CASE PRESENTATION AND

DISCUSSION
ON
PULMONARY TUBERCULOSIS
JHAYNUR-REZZA A. BALAHIM
General Data:
NAME: ES
AGE: 51 year-old
SEX: Male
OCCUPATION: stevedore
ADDRESS: Isabela, Basilan
RELIGION: Islam
Chief complaint:
Cough
HISTORY OF PRESENT ILLNESS
 6 months PTC, patient noted on and off productive cough
with yellowish non-bloody sputum. No consult done, no
medications taken.
 3 months PTC, still with persistent cough now associated
with weight loss, anorexia, weakness and sometimes
afternoon fever. Still no consult or medications done.
 2 days PTC, patient noted increased purulence of productive
cough associated with body malaise. Persistence of
symptoms prompted consult.
PAST MEDICAL HISTORY:
 No history of Hypertension, Diabetes Mellitus and
Asthma; With no history of previous hospital
admission and any surgery. No known allergies to
food and medications
PERSONAL & SOCIAL HISTORY
 Patient works as a stevedore at the pier.
 He is a cigarette smoker with 50 pack-years history
but denies alcoholic beverage consumption and
illicit drug use.
 Lives with his wife and 6 children.
 His usual diet consists of fish, vegetables and rice.
PHYSICAL EXAMINATION
 General: Awake, Cachectic looking, Coherent,
not in respiratory distress
 Vital Signs: Temp: 37.2°C BP:100/60 mmHg
 PR: 98 bpm SpO2: 99% (room air)
 RR: 20 cpm Weight: 45 Kg
 HEENT: Atraumatic head; Anicteric sclerae, pink palpebral
conjunctiva; no ear deformities or tenderness; no alar
flaring; no cervical lymphadenopathies palpated
 Chest/lungs: Equal chest expansion, no tenderness
on palpation, Crackles upon auscultation of both
lung fields
 Cardiovascular: : Adynamic precordium; No Heaves
and Thills; Normal rate and regular rhythm, no
murmurs noted
 Abdomen: Soft, flat abdomen; Normoactive bowel
sounds; non-tender abdomen
 Extremities: good peripheral pulses; CRT <2seconds;
Clinical Diagnosis:
Pulmonary
Tuberculosis
Clinically diagnosed
 Cues/Basis:
 + Cough of 6 months duration,
 weight loss,
 anorexia,
 weakness
 and sometimes afternoon fever
 Paraclinical diagnostic procedures
  benefit risk Cost availability

DSSM primary diagnostic method for definitive Low risk Free at ZCMC Available

diagnosis of active TB

Gene Xpert Used to test for presence of M. Tuberculosis Low risk Free at ZCMC Available

And rifampicin resistance

Chest X Ray Recommended for patients with suspected Low risk 150 (OPD-ZCMC) available

PTB
Treatment
Pretreatment diagnosis:
 Pulmonary TB Bacteriologicaly confirmed

Goals of treatment for primary diagnosis

 Treat the infection
 Reduce risk of infecting others
treatment modality
 -Following Guideline on treatment for new PTB case, 2
months of isoniazid(225mg/day), Rifampicin(450mg/day),
Pyrazinamide (1.125g/day) and Ethambutol(675mg/day) in
the initial phase with an additional 4 months of isoniazid
and rifampicin as continuation.
How to evaluate result or
outcome
 Repeat DSSM at end of 2nd and 5th month. If Negative
at either, considered Cured. If still positive at 5 th
month, considered treatment failed and refer Xpert
MTB site for further tsting.
Prevention and Health Promotion
Final diagnosis: Pulmonary TB Bacteriologicaly confirmed

Describe how you will advise patient on prevention of disease and

health promotion
 - advise patient on strict compliance with maintenance medication
and of follow-up checkups
 - cough or sneeze into a tissue paper or on the bend of elbow
 - the medications would have some side effects, report to health
center/hospital if patient presents with Major Side effects such as
jaundice, visual impairment, convulsions and anemia
 - strict compliance to medications