A case study on tuberculosis

It may serve the academic needs of medical & pharmacy students

1. TUBERCULOSIS G.MAHESH PHARM-D VI YEAR 26-01-2014

2. Case Name: Ms. R Age: 56yrs Gender: M Depart: Chest&Tb D.O.A : 14-01-14 D.O.D : 19-01-14 CHIEF COMPLAINTS : C/O cough with expectoration which is whitish in color since 2 months.

3. HISTORY OF PRESENT ILLNESS: Patient was apparently normal 2 months ago when he developed cough with expectoration which is whitish in color which is not foul smelling. H/O fatigue, lethargy, weight loss of about 6 kg and fever.

4. PERSONAL HISTORY AND HABITS : Normal bowel and bladder habits SMOKER: Yes ALCOHOLIC: Yes PHYSICAL EXAMINATION: TEMP: 100 PR: 78/min RR: 18/min BP: 120/80 mm/Hg

5. SYSTEMS EXAMINATION: CVS: S1,S2 + RS : Crepts CNS: NFND P/A: soft LAB INVESTIGATION REPORT: Hb : 13.5g/dl RBC : 4.9million cells/cu mm PCV : 39.4 % WBC : 6,400 cells/cu mm DC : P 67. ; L 32 ; E 1.7 ; M 2.9 ; B 0.3

6. Platelet count : 3.02 lakhs/cu mm Electrolyte profile: Bicarbonate: 27 mmol/L

7. Liver function tests: Bilirubin Total : 0.9mg/dl Bilirubin Direct : 0.2 mg/dl SGOT (AST) : 9U/L SGPT (ALT) : 17U/L Total Protein : 7.1 g/dl Albumin : 3.7 g/dl Globulin : 3.4g/dl Alkaline Phosphatase: 115 U/L

8. Others: chest X ray: Significant cavities found Sputum AFB: A + B+ DIAGNOSIS: PULMONARY TUBERCULOSIS

9. DRUG CHART S:no DRUGS DOSE FREQUENCY R.O.A DURATION 1. T.Para 500mg SOS PO 5 Days 2. Inj.Ceftrioxone 500mg BD IV 5 Days 3. T.AKT 4 (Isoniazid+Rifampicin+Pyrazenamide+Ethambutol) 2I, R 1, Z 1, E 1 2 Tabs 3 times a week PO 5 Days 4. Inj. Amikacin 250mg OD IV 2 Days

10. SONP NOTES: Subejective: A 56 years old male patient was admitted in the hospital with c/o cough with expectoration which is whitish in color since 2 months . H/O fatigue, lethargy, weight loss of about 6 kg and fever. Personal history: He is a smoker and alcoholic Objective: systemic and physical examination was found to be normal SGPT and SGOT were found to be Decreased. chest X ray: Significant cavities found Sputum AFB: A + B+

11. Assessment: PULMONARY TUBERCULOSIS . Plan : Patient was given treatment with T.Para , Inj.Ceftrioxone,T.AKT 4,Inj. Amikacin.

12. DISCUSSION: T.Para(Paracetamol): It is an analgesic and antipyretic drug used to relieve from fever and pain. Take one tablet whenever required. Inj.Ceftrioxone: It is an antibiotic used to treat any infections. It is given twice daily. T.AKT 4:(Isoniazid+Rifampicin+Pyrazenamide): These drugs are given to treat active tuberculosis infection. Take 2 tablet of each thrice weekly. Inj . Amikacin: It is an antibiotic. This injection is given twice in a week