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1. Mr. Muthu, a 49-year-old unemployed man presented to a hospital

emergency department complaining of chest pain on the right side

2. which was more severe on deep breathing, and had several recent

episodes of coughing up a small amount of blood mixed with

sputum during the past week.

3. Overall, he had been coughing for

six months

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1. Mr. Muthu, a 49-year-old unemployed man presented to a hospital

emergency department

middle age, prone to get infection or disease such as lung disease

prone to drinking and smoking

unemployed,limit access to check their health,lower sosioeconomic poor living condition

2. complaining of chest pain on the right side,which was more severe on deep breathing

disease is not related to heart,more related to repi system

this type of pain known as pleuritic chest pain that could suggest inflammation or infection of pleura

3., and had several recent

episodes of coughing up a small amount of blood mixed with sputum during the past week

hemoptysis

due to erosion blood vessel in lung area

due to high pressure in thoracic :lung or heart

4. Overall, he had been coughing for

six months

more than 8 week consider chronic

higher infection,ex; TB,COPD

might be COPD or TB,astma also included since persistent coughing

DIFFERENTIAL DIAGNOSIS

related to pulmonary TB

COPD

ASTMA

Lung cancer

Pneumonia

Pulmonary embolism

INVESTIGATION

HOPI (socrates)

Past medical history

Social history

Family history

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1.orofuse nocturnal sweating - known as night sweat refer as excessive sweating that ocur during sleep.

2.hyposomnia- hypo mean less,somnia mean sleep, reduced or less sleep

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1.On further questioning, Mr. Muthu informed the doctor, that the

cough was more severe in the morning.

2.Apart from coughing, he had been feeling feverish, and having

profuse nocturnal sweating for the last six months.

3.Also, he had

shortness of breath after climbing upstairs for the last one month.

4.Mr. Muthu reported having loss of appetite, loss of weight and

hyposomnia for the past three weeks.

5.Lately, he started getting

tired easily.

6.He denied any leg or abdominal swelling.

7.He denied having contact with patients with chronic coughs.

8.Past medical history

No history of asthma, COPD, heart disease, or history of previous

hospitalisations or trauma.

9.Family history

His family history was unremarkable.

Allergies and medications

Nil of significance.

101.Social history

He had been smoking about 20 cigarettes per day for the past 20

years.

11.He was unable to continue his job and remained unemployed.

No history of drug abuse.

Did not consume alcohol.

No history of recent long air travel

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1.On further questioning, Mr. Muthu informed the doctor, that the

cough was more severe in the morning.

-due to mucus accumulation overnight,morning predoiminant cough is due to copd, could also be consistent with post nasal drip,GERD or TB

2.Apart from coughing, he had been feeling feverish, and having

profuse nocturnal sweating for the last six months.

-feverish, low grade fever which is response to chronic infection

-profuse nocturnal sweat, due to cytokine release response to earlier infection,could also indicate sypmtom for TB

-last 6 nmonth indicate the disease is already chronic

3.Also, he had

shortness of breath after climbing upstairs for the last one month.

-SOB maybe because of sputum accumulation

-smoking habit cause inflammation in the airways

-exertional dyspnea

4.Mr. Muthu reported having loss of appetite, loss of weight and

hyposomnia for the past three weeks.

-common symptom for tb patient

-hyposomnia could be due to few cause, hyperthyroidism, and persistent cough

-unemployment could also cause mental issue (phsycological cond,stress)

5.Lately, he started getting

tired easily.

-hemotypsis could lead to anemia,low blood supply to muscle cause not enough energy

-poor sleep quality

-malnutrition

6.He denied any leg or abdominal swelling.

-no edema

-not related with heart and kidney function

7.He denied having contact with patients with chronic coughs.

-reduced direct contact with patient that have TB

-TB could exist in latent stage

8.Past medical history

No history of asthma, COPD, heart disease, or history of previous

hospitalisations or trauma.

-could be due to medication

9.Family history

His family history was unremarkable.

Allergies and medications

Nil of significance.

101.Social history

He had been smoking about 20 cigarettes per day for the past 20

years.

-heavy smoker

-quantity consider high amount which could cause higher effects

-ciggarates contain carcinogen cause mutation,that lead to not efficient mucus clearance

-could lead to cancer development

-smokes could alter the surfactant

11.He was unable to continue his job and remained unemployed.

-no proper care due to no money

-unactive mean low mobility causing DVT

No history of drug abuse.

Did not consume alcohol.

No history of recent long air travel

DIFFERENTIAL DIAGNOSIIS

pulmonary TB

COPD

lung cancer

Pulmonary embolism

pneumonia

FURTHER INVESTIGATION

check vital sign-respiratory rate,BP

general inspection - anemia sypmtom , finger clubbing

sputum culture- standard for TB test

mantoux test- TB

chest XRAY- checks for lesion

Auscultaion- sound that is abnormal (crackle , wheezing)

FBC-checks for abnormal blood

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1. nail clubbing - where the tip of fingers become enlarged and the nails curve downward around the fingertips like an upside down spoon

2. bilateral crepitation - abnormal breath sound (crackels)

3. bronchial breath sound - high pitch and loud sound heard primarily over the trachea and large airways

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1. Temp slightly high

2. HR normal (boarderline)

3. RR normal

4. BP slightly high

5. BMI underweight

6. pallor

7. nail clubbing

8. bronchial breath sound

9. bilateral crepitations over upper lobe

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1. Temp slightly high

sign of infection

body try to compensate to get higher metabolic activity

2. HR normal (boarderline)

tachycardia

3. RR normal

4. BP slightly high

bc of the tachycardia

hyperventilation

5. BMI underweight

loss of appetite

hyposomnia

6. pallor

hemoptysis-anaemia

7. nail clubbing

hypoxia due to anaemia

O2 saturation cant be detected, need to use ABG test

8. bronchial breath sound

MTB live in O2 tension area, apex of lung less O2 conc. compare to base

9. bilateral crepitations over upper lobe

pus or fluid in alveoli

DIFFERENTIAL DIAGNOSIS

PTB

COPD

lung cancer

FURTHER INVESTIGATIONS

sputum - AFB

chest x ray

HIV test - relate to TB

FBC

Mantoux test or tuberculin skin test

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1. hemithorax-right part of chest(middle)

2. cavitating lesion- area tissue undergoes necrosis and form cavity or hollow space

3. consolidation-air replaced by pus,fluid,bloodor cells__lungs wide

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1. low HB

2. MT skin test-positive

3. MCV,MCHC,WBC- normal

4. HIV- negative

5. chest x-ray(A: normal and B: cavitating lesion): The chest x-ray

revealed reduced lung volume of right hemithorax,

6. the presence of

bilateral pulmonary infiltrate (white triangles) suggesting

consolidation,

7. and “cavitating lesion “ (black arrows) present in the

right apical region.

8. Sputum smear Gram stain:4+ squamous epithelial cells,1+

segmented neutrophils, no organisms, no malignant cells.

9. Sputum smear AFS (acid-fast stain): Acid-fast bacilli (AFB) smear-

positive sputum.

10. Sputum culture and sensitivity: Mycobacteria tuberculosis was

sensitive to streptomycin, isoniazid, rifampicin and ethambutol.

11. The patient was diagnosed to have PTB and started on a standard

regimen of 4 first-line anti-TB drugs

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1. low HB-anemia

2. MT skin test-positive

3. MCV,MCHC,WBC- normal

4. HIV- negative

5. chest x-ray(A: normal and B: cavitating lesion): The chest x-ray

revealed reduced lung volume of right hemithorax,-reduced lung volume(right apex of lung dh kena TB)

6. the presence of

bilateral pulmonary infiltrate (white triangles) suggesting

consolidation,

7. and “cavitating lesion “ (black arrows) present in the

right apical region.

8. Sputum smear Gram stain:4+ squamous epithelial cells,1+

segmented neutrophils, no organisms, no malignant cells.

9. Sputum smear AFS (acid-fast stain): Acid-fast bacilli (AFB) smear-

positive sputum.-MTB

10. Sputum culture and sensitivity: Mycobacteria tuberculosis was

sensitive to streptomycin, isoniazid, rifampicin and ethambutol.

11. The patient was diagnosed to have PTB and started on a standard

regimen of 4 first-line anti-TB drugs

Final diagnosis

Pulmonary TB

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LEARNING ISSUES RESP CASE 1 with learning activity