Disseminated TB with COPD with HTN

1. Case Presentation
Dr. Shahin Akter Nipa
MD Resident (Phase A)
Ward - 13

2. •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 --

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

4. 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.

5. • 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.

6. • 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.

7. • 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.

8. 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.

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

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

11. • 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.

12. • He is from low socioeconomic background.

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

14. 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

15. Continued…
• There was no anaemia, clubbing, koilonychia,
lymphadenopathy, edema
• Skin condition is normal

16. On respiratory
system examination
Inspection:
• shape of chest: normal
• There was supraclavicular excavation

17. Palpation:
Trachea : central in position
Apex beat: left 5th intercostal space in
midclavicular line,normal in character
chest expansion: normal

18. Percussion
• percussion note: resonant
• Area of liver dullness:In 5 th intercostal space in right
midclavicular line

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

20. 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

21. • Reflexes:
Jerks biceps triceps supinator knee ankle plantar
Right +++ +++ +++ +++ +++ flexor
Left +++ +++ +++ +++ +++ extensor

22. Coordination: impaired in left side
Romberg's: absent
Gait: ataxic

23. • Sensory system: intact

24. Other System Examinations
• Other system reveals no abnormality.

25. • My provisional diagnosis is Disseminated TB with
COPD with HTN

26. D/D
Secondary brain metastasis from lung or unknown
primary with COPD with HTN

27. THANK YOU