FIBROSIS OF LUNG secondary to pulmonary tuberculosis

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A 28 yr female patient  came to OPD with chief complaints of left side flank pain, 
shortness of breath 
One episode of hematuria and dysuria

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 15yrs back then she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT.and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria.

PAST HISTORY: 
Hematuria,k/c/o tuberculosis in childhood
No h/o of diabetes , hypertension, epilepsy and no previous surgeries.

PERSONAL HISTORY: 
Married
Appetite:normal 
Diet : mixed 
Bowels: irregular 
Micturition:normal 
Non alcoholic non smoker and no drug allergies

FAMILY HISTORY:
No significant family history of diabetes, hypertension,heart disease,asthma, tuberculosis

MENSTRUAL HISTORY:
Irregular menstrual cycle

GENERAL EXAMINATION:
on General examination patient was conscious coperative coherent and well oriented to time place and person 
No palor
No cyanosis
No lymphadenopathy
No clubbing
No icterus

VITALS :
Temperature:98.4F
Pulse : 76/ min
Respiratory rate : 14/min
BP: 120/80 mmHg
 
SYSTEMIC EXAMINATION:

CVS :
S1 S2 are present 
No thrills
No murmers

Respiratory system:
Dyspnoea
No wheezing
Trachea shifted to right side 
Breath sounds : tubular

Abdomen :
Shape : scaphoid
No tenderness
Liver and spleen not palpable
Bowels sounds are present

CNS :
Conscious
Speech : normal 
No neck stiffness  
no kernigs sign
Sensory and motor system are normal 

PROVISIONAL DIAGNOSIS:
Right upper lobe fibrosis secondary to old pulmonary tuberculosis 

INVESTIGATIONS 
Haemogram
Liver function tests
Renal function tests
Complete urine examination
Chest x ray

TREATMENT :
TAB ULTRACET QID
TAB MVT PO/OD

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