A 50/F with SOB since 20 days, Odynophagia since 3 days CBBLE UDHC similar cases
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A 50yr old female came with c/o shortness of Breath (grade 2) since 20 days
C/o difficulty in swallowing solids and liquids since 3 days
Not able to open mouth since 1 day
HOPI: Pt was apparently alright 10 yrs ago and went to Hospital in view of headache, easy fatigability and was diagnosed with hypertension and started on medications
6 years ago hospital in view of weight gain and easy fatigability and was diagnosed with Hypothyroidism and is using Thyronorm 50mcg
Later was diagnosed with Rheumatoid arthritis but is not on any medication
3 months ago diagnosed with DM and is not in medication
2 months back pt had c/o cough with expectoration, pain in chest region. Was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use she started developing redness and itching all over the body, ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back
20days back after being discharged from a hospital admitted for ATT induced Erythroderma. She is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.
From 3 days she is having difficulty in swallowing solids and liquids and from 1 day not able to open her mouth because of pain and c/o reddish discolouration of the tongue.
PAST HISTORY: k/c/o DM since 3 months, (not on medication)
HTN since 10 yrs
(On medication)
K/c/o Pulmonary miliary TB on ATT using 3 tablets /day ( HRZE)
K/c/o Rheumatoid Arthritis and not on medication
K/c/o Hypothyroidism since 6 years On Thyronorm 50mcg
O/E : Pt is conscious, coherent and irritable
Pallor +
Icterus +
No cyanosis/ clubbing/ lymphadenopathy
Vitals at the time of admission:
Temperature:100F
PR: 98bpm
BP:130/80mm Hg
RR:27cpm
Spo2: 95%
GRBS:105gm%
CVS: JVP NORMAL, Apex beat 5th IV space mid clavicular lines1s2 +
RS: BAE + , B/L crepts + (ISA, IAA)
P/A: soft, non tender , BS +
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 - 70
CRP - POSITIVE
Chest X-ray
X-ray neck lateral view
ECG
USG ABDOMEN
Few small volume medianal lumph nodes noted
Both lungs are studded with tiny nodular densities - Likely Milliary tuberculosis.
Small air filled cyst noted left lower lobe.
No evidence of effusion.
Non-obstructive left renal culculus.
Diagnostic nacendoscopy
Diagnosis
Steven-johnson syndrome secondary to ATT with
Urosepsis with
Milliary pulmonary tuberculosis with
?nephrotic syndrome
Treatment
IVF NS/RL/DNS @ 75 ml/hr
Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins
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
Reference
SOAP NOTES Day 2
S: Reduced oral ulcer pain
C/o Burning Micturition
O: O/E
Pt is c/c/c
Pallor +
Icterus +
Cyanosis, clubbing, lymphadenopathy not present
Vitals:
PR: 110bpm
BP: 120/80mm Hg
RR: 24 cpm
CVS: s1s2 +
RS: BAE +
P/A: soft, non tender BS +
A:
AKI secondary to Urosepsis
Dysphagia under evaluation
? Secondary to ATT induced STEVEN JOHNSONS ( oral ulcers) with MILIARY TB ( on ATT from 3/1/22)
H/o ATT induced Erythroderma (stopped ATT on 1/2/22) restarted on 21/2/22
K/c/o HTN, Hypothyroidism since 10yrs and
K/c/o DM since 3-4 months
? Rheumatoid Arthritis 10 yrs ago
HFPEF ( moderate LV dysfunction, LAD Akinesia, EF-58%)
P:
1) IVF- NS,RL: urine output + 30ml/hr
2) Inj. PIPTAZ 2.25gm IV TID
3) Neb IPRAVENT 1 resp INH TID
BUDECORT 1 resp INH TID
4) Inj. HUMAN ACTRAPID acc to GRBS
5) GRBS monitoring 6 th hrly
6) T. THYRONORM 50ug PO OD
7) Inj. PANTOP 40mg IV OD
8) T. Amlong 5mg PO OD
9) MUCOPAIN GEL for L/A ( 10 mins before each meal in oral cavity)
10) BETADINE mouth wash TID
11) LIQUID PARAFFIN all over the body TID
12) STOP ATT
13) strict I/o charting, temperature charting 4th hrly
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