TB PRESENTATION, a case study based on TB

Case presentation

1. TB PRESENTATION MODERATOR:DR DITU PRESENTER: EMELY ZIMBA

2. DEMOGRAPHICS NAME : PROMISE TEMBO AGE : 1Y 7MONTHS SEX :F RESIDENT : MULENGA RELIGION : CHRISTIANITY(CATHOLIC) REFFERAL : MULENGA CLINIC INFORMANT :AUNT D.O.A :20/06/24 D.O.H :25/06/24(KAFUBU WARD)

3. PRESENTING COMPLAINTS BODY HOTNESS X 6/12 COUGH X 6/12 LOSS OF BODY WEIGHT X 6/12

4. HISTORY OF PRESENTING COMPLAINT The patient was well until 6 months ago when she started experiencing the above symptoms. The pt was then taken to mulenga clinic where she was tested for malaria but the RDT was negative and the pt was initiated on septrine and paracetamol. The informant explained that the symptoms did not resolve hence the pt was rushed back to the clinic and was later referred to KTH.The pt presented with body hotness which occurred in episodes but was not associated with any convulsions, loss of consciousness or any abnormal movements. The pt also experienced a cough was non productive and was associated with night sweats and difficulties in breathing however it was not associated with any chest pain, hemoptysis or loss of appetite. The pt also experienced loss of weight which was gradual in onset.

5. REVIEW OF SYSTEMS CVS-no chest pain -no dyspnea - no cyanosis -no fatigue GIT-no vomiting -no abdominal pain GUT-no blood in urine -no dysuria -no polyuria -no pain when passing urine MSS-no rash -no joint swelling -no yellowing of eyes or palms

6. PAST MEDICAL HISTORY No history of any hospital admissions No history of similar illness No history of any operations or accidents No history of diabetes,epilepsy,asthma,TB,hypertension or sickle cell RVD NR-VERBALLY

7. PAST DRUG HISTORY SEPTRINE X 7/7 PARACETAMOL X 5/7 PRESCRIBED FROM MULENGA CLINIC NO KNOWN DRUG OR FOOD ALLERGIES DENIES USE OF HERBAL MEDICATION

8. BIRTH HISTORY Pt was born from mulenga clinic The pregnancy was term and was delivered via SVD There were no complications during birth The baby cried and passed meconium and urine

9. IMMUNISATION HISTORY IMMUNISATION WAS UP TO DATE UNDER FIVE CLINIC CARD WAS NOT SEEN AS IT WAS WITH THE MOTHER

10. NUTRITION HISTORY PT WAS BREASTFED UP TO 1Y3MONTHS AFTER WEANING,PT WAS FED PORRIDGE WHICH SOMETIMES CONTAINED GROUNDNUTS PT IS FED PORRIDGE TWICE IN A DAY MORNING AND EVENING AND FEEDS ON NSHIMA AT LUNCH AND SUPER

11. DEVELOPMENTAL HISTORY SITTING-5MONTHS CRAWLING- 6MONTHS STANDING -8MONTHS WALKING -10MONTHS

12. SOCIAL BEHAVIOUR PT SMILES RECOGNIZES MOTHER SHE WAVES BACK ABLE TO UNDERSTAND SIMPLE QUESTIONS ABLE TO ASK FOR THINGS ABLE TO POINT AND TALK

13. FAMILY HISTORY NO HX OF DIABETES, ASTHMA, EPILEPSY, TB, HXN or SCD

14. SOCIAL HISTORY PT LIVES WITH HER MOTHER AND OTHER RELATIVES IN A 4ROOMED HOUSE PT HAS ONE SIBLING NO HISTORY OF BEING EXPOSED TO ANYONE WITH TB NO HISTORY OF SMOKING FROM THE PEOPLE SHE LIVES WITH

15. SUMMARY PRESENTED P.T. F/1YR7MONTHS 5 DAYS POST ADMISSION WHO CAME IN AS A REFFERAL FROM MULENGA CLINIC WITH COMPLAINTS OF BODY HOTNESS,COUGH AND LOSS OF BODY WEIGHT FOR 6 MONTHS.THE COUGH WAS NON PRODUCTIVE AND WAS ASSOCIATED WITH NIGHT SWEATS AND SIGNIFICANT WEIGHT LOSS. HOWEVER THERE WAS NO LOSS OF APETITE,NO WEEZE,NO HEMOPTYSIS AND NO SHORTNESS OF BREATH.IMMUNISATION WAS UP TO DATE AND THERE WAS NO DELAY IN DEVELOPMENT.

16. DIFFFERENTIAL DIAGNOSIS TB LUNG ABSCESS

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