml of whiskey or 1 ltr toddy.

Family History

Wife tested RVD positive simultaneously 

Surgical History 

H/o appendicectomy 10 years back.

Social  History

Married for 23 years with 1 daughter & 2 sons. On probing further patient has multiple sexual partners.

Clinical images : 

Problem representation :

50/M construction worker with known retroviral disease (HIV-1) now has a foreground of cough with copious expectoration, fever, drenching night sweats and weight loss with loss of appetite.

The collective syndrome of fever with cough and sputum localises it to the respiratory tract. The symptom of copious mucoid sputum suggests that there is mucus glands hypersecretion due to inflammation.

Cachexia is indicative of chronic systemic inflammation and is also supported by involuntary weight loss, eq r muscle and fat tissue and an elevated BMR.

The presence of abdominal and neck swellings are suggestive of lymph nodes. The presence of lymph nodes on both sides of the diaphragm indicates generalised lymphadenopathy

Provisional Diagnosis : 

RETROVIRAL DISEASE WITH ?AIDS DEFINING ILLNESS ( ExtraPulmonary Tuberculosis / Lymphoma ).

Clinical Examination

Initial examination revealed, the patient was conscious, coherent and co-operative, lying in bed in supine position. 

Vitals were taken in supine and sitting position - 

Vitals :

Temp - Afebrile

PR - 96 bpm

BP - 110/80 mm Hg

RR - 18 cpm

GRBS : 106 mg/dl

General Examination

General Condition - Thin built & malnourished 

Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. Bilateral, purplish reticular markings noted on the sclera of both eyes. Palpebral conjunctival pallor +. No icterus. No cyanosis. 

Systemic Examination 

Lymphatic system 

On inspection : found to have globose swelling measuring 2 X 1 cm in the posterior triangle of neck on the right side, no scars & discharging sinuses, no discolouration of the skin over the swelling.

Palpation : inspectory findings are confirmed on palpation of cervical group of lymph nodes.

On Palpation multiple small lymph nodes felt over the periumbilical area of the abdomen.

2 X 2 cm swelling felt in the left inguinal area. 

No gross swellings observed in axillary and popliteal area.

CVS : JVP not raised, apical impulse in 5th intercostal space 1cm medial to mid clavicular line, S1 S2 heard, No murmurs 

RS : Bilateral air entry present , Normal vesicular Breath sounds

P/A : soft, Non tender. Multiple lymphnodes palpable lymph nodes in periumbilical area

CNS : Higher mental functions intact.

Cranial Nerves : intact

Motor system :      

   

Tone.                        R.                L

Upper limbs.       Normal.            Normal

Lower limbs.      Normal.            Normal 

Power

Upper limbs.         5/5.                 5/5

Lower limbs.        5/5.                 5/5

      

All reflexes are intact

Sensory system intact.

Cerebellar functions intact.

Gait normal.

         

Investigations :

ECG

2D ECHO

USG ABDOMEN WITH NECK SCREENING

CHEST X-RAY PA VIEW

ESR : 45 mm/1st hour

CRP : positive (>2.4)

CD4 count : 180 cells/cumm

Labs indicate a normocytic anemia and a borderline low TLC count which could suggest a bicytopenia.

The low TLC count could suggest depressed bone marrow function or bone marrow infiltration.

The CD4 count and the positive HIV test confirm chronic secondary T cell mediated immunodeficiency due to HIV, in immunological and suspected clinical failure. 

Summary

50/M with immunological and clinical failure of suppression of HIV has a 3 month history of new onset systemic inflammation localising to lungs and lymph nodes.

Functional Problem - Cough, expectoration, cachexia

Anatomical Problem - Larger airways (bronchiectasis strong possibility) and lymph nodes.

Pathology - Inflammation 

Etology - Infections - TB (most likely) NTM, HIV-2 Co infection, Brucellosis.

Malignancies - Non Hodgkins Lymphoma - DLBCL, Multicentric Castleman's Disease, Hodgkins Lymphoma (less likely)

Autoimmune - Sarcoidosis, 

Drugs - Unlikely.

Provisional Diagnosis: 

RETROVIRAL DISEASE WITH AIDS DEFINING ILLNESS ( ?EXTRAPULMONARY TUBERCULOSIS / LYMPHOMA )