CASE PRESENTATION ON TUBERCULOSIS

This is a case presentation on pulmonary tuberculosis in SOAP format especially for pharm d students.

1. CASE PRESENTATION ON PULMONARY TUBERCULOSIS DONE BY : ASHIMA JOSEPH IV PHARM.D

2. CASE ABSTRACT: A 50 Year old male was admitted in Karpagam hospital on 21/2/2020 His chief complaints were cough, poor appetite, excessive joint pain for 1 week, chest pain for 1 month, weight loss, evening rise in temperature, and breathlessness. On physical examination he was found to be afebrile, conscious and oriented. On laboratory examination his hemoglobin, total count, lymphocytes, MCH, MCV, MCHC and RBC levels was found to be decreased. He had a past medical history of tuberculosis and he discontinued the medications. Finally on laboratory and specific investigation the patient was diagnosed as PULMONARY TUBERCULOSIS.

3. He was treated with following medication ATT-CAT- II (8MONTHS) T.Dolo

4. PATIENT DETAILS NAME Mrs. X AGE 50 YEARS SEX MALE IP.NO K18061268 DATE OF ADMISSION 21/2/20

5. SUBJECTIVE

6. Reasons for admission Cough poor appetite excessive joint pain for 1 week chest pain for 1 month weight loss evening rise in temperature breathlessness

7. Social History: Smoker -yes Alcoholic-yes Marital status-Married Allergies-Nil Past medical history- TUBERCULOSIS Past medication history-ATT CAT-I DISCONTINUED

8. OBJECTIVE

9. VITALS: COMPONENTS OBSERVATION NORMAL VALUES BLOOD PRESSURE 120/80 mm Hg 120/80 mm Hg RESPIRATORY RATE 16 breaths/min 12-20 breaths/min PULSE 100 beats/min 60-100 beats/min TEMP ARATURE 98.4 °F 98.4 °F

10. On Examination: Afebrile Conscious Oriented

11. LABORATORY INVESTIGATIONS: COMPONENTS FINDINGS NORMAL VALUES HAEMOGLOBIN 7.1 gm/dl 14-18 gm/dl TOTAL COUNT 11,800 cells/cu.mm 4,000-11,000 cells/cu.mm PLATELETS 4,30,000 1.5 to 4.5 lakh/ cumm MONOCYTES 1.8% 2-10% TOTAL RBC 3.39 millions/ cumm 4.7-6.1 millions/ cumm MCH 21.1 Pg /cell 27-33 Pg /cell MCHC 28.3 gm/dl 33-36 gm/dl LYMPHOCYTES 14.6% 20-40% MCV 74 fl 80-96 fl RBS 118.4 mg/dl 70-140 mg/dl

12. SPECIFIC TEST: Sputum culture and sensitivity test (+ ve ). Chest X-ray.

13. ASSESSMENT

14. CAUSES: Tuberculosis is caused by bacteria (Mycobacterium tuberculosis) that spread from person to person through microscopic droplets released into the air. This can happen when someone with the untreated active form of tuberculosis coughs, speaks, sneezes, spits, laughs or sings. RISK FACTORS: Low body weight Babies and young children, whose immune systems have not matured People with chronic conditions such as diabetes or kidney disease People with HIV/AIDS Organ transplant recipients Cancer patients undergoing chemotherapy People receiving certain specialized treatments for autoimmune disorders 

15. DIAGNOSIS PULMONARY TUBERCULOSIS

16. PLAN

17. BRAND NAME GENERIC NAME GIVEN ROUTE GIVEN DOSE FREQUENCY ATT-CAT- II (8MONTHS) Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin(S) Oral Oral Oral Oral IM 2 Months –R150,H75,E275,Z400,S750 1 month-R150,H75,E275,Z400 5 Months- R150, H75,E275 TID T.Dolo Paracetamol Oral 650mg SOS DRUG CHART

18. DRUG PROFILE DRUG CLASS MOA ADR ATT-CAT- II Isoniazid(H) Rifampicin(R) Pyrazinamide(Z) Ethambutol (E) Streptomycin(S) Antituberculosis drug inhibition of mycolic acid synthesis  inhibits bacterial RNA synthesis by binding strongly to the beta subunit of DNA-dependent RNA polymerase, preventing attachment of the enzyme to DNA, and thus blocking initiation of RNA transcription inhibition of mycolic acid synthesis inhibits the synthesis of metabolites, subsequently impairing cell metabolism and cell multiplication eventually leading to cell death  inhibit normal bacterial protein synthesis Peripheral neuritis, hepatotoxicity, anemia , GI disturbances Hepatotoxicity, fever, chills, joint pain,GI disturbances Hepatotoxicity, hyperuricemia , GI disturbances skin rashes Optic neuritis, hyperuricemia , GI disturbances, skin rashes Ototoxicity, nephrotoxicity, neuromuscular blockade Paracetamol Antipyretic and analgesic Inhibit release of prostaglandins in the CNS and by inhibit endogenous pyrogens at the hypothalamic thermoregulator center Nephrotoxicity, hepatotoxicity, skin rashes and GI disturbances

19. PHARMACIST INTERVENTION

20. DRUG-DRUG INTERACTION ISONIAZID -- ACETAMINOPHEN Concurrent use of ACETAMINOPHEN and ISONIAZID may result in an increased risk of hepatotoxicity. Mechanism- inhibition of CYP2E1-mediated metabolism of acetaminophen by isoniazid . Acetaminophen use should be avoided or limited in patients taking isoniazid. ISONIAZID-RIFAMPIN Concurrent use of RIFAMPIN and ISONIAZID may result in hepatotoxicity . Mechanism- increased isoniazid metabolism For patients on concurrent isoniazid and rifampin , monitor liver function tests PYRAZINAMIDE-RIFAMPIN Concurrent use of PYRAZINAMIDE and RIFAMPIN may result in severe hepatic injury. Patients should be monitored throughout the entire course of therapy since a majority of patients have onset of symptoms of liver injury after the fourth week of therapy.

21. DRUG-FOOD INTERACTION ACETAMINOPHEN-CABBAGE Concurrent use of ACETAMINOPHEN and CABBAGE may result in decreased acetaminophen effectiveness. Cabbage may enhance the glucuronidation of acetaminophen to inactive metabolites. RIFAMPIN-FOOD Concurrent use of RIFAMPIN and FOOD may result in decreased rifampin concentrations. Rifampin should be administered one hour before or two hours after a meal with a full glass of water. ISONIAZID-FOOD Concurrent use of ISONIAZID and FOOD may result in decreased isoniazid exposure. Isoniazid should be administered on an empty stomach.

22. PATIENT COUNSELLING Educate the patient about the disease severity, the importance of adherence to therapy and the complications of tuberculosis . Patient are advice to use tissues to cover when they cough and sneezes Tissues should be disposed appropriately and not left on outer space A surgical mask must worn by the patient whenever they leave the isolation room. Take medications properly.

23. PATIENT COUNSLLING-BASED ON DRUG PROFILE Isoniazid should be administered on an empty stomach Rifampin should be administered one hour before or two hours after a meal with a full glass of water. Rifampin stains body fluids such as urine, saliva, sweat, sputum, etc. orange red which is harmless.

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