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Mr. M.D. August 2, 1969

48 Years old Catholic

Male Farmer


Married First


Tabuk, Kalinga January 24, 2019; 11 pm
Chief Complaint
Difficulty of Breathing
History of Present illness
1 week before 2 Weeks PTA 6 days PTA
New Year • patient went to their
farm early
• Still with the cold
• The patient has colds • About to drive their
kuliglig but vision
become blurry
• Did not seek medical • Patient developed then dark
consultation cough
• Patient lost consciousness
• No fever, cough, • Accompanied by • Patient was rushed to
headaches, difficulty of white sputum production nearby hospital
• Patient denies chest
• No fever and pain, DOB, light
headaches headedness but
easily gets tired
History of Present illness
5 days PTA 3 hours PTA On the Day
• Patient was admitted to • Difficulty of breathing
of Admission
the hospital worsens • Upon arrival,
• Patient cannot get patient have undergone
• X-ray and ECG was thoracentesis and was
comfortable and he
done - unremarkable admitted
cannot breathe

• Fever every night for • X-ray and chest

the next 5 days for ultrasound was done
2 hours duration
• Lung fluid of about 1
• Difficulty of breathing liter in volume was found
but tolerable
• Patient was transferred
Past Medical History
Had chickenpox when he was a child

No history of hospital admissions

No history of surgical operations

No history of allergies to food and medication.

However, according to the couple when he took
an antibiotic in CVMC, he developed a rash on his back
which resolved after discontinuing the use of the antibiotic
Not taking vitamins, oral supplements or any
maintenance medication
Family History
Married to wife since 2001

Had 5 children, all alive and healthy

Father 70 years old, alive and has tuberculosis

Mother 60 years old, alive with no noted illnesses

Wife diagnosed with tuberculosis in 2007.

Treatment for 6 months after diagnosis and
claims she's cured
No other history of hepatitis, diabetis, asthma,
kidney diseases, epilepsy, cancer or mental
Personal and Social History
Patient is not a smoker Unheated drinking water comes
from a deep well less than 30
meters away from their house
Patient is not an avid alcohol
drinker Patient loves eating vegetables
more so than meat. He chews bettle
Last time he drank alcohol was nut in between meals
during the new year's eve.
Sleeps usually at around 8:00 pm
and wakes up at about 4:00 am to
Patient's family lives in a 2 -roomed get ready for farm work
bungalow house with galvanized
Review of System
Constitutional Respiratory
(+) fever, (+) Easy fatigabiliy, body weakness, (+) cough, (+)phlegm, (+)dyspnea,(-) hemoptysis
weight loss
Skin Heart
(-) rashes, itching, lumps, dryness or color change. (-) chest pain, edema.

Head Gastrointestinal
(-) headaches, light headedness (-) abdominal pain, diarrhea, constipation

Nose and Sinuses Genitourinary

(+) colds,(-) nasal stuffiness (-) dysuria, incontinence, urinary retention.

Ears Musculoskeletal
(-) tinnitus, ear pain, good hearing (-) joint pain,muscle weakness, backpain, myalgia

Mouth and Throat Neurologic

(-) Sore throat, toothache, gum bleeding (-) paralysis, numbness, or seizures

Neck Hematologic
(-) pain, lump or stiffness (-) easy bruising, pallor
Physical Examination

The patient is an average built man who is coherent and cooperative and responds
quickly to questions. He is afebrile but tense looking and obviously in pain due to the
CTT in place on his lower left lung. He is hooked to an IV line and lies on
his right side.


BP: 140/90 mmHg RR: 27 cpm

HR: 92 bpm SPO2: 92%
T: 37.4 degree Celsius
Physical Examination

Normocephalic head with symmetry.
Absence of trauma, scalp or facial lesions, tenderness or masses

Icteric sclera. Both pupils are round and equally reactive to light.
Extraocular movements are intact. No hemorrhages or exudates seen.

Symmetric with no signs of swelling and redness.

Bilaterally symmetric. Mucosa is pink with midline septum and no signs of sinus

Lips, tongue and gums are normal in color with no signs of lesion.
Physical Examination

Oral mucosa is pink with good dentition and midline tongue. Pharynx without exudates.


Trachea is midline. Absence of tenderness or masses. Absence of palpable lymph nodes


CTT in place on his lower left lung with cloudy pink to red fluid drained.
Presence of wheezes and crackles on left anterior lung field.
Physical Examination

Adynamic precordium with PMI at 5th intercostal space at the left midclavicular line.
No heaves or thrills. Muffled heart sounds noted


Flat abdomen and absence of discoloration. Bowel sounds are active heard in all
quadrants and in normal range. No tenderness or masses


Pale to pinkish nail beds. White discoloration on the right lower extremitiy. No clubbing
nor cyanosis. Warm and without edema. No tenderness, masses or any form of pain.
Physical Examination
GCS: 15/15
Cerebrum: Conscious. Coherent. Oriented to person and place.
Cranial Nerves:
I Can smell
II Blinks eyes spontaneously; can see near objects.
III,IV,VI Intact extraocular muscle movement. No nystagmus, diplopia noted.
Both pupils reactive to light, direct and consensual.
V Intact facial sensation.
VII Negative facial asymmetry. Symmetrical forehead wrinkling. Can grin and with
even smile.
VIII Can hear normal voice sound
IX, X Uvula is at midline. Can swallow
XI Can shrug shoulder symmetrically.
XII Tongue is on midline.

Motor: No involuntary movements. No atrophy.

Sensory and Intact sensory
Cerebellum: No dysarthria, ataxia.
Miscellaneous: No nuchal rigidity, negative Babinski.
Salient Features
48 year old male X-ray and Ultrasound

Farmer History of Tuberculosis in the family

Difficulty breathing Easy Fatigability

Colds and cough (>2 weeks) RR = 27, SPO2 = 92%,

Worsening dyspnea Wheezes and crackles on left lung

Fever every night Thoracentesis


(T/C) Pulmonary Effusion

secondary to
Pulmonary Tuberculosis
Difficulty breathing, cough, colds, phlegm
S ,
Fever, Worsening dyspnea,
Easy fatigability
O Family hx of tuberculosis, RR = 27,
SPO2 = 92%, Wheezes and Crackles

A Pleural Effusion secondary to
Pulmonary Tuberculosis

P HIV screening testDSSM, Tuberculin Sk
in test, start Anti-TB Drug regimen
Red rash on the patient's back and fever

O Icteric sclerae

A Immunologic hepatitis secondary to
antibiotic hypersensitivity

P AST, ALT, discontinue use of antibiotics
Case Discussion
Epidemiology of
Still one of the
top 10 causes of
Death in 2017!
There are estimated
1.3 million deaths due to
TB worldwide
10 million developed TB
Men of>cases
Womenworldwide are
reported in countries:
• India (27%)
• China
• Indonesia
• Philippines (6%)
• Pakistan
• Nigeria
• Bangladesh
• South Africa
Latest Status of TB Epidemic
PTB: in the Philippines
PTB: in India
PTB: in India PTB: Philippines
Top 10 Leading
Causes of Morbidity
in the Philippines
Top 10 Leading Causes of Mortality in the Philippines
Top 10 Leading Causes of Morbidity in the Cagayan Valley
Causes of Death by Region, Province and City
Thank you
What is Pulmonary

• Caused by Mycobacterium tuberculosis

• 85% of patients developed TB in the lungs
• Transmission of PTB is thru droplet nuclei, which are
aerosolized by coughing, sneezing, speaking
• TB Lesion: epithelioid granuloma with central
caseation necrosis
What are the manifestation of
• Cough of two weeks or more should lead to high
index of suspicion for PTB
• Fever, especially rising in the evening, night sweats,
chest pain, weight loss, loss of appetite, coughing up
Clinical Manifestation
• Classified as pulmonary, extrapulmonary or both
Pulmonary TB
• Primary or post-primary (Adult type, secondary)
Primary Disease
• occurs soon after the intial infection with the organism
• asymptomatic or with fever and pruritic chest pain
• Often seen in children
Postprimary (Adult-type) Disease
• reactivation or secondary TB that may result from
endogenous reactivation of distant LTBI or recent
Extrapulmonary TB
• Most commonly involved: Lymph nodes, pleura,
GUT, Bones, and joints, Meninges, peritoneum
What is Presumptive TB?

• Any person who presents with symptoms or signs sugge

stive of TB for adults (>/= 15 y/o):
• Cough of 2 weeks duration
• Associated symptoms: weight loss, fever,
hemoptysis, chest/back pain, fatigue, night sweats,
• Chest X-ray findings suggestive of PTB
What is TB Exposure?

• Individual is in close contact with an active adult T

B case but without signs and symptoms of TB,
negative TST reaction and no radiologic or
laboratory findings suggestive of PTB
What is TB infection or
latent TB infection (LTBI) ?
• When a person breathes in the TB bacteria, in most case
s,the body is able to fight them to stop them from growin
g. The bacteria become inactive, but do not die. They lie
latent, and can become active later. This state is called
TB infection. People who are infected with TB do not
feel sick, do not have any symptoms, and cannot
spread the disease. But they could develop TB disease
at some time in the future
• Positive for TST reaction
What is
TB disease?
Not all people with TB infection get active TB disease. Only
when people infected with the TB bacteria start showing
signs and symptoms associated with TB are they
considered to have active TB disease. Some people
develop TB disease soon after becoming infected, before their
immune system can fight back. Other people may get sick later
, when their immune system becomes weak for some reason.
What is TB disease?
People with weak immune systems are more
vulnerable to TB. This includes babies and young children,
people infected with HIV and those who have the following con
ditions: diabetes mellitus, silicosis, cancer of the head or neck,
leukemia or Hodgkin’s disease, severe kidney disease, low bo
dy weight, certain medical treatments (such as corticosteroid tr
eatment or organ transplants).
What are the classification of TB
disease based on anatomical site
• Pulmonary TB

• Extrapulmonary TB
Pulmonary TB
Pulmonary TB
Extrapulmonary TB
Treatment regimen for TB
Pulmonary Tuberculosis
Pulmonary Tuberculosis
Thank you