CASE PRESENTATION
PULMONARY TB
1/10/ 2021
DRMALKIA
Patient information
 Name: C.W
 Age: 20 years
 IP number: 695758/21
 Sex: Female
 DOA: 28/7/21
 discharge 16/8/2021
 Time in the ward: 19 days
complains
 diarrhea for 2 weeks
 cough for 2 months
 general body weakness for 2 months
 weight loss for 2 month(cannot quantify)
 headache on and off for 2 months
HPI
 Known ptb patient and defaulter of medication for
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unknown time
known iss not on haart
complains of above symptoms for 2 months
no hx of LOC or convulsions
reported Tb for gene-expert was positive and
initiated on anti tb.
PMSH
 index admission
 known iss not on haart
 tb patient and defaulter
 no hx of surgeries or blood transfusion
 no allergies known
FMSH
 Single
 no nhif beneficiary
 no hx of chronic family illnesses
 hx of smoking
 no hx of alcohol use
 hx of iv drug abuse
On examination
 Sicklooking,not in resp distress
 wasted
 (pallor++,jaundice+,lymphadenopathy,cyanosis,ede
ma,dehydration++)
 Vitals;
SPO2-100% on RA
PR;105b/m
BP; 95/60
RR;20b/m
Temp;36.0
 P/A;mwr,not distended,soft,tender epigastric
region,no organomegally,bowel sounds present
 RESP:BAE with mid zone crackles
 CVS;S1 S2 heard no murmurs
 CNS;gcs 15/15,normal reflexes,PBRL
OTPP lethargic
IMPRESSION
 Severe microcytic hypochromic anemia
 known PTB
 known ISS
 acute GE with dehydration
PLAN
 FHG,UECS,RBS
 stool for hpylori occult blood and ziel nelson
 cd4 count and viral load
 Monitor vitals,rbs 6 hrly
 Keep warm
 ivf 1.5l over 24 hours
 crp/ir/pct with cxr
 continue with started anti tb
 nutritional review
 ccc review
 vdrl
 hep b and c
 urinalysis
 pcr covid 19
 gxm
 transfuse 2 units whole blood
Lab results
 FHG; wbc 4.2,lym 0.6,gran3.3
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hb 4.4 mcv61.8
plts 246
Bilirubin total 6.6
b direct 4.6
repeat Bilirubin total 3.8
b direct 2.1
pct 0.899 crp 70.93
REPEAT HEMOGRAM
Medication given(t sheet)
 albendazole 400mg bd
 ceftriaxone 2g od
 pabrinex 1 and 2 in 500 mls ns od for 3 days
 RUTF 2 sachet per day
 iv pcm 1g tds
 iv encefer 2 vials in 500mls ns alt days
 po esomeprazole 40 mg bd
 fluconazole 400 mg od
 acyclovir 400 mg tds
 RHZE
 lactulose 15mls tds
 dulcolax 10mg bd
 relcer gel 15 mls tds
 tramadol 50 mg bd po tothema 2 vials od
 ensure 1 tin
at the ward
plans at admission was executed and patient was
commenced on haart and anti tbs
hpylori test negative
vdrl neg
serum crag neg
stool cyst and ova--- no cyst or ova seen
patient developed oral candidiasis and was managed
with chlorhexidine mouth wash
 patient also had hyperkalemia of 6.43 and iv calcium
gluconate, insulin 10iu in 50mls of 50%dextrose was
given
 discharged home through ccc and mopc
THANK YOU