casepresentation ptb incomplete

Communicable

Infectious

and

diseases

IntroductionIntroduction

Patient’s ProfilePatient’s Profile

Physical AssessmentPhysical Assessment

Anatomy and PhysiologyAnatomy and Physiology

PathophysiologyPathophysiology

Medical ManagementMedical Management

Laboratory and DiagnosticsLaboratory and Diagnostics

8

PULMONARY

TUBERCULOSIS

UPH – Dr. Jose G. Tamayo Medical University

COLLEGE OF NURSING STO. Niño, Biñan, Laguna

LEVEL IV

January 2008

Section

INTRODUCTION

TUBERCULOSIS

Is a disease caused by bacteria that attacks the lungs, or any part of the body such as the kidney, spine and brain. If not treated properly, TB can be fatal.

It is spread through the air from one person to another. the bacteria are put into the air when a person with active TB of the lungs or throat coughs or sneezes. People nearby may breathe in these bacteria and become infected.

Mycobacterium Tuberculosis - primarily infective agent

TUBERCULOSIS

Symptoms of Active TB may include:Bad cough that last longer than 2 weeksPain in the chestCoughing up of blood or sputumWeakness or fatigueWeight lossFeverUsually has a positive skin testSweating at nightMay spread TB to othersx-ray or positive sputum smear or culture

RISK FACTORS FOR TB:

Infected with HIV

Close contact with someone who has an active TB

Person without adequate health care

Living in the crowded or unsanitary living conditions

Have been with TB bacteria in the past two years

Infants and young children

People who injected illegal drugs

People with weak immune system

Elderly

Those that were not treated properly for TB in the past

Examination of the lungs by stethoscope can reveal crackles. Enlarge tender lymph nodes may be present in the neck or other areas. Fluids may be detectable around a lung. Clubbing of the fingers or toes may be present.

Test may include:

>chest x-ray >thoracentesis>sputum cultures >bronchoscopy>tuberculin skin test

The goal or treatment for pulmonary tuberculosis is to cure the infection with drugs that fight the tuberculosis bacteria. The initial treatment may involve a combination of many drugs, it is continued until lab tests show which medicine works best. Treatment usually last for six (6) months but longer treatment may be needed for person with AIDS or whose disease responds slowly.

PATIENT’S PROFILE

NAME : Mr.I.RADDRESS : Peter Street,

Dasmariñas CaviteSEX : MaleCIVIL STATUS : MarriedDATE OF BIRTH : September 6, 1972AGE : 36 yrs oldCITIZENSHIP : FilipinoRELIGION : Iglesia ni CristoDATE OF ADMISSION : January 4, 2008TIME OF ADMISSION : 10:55AM

PERSONAL DATA Patient is Mr. I.R, a 36 years old male from Peter St. Dasmariñas Cavite. He is married, an Iglesia ni Cristo. He is a former employee of a printing company for one and a half year, and worked as a financial encoder in a soda factory for five years and currently works as a tricycle driver. He was admitted at University of Perpetual Help Medical Hospital last January 4, 2008 at 10:55am.

CHIEF COMPLAINT Difficulty of Breathing

HISTORY OF PRESENT ILLNESS

Few days Prior to admission. Patient had episode of difficulty of breathing associated with non productive cough, temporarily relieved by Oxygen inhalation. Patient previously admitted in Trecemarteres Hospital, where in the patient was diagnose of PTB, Pneumonia.

2 Days PTA patient seek consultation for follow up to a private Medical Doctor where patient was prescribed home medications. 4 hrs. PTA patient has recurrent difficulty of breathing, patient mentioned to seek consultation at University of Perpetual Help Medical Hospital hence admitted.

PAST MEDICAL HISTORY

- September 1997 patient sought consultation and was diagnosed with PTB- Masinog Hospital - December 16,2007 –Patient was admitted

with the same diagnosis – at Trecemarteres Hospital - Patient has a history of allergy to shrimp paste - No known allergies to drugs

FAMILY HISTORY Mother = (+) HPN (+) PTB (+) DM ( -) CA

Father = (-) HPN (+) PTB (-) DM (-) CA

SOCIAL HISTORY

Patient is a cigarette smoker for 20 pack years, an alcoholic beverage drinker, consumes about 6-8 bottles per drinking spree. The patient’s usual hobbies are drawing, singing and playing billiards.

PHYSICAL ASSESSMENT

General appearance: Vital Signs:

• Thin body build BP=120/80mmHg• Dresses appropriately RR=32cpm• No body odor PR=116bpm• Weak in appearance T=38.1°C

Mental Status:

Conscious and coherentPleasantCooperativeOriented to time place and personUses simple words as means of communication

Skin:

• Color : fair complexion• Uniformity : generally uniform• Skin moisture : present in skin folds

and axilla• Skin turgor : dry skin with poor skin

turgor• Temperature : warm to touch

Nails

•Nail plate : convex curvature, 160° angle

•Nail condition : rough, thick, and brittle

•Nail bed color : brown•Texture : smooth texture•Capillary refill : within 2 seconds

Head and face•Skull : rounded and smooth contour

•Hair texture : black, fine and evenly distributed, silky and resilient, no infection and infestation

•Scalp : fair in complexion, no lesion and tenderness

•Facial movements : symmetric facial movement. Can elevate and lower

eyebrows, close the eyes, smile and puff cheek, show teeth and stick out tongue.

Eyes•Peri-orbital area : thick eyebrows, black in color

•Eyelashes : equally distributed, curled slightly outward

•Eye lids : skin intact, no discharge and discoloration closed symmetrically

•Conjunctiva : pale palpebral conjunctiva Bilateral blink response and symmetric firm eyeballs

•Pupils : equal in size and have both brisk reaction to light and

accommodation, 2-3mm on both right and left

•Iris : flat and round

Ears

Auricles: fair complexion, symmetrical elastic, and mobile when pinch, and

aligned with the outer cantus of the eyes.

NoseWith O2 inhalation at 3-5 lpm via nasal cannula

•External nose: fair complexion, symmetric and not tender

•Nasal septum: intact and in midline

•Nasal cavity: pink colored mucosa

Mouth and Pharynx

•Lips : dark lips, dry mucous membrane

•Teeth : yellowish in color

•Gums : dark in color and moist

•Tongue : in midline, slightly rough with whitish coating, moves freely and non-tender, smooth tongue base with prominent veins.

•Pharynx : pink and smooth

•Uvula : is in midlinePresence of gag reflex

Neck

•Neck muscles : equal in size

•Muscle strength : has resistance to pressureNormal head flexion (chin to chest)Head extension (chin points up)

•Lateral flexion: right and left

•Lateral rotation: right and left

•Trachea: midline

Chest

•Shape : symmetrical

•Spinal alignment : normal

•Breathing Pattern: Rate= Tachypneic Breath sounds= positive

crackles on right lung field

•Heart sounds : normal, no murmur

•Anterior and posterior lung expansion: decreased lung expansion

Abdomen

•Color: fair in complexion

•Contour: symmetrical

•Auscultation: normal bowel sounds, presence of muscles guarding

•Palpation: soft, flat, non-tender

Upper Extremities

No physical deformities noted.

•Muscles strength : normal and has resistance to force

•Pulses : radial and brachial pulses are normal and palpable

•Range of motion: shoulder can extend, abduct, adduct, and rotate

Elbows can flex and extend. Wrist can flex and extend. Phalanges abduct, adduct flex,

and extend. Pronation and supination of the forearms.

•Right arm: with IVF D5 NM x 12 hours

Lower extremities

No physical deformities on both leg noted.

•Pulses: popliteal, posterior tibial and dorsalis pedis are normal and palpable.

•Range of motion: normal on both leg

ANATOMY AND PHYSIOLOGY

THE RESPIRATORY SYSTEM

Pathophysiology

Risk factors:Smoking – 2 packs/day

Nature of work- employee of printing company,

finance encoder, tricycle driver

AlcoholFamily History

Low nutritional status

Inhaled Mycobacterium bacilli/ air borne transmission through

nasal entry

Pass down the bronchial tree and transmitted to the alveoli

Deposited and begin to multiply

Depressed immune system

Transported through bronchi

Phagocytes (neutrophils and macrophages) engulf many of

the bacteria

Accumulation of exudates in the alveoli causing

bronchopneumonia

Granuloma formation surrounded by macrophages

Inflammatory reaction occur

( DOB, COUGH, LOW GRADE FEVER IN THE

AFTERNOON)

Phagocytes (neutrophils and macrophages) engulf

many of the bacteria

Accumulation of exudates in the alveoli causing bronchopneumonia

Granuloma formation surrounded by macrophages

fibrous tissue mass (ghon’s tubercle)

necrotic, forming a cheesy mass

calcified – form collageneous scar

Become dormant – no further progressive of active disease

After initial exposure and infection, patient develop active disease because of

weak immune system response

Active disease occur due to reinfection and activating dormant bacteria

Ghon’s tubercle ulcerates

Release cheesy material into the bronchi

Ulcerated tubercle heals and forms scar tissue

Causes recurrence of bronchopneumonia and tubercle

formation.

Bacteria becomes airborne – further spread of disease

Medical management

DOCTOR’S ORDER RATIONALE

Jan. 4, 08 4pm

Pls. Admit patient to ROC under the service of Dr. B

Secure consent and management

NPO temporarily except meds

VF: D5Nm 1L x 12°

For proper medical management and treatment and for further evaluation

For legal purposes and in order for the patient to know all management and treatment to be done

Due to episodes of difficulty

of breathing

For maintenance of fluid

and electrolytes

Bp:100/60HR:120RR: 32T: 36.2

Bp:100/60HR:120RR: 32T: 36.2

DOCTOR’S ORDER

RATIONALE

LABS: CBC,

Serum K,

ALT,

Crea ,

U/A

CXR- PA upright

FT4, TSH

2D ECO

CBC- to evaluate level of blood component

Serum K- evaluate electrolyte imbalance

ALT- evaluate level of liver enzymes

U/A- evaluate urine chemistry

CXR- determine lung abnormalities

2D ECO- to view the heart (cross sectional)


Meds:

Combivent neb. q4°

Lanoxin 0.25mg/ tab, 1 Tab OD

Myrin P Forte 3 Tabs OD

Ventolin Expectorant 10cc TID


Refer to Dr. O for pulmo

O2 inhalation at 3 LPM via NC

Monitor V/S q 2° and record

Record I and O q shift

Refer accordingly

Provide better oxygenation

Serve as baseline and evaluate abnormality

To determine fluid balance


Jan. 4, 08 7pm

Lanoxin 0.25mg/ tab, 1 Tab OD

Myrin P Forte 3 Tabs ODJan. 4, 08 11:58pm

Ventolin Expectorant 10cc TID


Jan.5, 082:05am

Refer to Dr. O for pulmo

O2 inhalation at 3 LPM via NC

Jan.5, 08 10:50am

Monitor V/S q 2° and record

Record I and O q shift

Refer accordingly

Provide better oxygenation

Serve as baseline and evaluate abnormality

To determine fluid balance


Jan.5, 08 10:50am

May have Soft diet w/ SAP

Vigocid 2.25mg IV q8°

ANST(-)

Give solu-cortef 150mg IV now then q8°

IVF to FF: D5Nm 1L x 12

For sputum AFB smear x3

Streptomycin SO41g IM OD ANST (-)

To prevent aspiration

For maintenance of fluid and electrolytes

Taken to isolate microorganism that is causing infection


Jan.5, 08 10:50am

Avelox 400mg 1 tab OD

Start side drip: D5W 250cc + 1 amp Aminophylline @ 10mgtts/min

Jan.5, 08 4:20pm

Spiriva 1g OD

Jan.6, 08 3pm

Continue Meds.




Jan. 7, 08 10:35

Consume Meds.

Appevon 1 tab BID

Aminophylline drip: D5W 250cc + 1 amp Aminophylline @ 10mgtts/min

Consume Aminophylline drip then shift to Ansimar 400mg Tab BID

Heraclene 1 cap TID

Request chest CT-SCAN w/ contrast

Act as bronchodilator

To confirm how extensive the damaged


Jan. 9, 08 12:30am

Repeat CBC

Decrease Solu-cortef to 100 mg IV q 8

IVF to FF: D5Nm 1L x 12°

NPO temporarily while dyspneic

Refer transfer

ABG now and refer

Combivent Neb. q 30mins for 3 doses then 2 doses for q 2° then q 4° thereafter


Due to episodes of difficulty of breathing

Identify the specific acid-base disturbance


Jan. 9, 08 1:00am

CBR w/o BRP’s

Jan. 9, 08 2:20am

Lactulose 30cc ODHS hold for BM > 3x a day

Jan. 9, 08 4am

Resume Aminophylline drip: D5W 250cc + 1 amp Aminophylline @ 10mgtts/min

Jan. 9, 08 10amSolu-cortef 150mg IV q 8 x 3 doses

Discontinue Ansimar


Jan. 9, 08 3:30pm

Continue other Meds.

V/S q 1 until stable

Inc. O2 inhalation to 5Lpm via NC

Jan. 10, 08 11:45am

Standby intubation set at bedside

Repeat ABG at 6am

Decrease myocardial O2 demand

For possible intubation


Jan. 9, 08 2:40pm

Transfer patient to ICU now

Inc. O2 inhalation to 10Lpm

Jan. 9, 08 7:10pm

Continue Solu-cortef 150mg IV for 8°

Ranitidine 50mg IV q 8 while on NPO

Place high back rest

For f

Facilitate breathing, for better lung expansion


Jan. 11, 08 7:10am

Dec. O2 to 5Lpm

Watch out for DOB and episodes of desaturation

Please limit visitor

Jan. 11, 08 11:10am

May have soft diet w/ sap

Transfer to room disposition c/o Dr. B and Dr. O


Provide privacy

DOCTOR’S ORDER RATIONALEJan. 11, 08 11:10am

Pulmo:

Repeat CXR- PA

Repeat ABG

shift IV Ranitidine to oral 150mg

may have DAT

no BRP’s

refer if there will be episode of DOB

Dec. O2 at 2Lpm via NC

Consume Aminophylline drip then shift to Ansimar 400mg/tab, 1 tab BID

Pulmo:

Maintain nebulization q 4°

CXR- determine lung abnormalities

Identify the specific acid-base disturbance

Indicate improvement of condition

Indicate improvement of condition

Laboratory and diagnostics

Roentgenological FindingsExamination: Chest PADate: January 4, 2008

This are fibronodular, fibrohazed, confluent hazed and fibro exudates infiltrates on the right lung field. There are confluent hazed densities with almost homogeneity of the left lung showing some patches and cystic lucencies on the left upper and midlung fields. These are tracheal and mediastinal shift to the left. The cardiac borders, left hemidiaphragm and sulcus are obscured. The heart size cannot be properly evaluated. There are pleuro-diaphragmatic adhesions on the right.

Conclusion:

The findings are highly suggestive of Pulmonary Tuberculosis, Bilateral, Extensive with Partial Volume loss of the left lung.

One has to rule in or rule out fibrothorax, left, pleuro-diaphragmatic adhesions, right.

Roentgenological FindingsExamination: Chest PADate: January 10, 2008

There are fibrohazed confluent hazed and fibro exudates infiltrates on the right lung field. There is an almost homogeneous left lung with patches and cystic lucencies. There are tracheal and mediastinal shift to the left. The cardiac borders, left hemidiaphragm and sulcus are obscured. The heart size cannot be properly evaluated.

Conclusion:The findings are highly suggestive of Pulmonary

Tuberculosis, Bilateral, Extensive with Partial Volume loss of the left lung.

Bacteriology

Examination: AFB SmearDate: January 6, 2008

Specimen : Sputum

Microscopy : Sputum #1 (1/6/08) Sputum #2 (1/7/08) Sputum #3 (1/8/08)

No AFB seen in 500 visual fields .

HEMATOLOGY

January 4, 2008

RESULTS INTERPRETATION SIGNIFICANCE

Hemoglobin 109 gm/l Low Decrease oxygen supply from the lungs to

the tissues

Hematocrit 0.33 Low May be due to nutritional deficiency

RBC 4.0 x 1012/l Normal

WBC 16.3 x 109/l High Indicates presence of infection.

Differential CountSegmenters

0.84 High Indicates bacterial infection.

Lymphocytes 0.16 Low Depressed immune system

RESULTS INTERPRETATION SIGNIFICANCE

Hemoglobin 133 gm/l Normal

Hematocrit 0.40 Normal

RBC 4.5 x 1012/l Normal

WBC 17.1 x 109/l High Indicates presence of

infection.

Differential CountSegmenters

0.92 High Indicates bacterial infection.

Lymphocytes 0.08 Low Depressed immune system.

HEMATOLOGY

January 10, 2008

PARAMETER

RESULT INTERPRETATION

Color Yellow NORMAL

Transparency

Slightly turbid

Precipitation of calcium phosphate; not pathological.

REACTION (pH)

6.0

Protein trace Excretion of 10-100 mg each 24 hour is normal but this amount is not detected by

usual tests.

Specific Gravity

1.015 NORMAL

Glucose (-) NORMAL

Pus 1-210-20/hpf Indicates bacterial infection of the urinary tract. The presence of occasional pus cells

may be normal per high power field; if accompanied by red cells, pus cells

indicates inflammation.

URINALYSIS (January 5,2008 )

RBC 1-3/hpt NORMAL

EPITHELIAL CELLS

Few NORMAL

MUCUS THREADS

Few In most circumstances its presence has no clinical significance

Clinical Chemistry ReportPriority: Routine Fluid: SerumDate: January 4, 2008

Clinical Chemistry ReportPriority: Routine Fluid: SerumDate: January 4, 2008

Test Normal Range

Result Interpretation Significance

Creatinine 71.0-133.0 60.4 mmol/L

Low Due to small stature

debilitation, decreased

muscle mass , some complex

cases of hepatic disease

Potassuim 3.50-5.10 4.41 mmol/L

Normal

ALT 21-72 28 u/L Normal

Blood Gas AnalysisDate: January 4, 2008 Time: 12nn Age: 36y/oRespiratory Rate: 30bpm Temperature: 37°C

Blood Gas AnalysisDate: January 4, 2008 Time: 12nn Age: 36y/oRespiratory Rate: 30bpm Temperature: 37°C

Patient Values Normal Values

Ph 7.459 7.35-7.45

pCO2 30 35-45mmHg

PO2 100

HCO3 21.5 22-26mmol/L

O2 SAT 98.2٪ 95-100٪

O2 Content 22.4 20ml/dL

Interpretation: Fully Compensated Respiratory AlkalosisInterpretation: Fully Compensated Respiratory Alkalosis

Blood Gas AnalysisDate: January 9, 2008 Time: 12:35amRR: 36bpm Temp: 35°C

Blood Gas AnalysisDate: January 9, 2008 Time: 12:35amRR: 36bpm Temp: 35°C


Ph 7.514 7.35-7.45

pCO2 31.9 35-45mmHg

PO2 53

HCO3 26.3 22-26mmol/L

O2 SAT 92.8٪ 95-100٪


Interpretation: Partially Compensated Respiratory Alkalosis Interpretation: Partially Compensated Respiratory Alkalosis

Blood Gas AnalysisDate: January 9,2008 Time: 6:00amRR: 28bpm Temp: 3 7°C

Blood Gas AnalysisDate: January 9,2008 Time: 6:00amRR: 28bpm Temp: 3 7°C


Ph 7.446 7.35-7.45

pCO2 38.2 35-45mmHg

PO2 138

HCO3 25.5 22-26mmol/L

O2 SAT 92.2% 95-100٪


Interpretation: Normal ABG


Blood Gas AnalysisDate: January 11, 2008 Time: 6amRR: 19bpm Temp: 37°C

Blood Gas AnalysisDate: January 11, 2008 Time: 6amRR: 19bpm Temp: 37°C


Ph 7.410 7.35-7.45

pCO2 42 35-45mmHg

PO2 147

HCO3 5.8 22-26mmol/L

O2 SAT 99.3% 95-100٪



ECG FindingsDate: January 4,2008

Sinus Tachycardia

ECG FindingsDate: January 4,2008

Sinus Tachycardia

Documents

casepresentation ptb incomplete