INTRODUCTION

Tuberculosis is a common and often deadly infectious disease caused

by mycobacteria, mainly Mycobacterium tuberculosis. Tuberculosis usually
attacks the lungs (as pulmonary TB) but can also affect the central nervous
system, the lymphatic system, the circulatory system, the genitourinary
system, the gastrointestinal system, bones, joints, and even the skin. Other
mycobacteria such as Mycobacterium bovis, Mycobacterium africanum,
Mycobacteriumcanetti, and Mycobacterium microti also cause tuberculosis,
but these species are less common. The typical symptoms of tuberculosis are
a chronic cough with blood-tinged sputum, fever, night sweats and weight
loss. Infection of other organs cause a wide range of symptoms. The
diagnosis relies on radiology (commonly chest X-rays), a tuberculin skin
test, blood tests, as wellas microscopic examination and microbiological
culture of bodily fluids. Tuberculosis treatment is
difficult and requires long courses of multiple antibiotics. Contacts are also
screened and treated if necessary. Antibiotic resistance is a growing problem
in (extensively) multi-drug-resistant tuberculosis. Prevention relies on
screening programs and vaccination, usually with Bacillus Calmette-Guérin
(BCG vaccine).
Tuberculosis is spread through the air, when people who have the
disease cough, sneeze or spit. One third of the world's current population
have been infected with M. tuberculosis, and new infections occur at a rate
one per second.[1] However, most of these cases will not develop the full
blown disease; asymptomatic, latent infection is most common.
 CLIENT’S PROFILE

Client’s Name:

Age:

Address:

Civil Status:

Sex:

Nationality:

Filipino
Religion:
Roman Catholic
Educational Attainment: High School Graduate
Height:
5’2”
Weight:
45 kg
Occupation:
House wife
Income:
none

Informant:

Date of Admission: August 4, 2008

Time of Admission: 6:45 pm

Chief Complaint: Cough, Loss of appetite, Presence of blood in the sputum

Admitting Diagnosis: Koch Pulmonary Infection Pneumonia

Attending Physician:

HISTORY Of PRESENT ILLNESS

Chief Complaint: cough
 Mrs. X a 56 yr. old female, Roman Catholic , Housewife, residing at Western

Wao, Lanao Del Sur was admitted at Polymedic General Hospital for the first time last

August 4, 2008.

Two weeks prior to admission onset of cough productive with yellowish phlegm,

+ night sweats, + low grade fever, + poor appetite, this day noted blood stitched sputum

hemophysis with back pain, associated with mass at left lower lip noted since 1986 when

the area was constantly traumatized any protruding one tooth and later develop a mass,

no bleeding noted.

Personal Health History

In relation to the health history of the family,. has not undergone any
previous hospitalization.
Family History

(-) Hypertension

(-) Diabetes Mellitus

(+) Tuberculosis of Husband

Past Medical History

Patient Mrs. X., who is 56 yrs. Old, was admitted to Polymedic General Hospital

last August 4, 2008 at 6:45 pm with chief complaint of cough, loss of appetite, presence

of blood in the sputum.

IV. MEDICAL MANAGEMENT

A. LABORATORIES

BLOOD CHEMISTRY

Date: 08-05-08
Result Normal range Rationale

Creatinine 0.90 0.70 within normal range

Fasting Blood Sugar 92.60 60-100mg/dL within normal limit

X-RAY

Date: 08-05-08

Impression: There is homogenous opacification of the right middle lobe. The rest

of the lung field are clear the heart is not enlarged. Midline structures are not displaced. The
diaphragms are intact te rest of the included structures are unremarkable.

Pneumonia with lobar consolidation, right middle lobe.

URINALYSIS

Date: 08-05-08

Specimen Result

Color straw
Appearance clear
Glucose (-) Negative
Protein (-) Negative
Reaction 6.0
Specific gravity 1.005
Microscopic WBC 6-8
RBC 3-6
Epithelial mucous threads none
Urates none
Bacteria none
 HEMATOLOGY

Date: 08-05-08
Result Normal range Rationale
WBC 9.6 1 8-10 normal
RBC 4.41 3.69-5.90 normal
Hemoglobin *11.4 11.70-14.00 LOW
Hematocrit 37.0 34 - 44 normal
MCV 83.9 70-97 normal
MCH *25.9 26.10-33.30 LOW
MCHC *30.8 32-35 LOW
Platelet count 262 150-390 normal

Differential Count:

Neutrophils *70.7 55-62

Lymphocytes *19.0 20-40
Monocytes 5.8 4-10
Eosinophils 4.4 1-6
Basophils 0.1 0.50-1.0
RDW-CV 13.3 11.5-14.5
DATE DOCTOR’S ORDER .RATIONALE
Please admit at room of choice To provide care and close
Under the service of Dr. Paglinawan monitoring
Secure consent to care Consent is essential for any
treatment; routine procedures are
covered by a consent signed at
admission.
TPR and BP q 4 hours Provide a baseline data for care.
During this period of time,
complications
Low fat low sodium To indicate specific diet for
patient
Start IVF 1L, D5LR at 15 gtts./min. Serve as a route for IVTT
medication and replaces fluid and
electrolyte losses due to
Laboratories
• Creatinine • To assess kidney function.
• Chest X-ray • To check lung status since
patient complained
shortness of breath.
• Urinalysis • A standard procedure;
used to check abnormal-
lities in the renal System
• CBC •
>Medications:
Moxifloxacin 400g Slow IV This medication is Bactericidal
drip OD, ANST interferes with DNA replication,
repair, transcription, and
recombination in susceptible gram
negative and gram- positive
bacteria, preventing cell
production and leading to cell
death.

Sinecod 1tab TID PO This medication is for acute

cough
of any etiology for pre or post
cough
sedation

Hemostan 500mg 1cap TID various clinica and surgical cases