A 47 year old female presented with shortness of breath and back pain

A 47 year old female came to the OPD with the Chief complaints of Generalized Itching since a month.
Shortness of breath since 10 days.
Abdominal pain since 7 days.
Lower back pain since 7 days.

HOPI:
A 47 year female who was a known case of Extrapulmonary TB with Ascites on ATT; Now presented to the OPD with complaints of Generalized Itching 7- 10 days after starting the ATT regimen. History of shortness of breath not associated with Orthopnea   History of gradual painless abdominal distention associated with lower back pain since a week. No history of chest pain, palpitations, bleeding manifestations, fever and cough. 

PAST ILLNESS:
A 47 year female who was apparently asymptomatic 6 years ago had complaints of giddiness and soughted for consultation and diagnosed with Diabetes Mellitus; she was started on oral hypoglycemic agents for initial 4 years and shifted to Insulin. 5 months ago she had complaints of pedal edema, she sought for consultation at a local hospital and got discharged after reduction in pedal edema. After a month of discharge she had complaints of painless gradual abdominal distention and SOB,  Therapeutic and Diagnostic ascitic tap was done under aseptic condition and reports were found to be Low SAAG Low protein. Shewas diagnosed with HTN and Hypothyroidism and started on treatment. Upon examination she had cervical lymphadenopathy.
FNAC was done on 25/06/2022 which showed findings s/o - Chronic granulomatous lymphadenitis - possible TB.
Ascitic fluid culture and sensitivity showed growth of E. Coli.
 Exicisonal biospy was done on 05/07/2022.  she was started on ATT from 21/07/2022. She had complaints of SOB and generalized itching and admitted in a local hospital, she underwent pleural tap under asceptic conditions and adviced to started on leukotriene receptor antagonist for 6 days;  ADA 1.80 U/L; Glucose 170mg/dl; protein 0.5 mg/dl; LDH 35 U/L. She has discharged after stabilization but her generalized itching was still present.
SURGICAL HISTORY:
S/P - Tubectomy done under LA 20 years ago.

PERSONAL HISTORY:
A 47 year married female, home maker.
Normal Appetite
Decreased food intake because of SOB d/t abdominal distention.
 Bowel - regular Normal Micturition.
No addictions.

FAMILY HISTORY:
Mother was Diabetic.

MENSTRUAL HISTORY:
Age at Menarche: 13 years.
Cycles are regular 3-4/28 day cycle.
Attained menopause at the age of 44.

OBSTETRIC HISTORY:
Age at Marriage: 18 years
P2A2
GENERAL EXAMINATION:
Patient was conscious and coherent.
Afebrile.
Pallor +; clubbing+; lymphadenopathy+; pedal edema +; cyanosis -; Icterus -.

VITALS:
Temp: 98.6°F; PR: 84 bpm; BP: 140/90 mmHg;
RR: 19 cpm; SpO2: 97% @RA; GRBS: 499 mg/dl.
CVS: S1,S2+; R/S: BAE+, Clear; P/A : Soft, non tender, BS+, Distended.
CNS: HMF +;
ECG AT PRESENTATION:

CHEST X RAY PA VIEW:

2D echo 
GRBS CHART
TREATMENT:
1. TAB. LASIX 40MG/PO/BD.
2. TAB. TELMA 40 MG/PO/OD.
3. TAB. METOLAZONE 10MG/PO/BD.
4. TAB. OROFER XT /PO/OD.
5. TAB. THYRONORM 100mcg/PO/OD.
6. CAP. BIO D3/PO/ONCE WEEKLY.
7. INJ. HUMAN ACTRAPID INSULIN/ ACCORDING TO GRBS/TID.
8. TAB. RIFAMPICIN 150MG
9. TAB. ISONIAZID 75MG
10. TAB. PYRAZINAMIDE 400MG
11. TAB. ETHAMBUTOL 275MG
12. GRBS MONITORING.
13. VITAL AND TEMP CHARTING 4TH HOURLY.

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