55 year old male with RT cavitatory lesion

CBBLE UDHC SIMILAR CASES 

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A 55 year old male farmer by occupation came with C/O fever since 10 days, breathlessness since 10 days, cough since 10 days.

HOPI:

Patient was apparently normal 4 years back, stopped farming due to B/L lower limb pains and neck pain.

Since 6 months patient attenders are complaining of stiffness in all joints and neck associated with tremors of upper limbs, mainly during holding mug, taking food to mouth.

The stiffness has increased more in the previous 1 month, patient could not get up from sitting position but if he is made to stand with attenders help and after walking some distance he is able to walk on his own. He is able to perform his routine works at a slow rate. Stooping while walking is present and takes short steps.

This time patient is having high grade fever ,SOB  since 10days ,cough with sputum

Sudden loss of speech 10days ago and after 2-3 days gained back his speech but it is hoarse and patient is not getting up from bed since 10days.

C/o nasal regurgitation of feeds ,not able to swallow since 10days

Admitted at other hospital and treated for LRTI with antibiotics.

Hrct chest was done showing b/l lower lobe consolidation,R lower lobe cavitatory lesion,bronchiectatic changes,lymph nodes.

Sputum AfB was done at outside hospital and report awaited.

Patient came with this history and intially got admitted in pulmonary and is taken over by our department when they referred the case to us in view of generalised stiffness and h/o tremors. 

O/E pt concious 

GCS- E4 V3 M1

RT insitu

Hoarse speech

Bp-110/60

Pr-80bpm

Jvp normal

Supra and infraclavicular hallowing

Very thin built

Cvs s1s2+

Rs-R IAA,ISA crepts+

Cns-

Pupils B/L NsRl

Diffuse hypertonia ,muscle wasting is present(appears  to be cog wheel type of rigidity),tremors are occurring when the patient is asked to hold a pen,but at rest no tremors.

With normal reflexes and flexor plantar.

Power appears to be decreased in all 4limbs. 

Tone           RT                           LT

    UL          INCREASED         INCREASED

    LL           INCREASED         INCREASED

POWER       

     UL         2/5                           1/5

     LL          1/5                           1/5

REFLEXES

     B.             ++.                          ++

     K.             ++                           ++

     A               ++                           ++

      S.             ++                           ++

PLANTAR        FLEXION               FLEXION

Investigations:

XRAY

ECG

USG

2D-ECHO

MRI BRAIN

Diagnosis:

Right lower lobe cavitatory lesion  with brochiectasis with bilateral lower lobe consolidation secondary to ? pulmonary kochs

?Old pulm Tb sequale

? Parkinsons 

Treatment:

    1. INJ. PIPTAZ 2.25gm/IV/QID

    2.INJ. PAN 40mg/IV/OD

    3.INJ. OPTINEURON 1AMP IN 100ml             NS/IV/OD

    4.NEBULIZATION WITH MUCOMIST-             8th hourly, DUOLIN-4th hourly,                 BUDECORT-4th hourly

    5.TAB. AZEE 500mg/PO/OD

    6.TAB. SYNDOPA PLUS 125mg/PO/TID

    7.PROTEIN POWDER IN 1 GLASS MILK 

       2 SCOOPS RT/OD

    8.MONITOR VITALS, I/O

    9. NEBULIZATION MUCORMIST 12th

        Hourly, followed by chest                            physiotherapy, followed by oral suction.