Tuberculosis Case Presentation [PDF]

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CLINICOSOCIAL CASE PRESENTATION TUBERCULOSIS A 50 years old male named Mr. Devaraj coming from Gundumedu presented to outpatient clinic in Saveetha UHTC following a 1 month history of cough with expectoration and low grade fever in the evenings. He also noted several episodes of haemoptysis within this time period and was experiencing right sided chest pain. He is also known case of Type – 2 Diabetes Mellitus on regular treatment for the past 15 years and a chronic smoker for the past 20 years and he used to smoke about 10 cigarettes per day and now for the past 2 months he stopped smoking.  Mr Devaraj is a security guard in an apartment. He earns about Rs. 15, 000 per month. His wife is a home maker. She has two daughters, the older daughter is 17 years and she is studying in Class 11 and her younger daughter is 10 years and she is studying in Class 5. He consumes mixed diet; his bladder and bowel habits are normal. Yesterday he had 1 cup of tea with 3 spoons of sugar in the morning at 6 am. At 8.30 am he had four idlis and sambar. For lunch, he had a cup of rice, a cup of rasam and a cup of spinach. In the evening he had a cup of tea with 3 spoons of sugar. At night he had a cup of upma with chutney.  They live in a kutcha house with a two rooms. There is a window in each room. The house is illuminated only with artificial source of light. They do not have a separate kitchen. They use LPG as their cooking fuel. There are few cats in their house. Vegetables are kept in open baskets in the kitchen. The disposal of kitchen water is indiscriminate. Breeding places for mosquitoes are present. They throw their solid waste in an open bin provided by the corporation. The drinking water supply is from a public tap which is placed in front of their house and the supply is for 2 hours in the morning every day. Water is stored in covered pots. They do not boil the water before consuming it. They do not have a toilet at home and hence they practice open air defecation. On examination he was found to have BP (120/80 mmHg); tachycardia (108 bpm); tachypnoeic (26 pm) and on auscultation decreased breath sounds with crepitations was audible on right side of the chest. His chest X-ray showed cavitary lesions and infiltrates in his left upper lobe. Sputum sample contained small amount of blood and numerous acid-fast bacilli.



DEMOGRAPHIC DETAILS: NAME: MR.DEVARAJ AGE: 50 GENDER:MALE OCCUPATION: SECURITY GUARD ADDRESS: GUNDUMEDU PER CAPITA INCOME: RS 3750 (RS.15000/4 MEMBERS) CHIEF COMPLAINTS: PATIENT PRESENTS WITH COMPLAINTS OF COUGH WITH EXPECTORATION AND LOW GRADE FEVER FOR THE PAST MONTH, ASSOCIATED WITH EPISODES OF HAEMOPTYSIS AND RIGHT SIDED CHEST PAIN. HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY NORMAL 1 MONTH AGO AFTER WHICH HE DEVELOPED COUGH WITH EXPECTORATION AND LOW GRADE FEVER ASSOCIATED WITH EPISODES OF HAEMOPTYSIS AND RIGHT SIDED CHEST PAIN. >FEVER PROGRESSED THROUGH THE DAY AND PRESENTED AS AN EVENING RISE IN TEMPERATURE. >COUGH WITH EXPECTORATION – COPIOUS IN AMOUNT, MUCOID CONSISTENCY, BLOOD STAINED SPUTUM >CHEST PAIN WAS A RIGHT SIDED SHARP TYPE OF PAIN WHICH WAS INSIDIOUS IN ONSET AND INTERMITTENT IN NATURE AGGREVATED BY EXERTION AND PHYSICAL ACTIVITIES WITHOUT RELIEVING FACTORS HEMOPTYSIS - FRANK BLOOD NO H/O NIGHT SWEATS NO H/O LOSS OF WEIGHT NO H/O LOSS OF APPETITE NO H/O BREATHLESSNESS NO H/O WHEE ZING NO H/O CARDIAC SYMPTOMS NO H/O RENAL SYMPTOMS



NO H/O ABDOMINAL SYMPTOMS NO H/O RIGHT HYPOCHONDRIAC PAIN PAST HISTORY: PATIENT IS A KNOWN CASE OF TYPE 2 DIABETES MELLITUS ON REGULAR TREATMENT FOR THE PAST 15 YEARS NO H/O CONTACT WITH OPEN CASE OF TB NO H/O SIMILAR COMPLAINTS IN THE PAST NO H/O TREATMENT FOR TB IN THE PAST NO H/O EXANTHEMOUS FEVER NO H/O RECURRENT LOWER RESPIRATORY TRACT INFECTION NO H/O HYPERTENSION / ASTHMA / EPILEPSY TREATMENT HISTORY: PATIENT HAS BEEN RECEIVING TREATMENT FOR DM FOR THE PAST 15 YRS NO TREATMENT FOR COUGH OR FEVER, NO H/O TB IN THE PAST FAMILY HISTORY: NUCLEAR FAMILY,4 MEMBERS NO H/O SIMILAR COMPLAINTS IN FAMILY MEMBERS NO H/O CONTACT WITH OPEN TB CASE



Name



Age



Relationshi p



Education



Occupation



Income



Health status



Devaraj



50



Head



Middle school



Security gaurd



15,000



TYPE 2 DM



Mrs devaraj



60



Wife



Middle school



Home maker



-



Aarti



17



Daughter



High school



Student



-



Lata



10



Daughter



Middle school



Student



-



Per Capita income/ month = Total income of family/ Total no. of family members = 15000/4 = Rs 3750



Socio economic status (According to modified Kuppuswamy scale), the family belongs to Upper Lower class. [Middle school – 3, Acc to ficci he is semiskilled – 3, Income – 2 (2018)]



CONTACT HISTORY NO CONTACT WITH OPEN TB CASE IN THE PAST OCCUPATIONAL HISTORY HE WORKS AS A SECURITY GUARD IN AN APARTMENT PERSONAL HISTORY: HE CONSUMES MIXED DIET H/O SMOKING : 200 PACK YEARS [FOR THE PAST 20 YEARS, 10 CIGARETTES PER DAY, STOPPED SMOKING FOR THE PAST 2 MONTHS] HAS NORMAL SLEEP PATTERN HAS NORMAL BOWEL AND BLADDER HABITS NO H/O ALCOHOLISM NO H/O BETEL NUT CHEWING NEARBY HEALTH FACILITIES: SMCH URBAN HEALTH CENTRE PRESENT NEARBY IMMUNIZATION STATUS OF THE FAMILY MEMBERS - BCG VACCINATION DIET HISTORY: Name DEVARAJ



Morning 1 CUP TEA WITH 3 SPOONS SUGAR + 4XIDLI + SAMBAR



Afternoon 1 CUP RICE + 1 CUP RASAM + 1 CUP SPINACH



Evening 1 CUP TEA WITH 3 SPOONS SUGAR



Night 1 CUP UPMA WITH CHUTNEY



Energy (K cal)



Protein (Gms)



1199



22



Energy Requirement



Energy intake



Energy deficit



1.0 CU = 2,400 Kcal



1199 Kcal



1201 Kcal



Protein Requirement



Protein intake



Protein deficit



1g/kg body wt = 70g



22 gms



48gms



ENVIRONMENTAL HISTORY: INTERNAL ENVIRONMENTAL HISTORY: TYPE OF HOUSE: KUTCHA OVERCROWDING: ABSENT TOILET: ABSENT, NON SANITARY - OPEN AIR DEFECATION VENTILATION: NOT SATISFACTORY LIGHTING: SATISFACTORY KITCHEN: NOT SEPARATE, FUEL FOR COOKING: LPG, EXHAUST FOR SMOKE: NOT PRESENT SOURCE OF DRINKING WATER: PUBLIC TAP, STORAGE:COVERED POTS, DISINFECTION METHOD: NONE, THERE IS NO BOILING OF WATER BEFORE DRINKING PRESENCE OF CATS EXTERNAL ENVIRONMENT HISTORY: WASTE DISPOSAL: OPEN BIN DISPOSAL WASTE WATER DISPOSAL: INDISCRIMINATE BREEDING PLACES FOR MOSQUITOS ARE PRESENT GENERAL EXAMINATION: The patient was conscious, oriented, well nourished, well built. No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalised Lymphadenopathy, Pedal oedema. Vitals: Pulse rate: 108/minute (Tachycardia) Respiratory rate: 26 cycles per minute (Tachypnoeic) Blood Pressure: 120/80 mmHg Height: 175cm Weight: 70kgs BMI = 24.1 (Weight/height in metre square) (normal)



SYSTEMIC EXAMINATION: CVS- S1S2 heard, No murmur RS- decreased breath sounds and crepitations on right side Abdomen- No Scar, Sinus, Organomegaly, Free fluid CNS- No focal neurological deficit, Reflexes Present



INVESTIGATIONS: XRAY - cavitary lesions and infiltrates in left upper lobe Sputum culture - blood and numerous acid fast bacilli detected SUMMARY: 50 year old male Mr Devaraj working as a security guard in an apartment , came with chief complaints of cough with expectoration and low grade fever in the evenings. He also had episodes of haemoptysis and right sided chest pain. He is a known case of type 2 Diabetes Mellitus for 15 years for which he takes medication regularly. He belongs to upper lower class and nuclear type family living in a kutcha house where there is no overcrowding, no toilet, no disinfection of drinking water, no proper waste disposal and cats present. On investigation his BP is 120/80mmhg, BMI: 24.1, energy intake: 1199Kcal, energy deficit: 1201Kcal, Protein intake: 22gms , protein deficit:48gms PROVISIONAL DIAGNOSIS: Tuberculosis



Q)Comment on the environmental risk factors ENVIRONMENTAL RISK FACTORS –     



Overcrowding Inadequate ventilation Recirculation of air containing infectious droplets Poverty Poor sanitation



Q)Mention the management : Investigations – Sputum culture and sensitivity testing – acid fast bacilli detected . X- ray chest - cavitary lesions and infiltrates in left upper lobe .



CBC including ESR , CRP HIV – ELISA Blood sugar testing – RBS , Oral glucose tolerance test. Urine examination .



Treatment – First line drugs –  



Bactericidal drugs – rifampicin , INH, streptomycin ,pyrazinamide Bacteriostatic drugs – ethambutol.



Second line drugs – includes ciprofloxacin , bedaquiline , amikacin , kanamycin , ethionamide , azithromycin , delamanid .  



Cessation of smoking Modification in diet Avoid intake of sugar, reduce fried oily foods , increase the intake of ragi , boiled green gram sprouts , peanuts , spinach , palak and other green leafy vegetables , khichdi , bitter gourd sabji , chicken and fish can be taken for protein , wheat dosa , snacks can include cucumber , chickpeas , ragi balls , moong dhal, Intake of low glycemic index foods – chappati , barley, chickpeas , jowar



ADVICE : Individual level (self care measures )  



  



Emphasis on regular medications to control diabetes and tuberculosis Maintain hygiene – wash hands after coughing and sneezing . Always cover the mouth with tissue when coughing or sneezing and seal the tissue in a plastic bag and dispose it . Avoid spitting in public places. Wash hands before eating . Avoid crowded places . Avoid sweets and sugar intake . Spend only a short time in rooms that other family members use



Family level –  



Screening of family members . Drug and diet monitoring to avoid further complications .



  



Ventilate the rooms . Don’t let visitors come to house except health care workers . BCG vaccination – provides protection against the complications of TB



Community level –   



Health education mainly for target risk groups. Knowledge about the mode of transmission , symptoms and complications of TB. Awareness about the health programmes – RNTCP, National strategic plan ,India ,The end TB strategy



Levels of prevention – Primary prevention - health education , awareness about the modes of transmission and associated complications , BCG vaccination to prevent complications and progression of disease , Environmental controls include proper ventilation , reducing overcrowding of homes and places, negative pressure patient isolation rooms , high efficiency particulate air filtration systems (HEPA). Secondary prevention- screening of target risk groups , detection of latent TB infection by tuberculosis skin test and its treatment, regular medications and diet should be followed . Tertiary prevention- aims to prevent disability and complications and measures taken include – specialized clinics in towns and cities , maintaining local and national registries for tb cases.



Health programs – Revised national tuberculosis control program , 1993 – adopted the DOTS strategy . The End TB strategy, 2016 National strategic plan,India, 2017 The Stop TB strategy, 2006