A 55 year old male came to the OPD due to weakness and inability to walk


History of Present Illness

Patient was asymptomatic a few days ago. He was brought to the OP due to extreme weakness and inability to walk. He was facing shortness of breath. On X-Ray examination, fibrotic lesions were more prominent in the left lung. Serum creatinine levels were high. 

Past History

He is a known case of diabetes (detected 2 years ago) and HTN (since 10 years). He is taking regular medication for these conditions. 

X Ray findings indicate the possibility of Tuberculosis.

H/O arthritis, gout and nephritis. High uric acid levels associated with pains were recorded during his previous hospital visits. 

A month ago, he indulged in heavy alcohol consumption and reduced food intake which may have led to the current complaints.

The first time he was hospitalized, it was about 10 years ago due to seizures that were not associated with any brain disease. 

The second time, the patient was admitted to a hospital 3-4 years ago due to stoppage of urination, SOB and swelling in the abdomen. He underwent dialysis and recovered soon after that.

The third time he was admitted to a hospital was due to delayed healing of a wound on the left foot (lateral malleolus). There was abscess formation but it was operated on and successfully removed. This was when diabetes was detected. There were repeated episodes of seizures during this time (8 times).

He has been taking medications regularly to manage high BP, diabetes, pain and vitamin and iron supplements. 

The medicines used were: Nefrogard (Alpha keto analogue used in treatment of CKD) ; Levogen (Iron supplements) ; Fabric 40 (febuxostat 40 mg-generally prescribed for gout) ; Ultracet (analgesic) 

Family History

Mother was a known case of HTN. 

Personal History

Poorly built, poorly nourished.
Regular alcohol consumption since 15 years.
Reduced appetite.
Non smoker. 
H/O constipation.
Normal sleep pattern.
No history of any allergies.

General Examination

Patient is poorly built. Muscle wasting present.
No sign of pallor, icterus, cyanosis, clubbing or lymphadenopathy. 







 







CVS

Normal pulse rate, rhythm, volume, condition of vessel wall and no radio-radial delay. Normal shape and appearance of chest on inspection.

S1 and S2 were heard. No murmurs. 

RS

Mouth-breathing present.
Normal shape and movements of the chest. Position of the trachea is central without any deviation to the sides. 

CNS

Patient is conscious, coherent and oriented with space and time. Speech is incomprehensible.
Cranial nerves appear normal and functional on examination.
Power, tone and deep tendon reflexes were examined and found to be normal.

Lab investigations

Sinus rhythm was observed in the ECG.
X Ray examination showed the presence of several fibrotic lesions in the left lung.
HRCT (High resolution Computed tomography) results were delayed due to technical issues.
AFB report is pending. 
CBNAAT (Cartridge Based Nucleic acid Amplification Test-done for diagnosing TB) could be performed depending on the presence or absence of Acid fast bacilli in the sample.
Serum creatinine levels were high.

















Provisional Diagnosis

Acute Kidney Injury (AKI) with Chronic Kidney Disease (CKD) who is a known case of diabetes, hypertension, gouty arthritis.

Treatment

Anti-Tuberculosis Therapy (ATT)
This treatment is given in 2 phases:
Phase 1: Lasts for 8-9 months and consists of Isoniazid, Streptomycin, Ethambutol and Rifampicin.
Phase 2: Lasts for 12-18 months and mainly includes administration of Isoniazid and Rifampicin.
Isoniazid and Rifampicin are 1st line drugs. Fluoroquinolones are second line drugs which are only given in cased of multi-drug resistance.


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