Tuberculosis

-Aashna
3 Year
rd
• Name-Mr.ABC
• Age:24
• Sex:Male

• Name of the locality:Kengeri

• Name of the PHC:BGS
• Name of the head of the family:Mr.XYZ

• Address:Uttarahalli Road
• District:Bangalore

• Religion:Christian
Family Structure
• Type of family:Nuclear
• Head of the family:Mr.XYZ
• Number of people in the family:3
• Profile of the family members:

S.No Name of Gen Ag Relation Marital Educati Occupa Income Health Remark
the der e to the Status on tion
family head of
member the
family
1. ABC Male 24 Son Unmarri Gradu Student 0 Patient
ed ate
2. DEF Fem 49 wife Married 2nd Home 0 Diabetic
ale PUC maker
3. XYZ Male 52 HOF Married Gradu Shop 50,000/ Diabetic
ate owner month
• Total annual income of the family : income from
all sources : 6 lakhs
Per capita income:2 lakhs
Scheme:Ration benefits
• Socio economic status:Lower class
(according to kuppuswamy scale)
• Card Holder:No card holder
• Total expenditure of the family:30 thousand per
month
Medical History

• Chief Complaint: Cough and weight loss since 1 month

• History of Presenting Illness: Patient was apparently normal 1

month back when he developed cough which was insidious
in onset and gradually progressive having 5-8 episodes in a
day with sputum which is not blood tinged and relieved on
taking home remedy and aggravated on performing exercise
weight loss of 10 kgs in the past 15 days.

• Treatment before admission: The patient took home remedy

for the cough. No treatment done for the weight loss.
Past History: No similar complaints in the past.
No history of previous hospitalization.

Family History: Nothing significant

Immunization History: Took the prescribed BCG dosage

 Diet History:

24hr recall method before illness

Time Food Quantity Calories(k Protein(g/

items cal) dl)
9 am Aloo 2 400 2
parantha
curd 1 cup 150 4
2pm Rice 2 cups 400 3
Sabzi 2 cups 250 4
4 pm tea 1 cup 50 3
biscuits 2 30 -
8pm Vegetabl 2 cups 100 6
e daliya
Epidemiological History:
No similar case in family/neighbourhood
No contact with a similar case
• Environmental factors influencing the condition:
Type of housing : Pucca House
Water Supply:24 hour water supply
Excreta Disposal : Toilet present in the house
Food sanitation : Maintained
No pests in the area
Overcrowding : Absent
Ventilation : Adequate
Lighting:- natural light – adequate
artificial light – inadequate
Mosquito breading areas – present
Fly breeding areas - present
On Examination:
Patient has an normal gait.
Patient is conscious and cooperative and alert
Poorly nourished

General Physical Examination:

No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Edema
 Anthropometry:

Parameters Actual Expected

Weight 55kg 70kg

Height 175cm -

BMI=55/1.75*1.75=17.959
Vitals:
Temperature:98.9 F
Pulse:100 bpm
Respiratory Rate:24 cycles per min
UPPER RESPIRATORY TRACT

Oral Hygiene:Healthy
No Tonsilitis
No Sinusitis
No Tenderness
No DNS
No Flaring Of Alae Nasi
No Post Nasal Drip
Pharynx Normal
LOWER RESPIRATORY TRACT
INSPECTION
Shape Of Chest:Elliptical
Spine:Normal
No Drooping Of Shoulder
Trachea:Centrally located
Use Of Accessory Respiratory Muscles:None
Apex Beat : Normal
Symmetry Of Chest:Symmetrical
No Visible Scars/Sinuses /Pulsations /Dilated Veins
Movements Of Chest – In Following Areas –
Supraclavicular: Same on both sides
Infraclavicular: Same on both sides
Mammary/Inframammary: Same on both sides
Suprascapular : Same on both sides
Infrascapular : Same on both sides
Interscapular : Same on both sides
Axillary: Same on both sides
PALPATION
Tracheal Position:Central
Apex Beat:Normal
Movements Of Chest:Present and
symmetrical on both sides No Local
Raise Of Temperature
No Tactile Vocal Fremitus
No Tenderness
No Palpable – Rub / Rhonchi /
Crepitations

Measurements ( cm ) – AP Diameter
Transverse Diameter
Chest Circumference Chest Expansion-
Inspiration and Expiration Hemithorax -
Inspiration and Expiration
AUSCULTATION
Normal vesicular breath sounds
Intensity Of Breath Sounds – Normal
No Adventitious Sounds
Vocal Resonence
Supraclavicular: Same on both sides
Infraclavicular: Same on both sides
Mammary/Inframammary: Same on
both sides
Suprascapular : Same on both sides
Infrascapular : Same on both sides
Interscapular : Same on both sides
l
PERCUSSION:
Supraclavicular: Same on both sides
Infraclavicular: Same on both sides
Mammary/Inframammary: Same on both sides
Suprascapular : Same on both sides
Infrascapular : Same on both sides
Interscapular : Same on both sides
Measurements:
Chest Circumference:77cm
inspiration-82 cm expiration-77cm
Expansion=5cm

AP diameter:24 cm
Transverse diameter:34 cm
Systemic Examination:

CNS:No focal neurological deficits

CVS:S1 and S2 heard and no murmurs heard
RS:Normal vesicular breath sounds heard.
P/A:Soft and non tender abdomen
Lab Investigations done:
Sputum smear examination
CXR
• Clinical Diagnosis: Tuberculosis
Management:

Administer the drugs-HRZE .

IP-Isoniazid.Rifampicin,Pyrizinamide,Ethambutol 8 weeks
CP-Isoniazid,Rifamicin,Ethambutol 16 weeks

According to the four weight band management:

55 KG-Third weight band-4 tablets of each drug in both
intensive phase and continuation phase
Thank You