Concluded Case

pulmonary tuberculosis with tuberculosis lymphadenitis

A 28 year old Indian male IT worker residing alone in London for past 1 year with h/o outside food intake ,had indigestion problem for past 6 month like burping, difficulty passing in stool , flatus passage often , bloating abdomen on and off, after each food intake audible bowel sound heard . now for the past one week he noticed left side supraclavicular lymph node enlargement 5× 6 cm size firm to hard in consistency no signs of inflammation present over the swelling .there is no significant weight loss or appetite loss ,not an alcoholic or smoker ,no night sweats ,no fever,no other swelling elsewhere in the body .h/o appendicectomy done 15 years back. No other significant past history ?!! What can be the DD and management for this case ?? Physical Examination Left side supraclavicular node palpation—soft to firm fluctuatant friable mass of 2*3 cm size ,no signs of inflammation, not matted, not attached to underlying tissue or not attached to skin. Right side supraclavicular node - not involved Per abdomen palpation— soft and no abnormal visible intestinal movement ,no free fluid ,no added sound Respiratory system-normal bronchovesicular breathing on both the side ,no added sound Cardiovascular system-no abnormality detected Cns- no abnormality detected Investigations X-ray chest — right side crowding of ribs , Hilar lymph node not involved Blood investigation—hb-12.5 g/ml Wbc—10,100 cells per mm3 Platelet normal , tlc normal with lymphocyte being reduced to 11%,urine routine-normal,thyroid function test normal , lipid and diabetic profile normal , serology negative,echo and ecg normal , serum electrolytes normal , rft and lft- normal Usg abdomen - para aortic and precaval lymph node enlarged (2cm size),,,rest other normal in usg abdomen

(Edited)

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Concluded answer

On further investigation:CT thorax and abdomen revealed -active pulmonary tuberculosis with tubercular lymphadenitis & then patient was put on anti tuberculosis drug for 6 month

All Answers

Are you confident that supraclavicular swelling is lypnode As it is noninflammatory and hard in consistency First take xray to r/o any bony swelling Secondaly swelling may be subcutaneous some likely fibroma or lipoma or may be a malignant tumor hence adv for MRI scan or hrct and consider fnac sos biopsy Symptoms presented are aerophagia likely psychological Adv for usg abdomenand consider endoscopy to r/o GERD or hitus Rx ppi with gasterokineticks Antacids Tab baclofen10mg to25mg 1bd or tds Digestive enzymes after food Also look for fatty liver disease and cholelithiasis

Thanx dr Dinesh Gupta
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Large supraclavicular lymph node ? Tuberculosis ? Lymphoma ? Kikuchi fujimoto disease ? Other diseases - Syphilis, fungal infection Adv Lymph node biopsy Specimen for histopathology, TB culture, TB gene Xpert Further treatment based on report

Valuable opinion
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SINCE... THERE. ARE. COMPLAINTS. OF G. I. T. DISORDERS... SO.. POSSIBLY.. ASSOCIATED. WITH ...TUBERCULOSIS WITH LYMPHADENITIS DD ....... G I T. . CANCER OTHER. LUNG. CANCER NASOPHARYNGEAL. CANCER . METASTASES LIPOMA /. FIBROMA

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? Right sternoclavicular joint arthropathy ? Supraclavicular lymph node enlargement. Suggest Ultrasound exam, CT scan, FNAC of mass .. GI symptoms are flatulent dyspepsia, and GD amscopy and abdominal ultrasound to be done. ? GERD, PUD, GB stone

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Supraclavicular lymph node seen may be due to A. Reactionary to infection of the draining area B. Tuberculous B lymphoma USG of neck Blood for routine examination with ESR Mantaux test. TB gold test FNA C for smear, AFB culture If necessary excision excision boost.

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LEFT SIDE.. SUPRACLAVICULAR SWELLING.. ? LUMP..LIPOMA.. ? LYMPH PATHOLOGY.. ? ABSCESS.. NEED'S.. FNAC..HPE..STUDY.. USG STUDY..

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Supraclavicular lymph nodes swelling due infective like tuberculosis, neoplastic,,adv CBC,FNAC,BIOPSY

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Ask for CBC ESR Blood SUGAR HIV Sputum for AFB CBNNAT USG of Throat FNAC and BIOPSY

Valuable opinion
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On further investigation:CT thorax and abdomen revealed -active pulmonary tuberculosis with tubercular lymphadenitis & then patient was put on anti tuberculosis drug for 6 month

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