Case PresentationDr. Shahin Akter NipaMD Resident (Phase A)

Ward - 13

•Mr Nurul Islam, 55years old, farmer, hypertensive, nondiabetic, smoker, nonalcoholic, hailing from Bashkhali admitted into ward-13 on 12.11.16 at 1:10 pm through emergency department with the complaints of --

•Headache for 4 months• Fever for 4 months•Cough for 1 year

Patient states, he was reasonably well 4 months back since then he has been experiencing headache which is diffuse, constant dull aching, more marked in the morning, worse with posture change and improve in lying and with analgesics and associated with vomiting.

•Gradually he developed dizziness during last 1 month which was described as movement of the surroundings. It was constant in nature and not aggravated with head movement. Due to that patient cannot stand still and also cannot move with out other’s support that leads him bed bound.

•He also complaints of fever for last 4 months which was low grade, continued, highest recorded as 101F, not associated with chills and rigor. There is no evening rise of temperature and night sweats. It was subsided spontaneously or after taking antipyretics. He noticed substantial weight loss during the period.

•He was suffering from cough for the last 10 years which was mostly dry with occasional mucoid expectoration with no diurnal variation. For the last 1 year it become troublesome, persistent with profuse expectoration of mucoid sputum. There is no respiratory distress, hemoptysis, chest pain.

He was hospitalized for three times in last 3 months and was diagnosed as a case of disseminated TB (Tuberculoma of brain with PTB). He was on anti TB drug with dexamethasone for the last 1 and half months. After getting treatment he was getting better. But for last two days his headache and vomiting recurs during once daily dose of dexamethasone.

•He denies any H/O trauma, convulsion, unconsciousness•His bowel and bladder habit is normal

•He is hypertensive for last 2 years and takes losartan potassium 50 mg once daily

•His father died 10 yrs back due to complication of pulmonary TB and his mother died 6 yrs before due to complication of stroke. All of his family members are in good health.

•He is from low socioeconomic background.

•He was smoker ( 45 pack-years).•He quit smoking for four months.

On general examination

• Patient was looking anxious with average body built ,decubitus was lying.• Pulse :74b/min• BP :110/80mmHg(no postural hypotension)• RR:12 breaths/min,• Temp: 98 F

Continued…

• There was no anaemia, clubbing, koilonychia, lymphadenopathy, edema• Skin condition is normal

On respiratory system examination

Inspection:• shape of chest: normal• There was supraclavicular excavation

Palpation:

Trachea : central in positionApex beat: left 5th intercostal space in midclavicular line,normal in character

chest expansion: normal

Percussion

• percussion note: resonant• Area of liver dullness:In 5 th intercostal

space in right midclavicular line

On Auscultation

• Breath sound: vesicular with prolonged expiration• Vocal resonance:normal• Added sound:Ronchi were present,more marked on expiration

Nervous system examination

•Higher cerebral function:Normal•Cranial nerves including fundoscopy:cranial nerves are intact,bilateral papilledema on fundoscopy•Motor function:muscle tone and power-normal

•Reflexes:Jerks biceps triceps supinator knee ankle plantarRight +++ +++ +++ +++ +++ flexorLeft +++ +++ +++ +++ +++ extensor

Coordination: impaired in left sideRomberg's: absentGait: ataxic

• Sensory system: intact

Other System Examinations

• Other system reveals no abnormality.

• My provisional diagnosis is Disseminated TB with COPD with HTN

D/D

Secondary brain metastasis from lung or unknown primary with COPD with HTN

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