CASE PRESENTATION

A male patient of age 52 years was admitted in pulmonary department on 25th September with the major complaints of fever, cough with expectoration, weight loss, polyuria & polydipsia

PATIENT DETAILS

NAMEMr:XYZAGE52 yrsSEXMIP No:201010380Wt59 KgHt56BMI21DeptPulmonaryDOA25.9.12DOD31.9.12

S - SUBJECTIVEO - OBJECTIVEA - ASSESSMENTP - PLAN

PROBLEM LIST

Pulmonary TuberculosisDiabetes Mellitus

PROBLEM LIST

SOAP ANALYSIS FOR TB

SUBJECTIVEREASON FOR ADMISSIONWeight loss since 1 month (65kg to 59 kg)Cough with expectoration x 3 wksC/o Fever > 2 wksHemoptysis x 2 wksChest pain x 1 wk

SOCIAL HISTORYAlcoholic : YTobacco:YSmoker :YAllergies: Not knownMartial status: MarriedChildren-2Cotton industryFather: TB-3 Yrs

PAST MEDICAL HISTORYK/C/O T2DM

PAST MEDICATION HISTORY

Inj. insulin 30/70 bd

OBJECTIVEPHYSICAL EXAMINATIONGeneral examination : P I C CL+E Vital signs : Pulse rate:72/minCVS : S1S2 +VEChest : Not clear on auscultationGIT : SoftEXT :NCNS :N

VITAL SIGNS

DaysDay1 Day2Day3Day4Day5Day6Day7Temp 101.5100.51009998.598.598.5BP130/90130/80130/80120/90130/80130/90130/80Pulse72727272727272

BLOOD COUNT

Hb13.5 gm/dlTLC6500 cells/cummESR20 mm/hrPolymorph74 %Lymphocytes34 %Basophils1 %Eosinophils 2 %Monocytes 2%

OTHER INVESTIGATIONSChest X-ray :Right lower lobe opacityCT Scan of Thorax : Large consolidation with formation in right lower lobe & upper lobe, Nodular lesion presentSputum Examination: Presence of acid fast bacilliGram stain: Plenty of gram + ve cocci & occassionaly gram ve bacilliSputum Culture : Organism isolated: Staphylococcus species

SENSITIVE TORESISTANT TOAmikacinCefuroximeCeftriaxoneClindamycinCotrimoxazoleNetilmycinOfloxacin

ASSESSMENT

DIAGNOSISTUBERCULOSIS

ASSESSMENT

EtiologyAlcohol useHeavy smokingDiabetes mellitusFamily history : fatherMalnutritionClose contact with people infected with TBImmunosuppressed patient

Indication for therapyTo control TB either by Preventing the development of infectious forms Reducing the period of infectivity of people with infectious disease

DRUGS PRESCRIBEDS.NoDRUGSDOSEDAYS OF TREATMENTT.NameG.NameD1D2D3D4D5D6D71T.Monto 3INH,Rifampin,Ethambutol300+450 +800mg1-0-02T.PyzinaPyrazinamide750 mg 1-013Neb.DuolinIpratropium Br/ Levosalbutamol20+100 mcg q4h4Inj.OframaxCeftriaxone1gm bd-5C.YogutPre pro biotic1-0-1-6T.DoloParacetamol650 mg 1-1-1---7Syp.Linctus codeineCodeine phosphate2tsp tds8C. BecosulesMultivitamin1-0-0

ALTERNATIVE THERAPY

DRUGSDOSECyclosporinPASAmikacinKanamycinCapreomycin250 mg od200 mg od500 mg od500 mg od1 g od

PLANDischarge Medications

DRUGSDOSET. INH,Rifampin,Ethambutol300+450+800 mg1-0- 0T.Pyrazinamide750 mg 1-01C.Multivitamin1-0-0

GOALS OF THERAPYGeneral goalsTo cure patientRestore QOLPrevent relapseReduce transmission

Patient specific goalsReduce fever, cough, chest pain, hemoptysis.To maintain normal weight

Goals achievedTemperature reductionSymptoms relievedPatients conditions improved

Monitoring parameter

THERAPEUTIC MONITORING & TOXICITY MONITORING

Chest radiographyIsolation of mycobacteriumCT scan of thoraxHematological testTuberculin testThoracotomyInterferon gamma release assayDNA based testingHepatitisRashesConstipationHyperuricemia

Discuss the condition & treatment given

Assess adherence to regimen

Check the LFT

Uric acid level

Cessation of smoking & alcohol consumption

Rifampin-orange colouration

About disease

About drugs

Points to physicianPoints to patient

LIFE STYLE MODIFICATIONResume activity in lifeAvoid alcohol & smokingAll fruit dietsFresh air, breathingLight exercises & yogasFollow upReview after 15 days

SOAP ANALYSIS FOR DIABETES

SUBJECTIVEPolyuriaPolypdipsiaFatigue

OBJECTIVE

Blood sugar mgs/dlDay 1Day 3Day 5 Day 7FBS16014514490RBS200195185170PPS180170175163

OBJECTIVE

RENAL FUNCTION TESTUrea 25Scr. Creatine0.8ELECTROLYTES (m.Eq/L)Sodium135Potassium4Chloride99Bicarbonates 26

URINE EXAMINATIONURINE EXAMINATION

Colour Pale yellowSugar ++ veBile salts-veWBCNilBile pigment-veRBCNil Albumin ++ veCasts NilPus cells2-3Epithelial cells2-3

ASSESSMENTDiagnosis: DiabetesEtiologyFamily history-mother (5yrs)Indication for therapyNormalize the blood glucose levelSymptoms to be controlledAssessment of therapy

DRUGSDOSEDAYSInj. Insulin30/70 1-0-1D1- D7

T. Glimeperide1mg odD1- D7

PLAN

Discharge medicationsInj. Insulin -30/70 unitsT.Glimeperide - 1mg od Goals of therapyEliminate symptomsPrevent long term complicationsPatient specific goalsTo reduce fatigue, polyuria, polydipsiaGoals achievedBlood glucose level reduced Improvement in patient condition

Monitoring parameter

Therapeutic monitoring & Toxicity monitoring

Monitor RBS,PPS,FBSGlycosylated HbProtein & sugar in urineSerum creatine & ureaHypoglycemiaDiarrhea, nausea,vomiting

Points to physician

Points to patient

Life style modificationCarry CandyExercise Foot careGo for eye check up

Follow upReview after 15 days-test

Glimiperide + rifampin Consult the current references For normal valuesDietHygieneBlood sugar monitoringAbout disease About drugs

THANK YOU

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