Casepresentation Ptb Incomplete

Communicable and

Infectious diseases

Section

8

UPH – Dr. Jose G. Tamayo Medical University COLLEGE OF NURSING STO. Niño, Biñan, Laguna

Introduction Patient’s Profile Physical Assessment Anatomy and Physiology Pathophysiology Medical Management Laboratory and Diagnostics

PULMONARY TUBERCULOSI S LEVEL IV

January 2008

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 weeks Pain in the chest Coughing up of blood or sputum Weakness or fatigue Weight loss Fever Usually has a positive skin test Sweating at night May spread TB to others x-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 ADDRESS

: Mr.I.R : Peter Street, Dasmariñas Cavite SEX : Male CIVIL STATUS : Married DATE OF BIRTH : September 6, 1972 AGE : 36 yrs old CITIZENSHIP : Filipino RELIGION : Iglesia ni Cristo DATE OF ADMISSION : January 4, 2008 TIME 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 (+) DM

(+) PTB ( -) CA

Father = (-) HPN (-) DM

(+) PTB (-) 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: • • • •

Thin body build Dresses appropriately No body odor Weak in appearance

Vital Signs: BP=120/80mmHg RR=32cpm PR=116bpm T=38.1°C

Mental Status: Conscious and coherent Pleasant Cooperative Oriented to time place and person Uses 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 both

: equal in size and have both brisk reaction to light and accommodation, 2-3mm on 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.

Nose With 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 nontender, smooth tongue base with prominent veins. •Pharynx : pink and smooth •Uvula

: is in midline Presence of gag reflex

Neck •Neck muscles

: equal in size

•Muscle strength : has resistance to pressure Normal 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 •Alcohol •Family History •Low nutritional status

Depressed immune system Inhaled Mycobacterium bacilli/ air borne transmission through nasal entry Pass down the bronchial tree and transmitted to the alveoli Deposited and begin to multiply Transported through bronchi

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

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

Bacteria becomes airborne – further spread of disease

Ulcerated tubercle heals and forms scar tissue

Causes recurrence of bronchopneumonia and tubercle formation.

Medical management

DOCTOR’S ORDER

RATIONALE

Jan. 4, 08 4pm Bp:100/60 HR:120 RR: 32 T: 36.2

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

For proper medical management and treatment and for further evaluation

Secure consent and management

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

NPO temporarily except Due to episodes of difficulty meds of breathing VF: D5Nm 1L x 12°

For maintenance of fluid and electrolytes

DOCTOR’S ORDER

LABS: CBC, Serum K, ALT, Crea , U/A CXR- PA upright FT4, TSH 2D ECO

RATIONALE 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)

DOCTOR’S ORDER

Meds: Combivent neb. q4° Lanoxin 0.25mg/ tab, 1 Tab OD Myrin P Forte 3 Tabs OD Ventolin Expectorant 10cc TID

RATIONALE

DOCTOR’S ORDER

RATIONALE

Refer to Dr. O for pulmo O2 inhalation at 3 LPM via NC Monitor V/S q 2° and record

Provide better oxygenation Serve as baseline and evaluate abnormality To determine fluid balance

Record I and O q shift Refer accordingly

DOCTOR’S ORDER

Jan. 4, 08

7pm

Lanoxin 0.25mg/ tab, 1 Tab OD Myrin P Forte 3 Tabs OD Jan. 4, 08 11:58pm

Ventolin Expectorant 10cc TID

RATIONALE

DOCTOR’S ORDER

RATIONALE

Jan.5, 082:05am Refer to Dr. O for pulmo Provide better O2 inhalation at 3 LPM via oxygenation NC Jan.5, 08 10:50am Monitor V/S q 2° and record

Serve as baseline and evaluate abnormality

Record I and O q shift

To determine fluid balance

Refer accordingly

DOCTOR’S ORDER

RATIONALE

Jan.5, 08 10:50am May have Soft diet w/ SAP

To prevent aspiration

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 (-)

For maintenance of fluid and electrolytes Taken to isolate microorganism that is causing infection

DOCTOR’S ORDER

RATIONALE

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. IVF to FF: D5Nm 1L x 12

For maintenance of fluid and electrolytes

DOCTOR’S ORDER

RATIONALE

Jan. 7, 08 10:35 Consume Meds. Appevon 1 tab BID Aminophylline drip: D5W 250cc + 1 amp Aminophylline @ 10mgtts/min

Act as bronchodilator

Consume Aminophylline drip then shift to Ansimar 400mg Tab BID Heraclene 1 cap TID Request chest CT-SCAN w/ contrast

To confirm how extensive the damaged

DOCTOR’S ORDER

RATIONALE

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

For maintenance of fluid and electrolytes Due to episodes of difficulty of breathing

Refer transfer ABG now and refer Combivent Neb. q 30mins for 3 doses then 2 doses for q 2° then q 4° thereafter

Identify the specific acidbase disturbance

DOCTOR’S ORDER 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 10am Solu-cortef 150mg IV q 8 x 3 doses Discontinue Ansimar

RATIONALE

DOCTOR’S ORDER

RATIONALE

Jan. 9, 08 3:30pm Continue other Meds. V/S q 1 until stable Inc. O2 inhalation to 5Lpm via NC

Decrease myocardial O2 demand

Jan. 10, 08 11:45am Standby intubation set at bedside Repeat ABG at 6am

For possible intubation

DOCTOR’S ORDER

RATIONALE

Jan. 9, 08 2:40pm Transfer patient to ICU now For f 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

Facilitate breathing, for better lung expansion

DOCTOR’S ORDER

RATIONALE

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 IVF to FF: D5Nm 1L x 12

Provide privacy

DOCTOR’S ORDER

RATIONALE

Jan. 11, 08 11:10am Pulmo: Repeat CXR- PA Repeat ABG shift IV Ranitidine to oral 150mg

CXR- determine lung abnormalities Identify the specific acid-base disturbance

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 Indicate improvement of condition to Ansimar 400mg/tab, 1 tab BID Indicate improvement of Pulmo: condition Maintain nebulization q 4°

Laboratory and diagnostics

Roentgenological Findings Examination: Chest PA Date: 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 pleurodiaphragmatic 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, pleurodiaphragmatic adhesions, right.

Roentgenological Findings Examination: Chest PA Date: 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 Smear Date: 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 Count Segmenters

0.84

High

Indicates bacterial infection.

Lymphocytes

0.16

Low

Depressed immune system

HEMATOLOGY January 10, 2008

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.

0.92

High

Indicates bacterial infection.

0.08

Low

Depressed immune system.

Differential Count Segmenters Lymphocytes

URINALYSIS (January 5,2008 ) PARAMETER

RESULT

INTERPRETATION

Color

Yellow

NORMAL

Transparenc y

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

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.

Pus

1-3/hpt

NORMAL

EPITHELIAL CELLS

Few

NORMAL

MUCUS THREADS

Few

In most circumstances its presence has no clinical significance

RBC

Clinical Chemistry Report Priority: Routine Fluid: Serum Date: 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 Analysis Date: January 4, 2008 Respiratory Rate: 30bpm Ph pCO2 PO2 HCO3 O2 SAT O2 Content

Time: 12nn Age: 36y/o Temperature: 37°C

Patient Values 7.459 30 100 21.5 98.2٪ 22.4

Normal Values 7.35-7.45 35-45mmHg 22-26mmol/L 95-100٪ 20ml/dL

Interpretation: Fully Compensated Respiratory Alkalosis

Blood Gas Analysis Date: January 9, 2008 RR: 36bpm

Ph pCO2 PO2 HCO3 O2 SAT O2 Content

Time: 12:35am Temp: 35°C

Patient Values 7.514 31.9 53 26.3 92.8٪ 27.4

Normal Values 7.35-7.45 35-45mmHg 22-26mmol/L 95-100٪ 20ml/dL

Interpretation: Partially Compensated Respiratory Alkalosis

Blood Gas Analysis Date: January 9,2008 RR: 28bpm

Ph pCO2 PO2 HCO3 O2 SAT O2 Content

Time: 6:00am Temp: 3 7°C

Patient Values 7.446 38.2 138 25.5 92.2% 22.7

Interpretation: Normal ABG

Normal Values 7.35-7.45 35-45mmHg 22-26mmol/L 95-100٪ 20ml/dL

Blood Gas Analysis Date: January 11, 2008 RR: 19bpm

Ph pCO2 PO2 HCO3 O2 SAT

Time: 6am Temp: 37°C

Patient Values 7.410 42 147 5.8 99.3%

Interpretation: Normal ABG

Normal Values 7.35-7.45 35-45mmHg 22-26mmol/L 95-100٪

ECG Findings Date: January 4,2008 Sinus Tachycardia