Академический Документы
Профессиональный Документы
Культура Документы
POSTING
CASE
PRESENTATION
PRESENTER :
KAARTHIGAN
RAMAIAH
ID NO.
: 06201204-00011
LECTURER :
DR.AZMAN
CONTENT
1.
2.
3.
4.
5.
6.
7.
8.
History taking
Physical examination
Provisional diagnosis
Diff erential diagnosis
Investigation
Management plan
Discussion and learning outcomes
References
HISTORY TAKING
Patients details
Name
: Wa n D a y a n g M e m i
Age : 40 years old
Ra c e
: Malay
G e n d e r: Fe m a l e
Ad d re s s : Ta n j u n g G a d i n g , M u a r
Occupation: Housewife
D a t e o f a d m i s s i o n : 2 6 /0 4 / 2 01 6
D a t e o f c l e r k i n g : 2 8 / 04 / 2 0 1 6
Chief complaint
S h o r t n e s s o f B re a t h f o r 3 w e e k s
History of presenting
illness:
Patient is a known case of
hypertension and pleural
tuberculosis. Patient started to
have shortness of breath 3 weeks
ago. She claimed that it is
worsening on sitting and waking
but not at rest. Patient also
presented with orthopnoea and
paroxysmal nocturnal dyspnoea
since 3 weeks ago. She needs to
sleep using 3 pillows. Patient also
added that she also had decreased
eff ort tolerance since 3 weeks ago.
She said it started to worsen 2
weeks ago in which patient claimed
that she started feeling lethargy
after walking around 30 metres.
3
Tu b e rc u l o s i s
Diagnosed 6 months ago
Patient is having recurrent pleural
eff usion.
She has done pleural tapping for 16
times due to this.
Patient
was
placed
under
a
treatment
regimen
for
6
months(D.O.T.S) and completed the
treatment.
She feels better now due to the
treatment.
Hypertension
Diagnosed 3 years back
Latest blood pressure reading is
176/90 mmHg
Taking medications for it
Compliant
So
far
no
complication
from
hypertension
like
headache,
palpitation, or blurring of vision
No Known Medical Illness
4
T. C a l c i u m c a r b o n a t e 5 0 0m g T D S
T. P y r a z i n a m i d e 5 0 0m g E O D
T. A m l o d i p i n e 5 m g O D
T. Fe rro u s Fu m a r a t e 2 0 0 m g O D
Fo l i c a c i d 5 m g O D
Vi t a m i n B 1 / 1 O D
T. I s o n i a z i d 3 0 0 m g O D
T. R i f a m p i c i n 3 0 0 m g O D
T. P y r i d ox i n e 5 0 m g O D
T. E t h a m b u t o l H C l 4 0 0m g E O D
Family history
Fa t h e r p a s s e d a w a y a t t h e a g e o f 6 3
d u e t o m y o c a r d i a l i n f a rc t i o n .
Mother is still alive and is 62 years
old with history of diabetes mellitus
and hypertension.
8 siblings, 5 males and 3 females
with No Known Medical Illness.
Social history
Pa t i e n t l i v e s i n v i l l a g e a re a .
Pa t i e n t c l a i m e d t h a t o p e n b u r n i n g
h a p p e n s c o n s t a n t l y.
Pa t i e n t g e t s a c l e a n w a t e r s u p p l y.
Pa t i e n t h a s n o f o o d a l l e r g y a n d
observes a normal balanced diet.
Pa t i e n t h u s b a n d i s a s m o ke r b u t
d o e s n t s m o ke i n f ro n t o f p a t i e n t .
Pa t i e n t i s n o t a n a l c o h o l i c .
Pa t i e n t a l s o c l a i m e d t h a t t h e re i s n o
pets in her house
Pa t i e n t c l a i m e d t h a t n o o n e i n h e r
family has TB and also her friends. 5
PHYSICAL EXAMINATION
Patient was alert, pink and thin and weak, there was a
cannula inserted on the left hand.
Vital signs :
Temperature: afebrile
Blood pressure: 176/90
Pulse rate: 85 bpm, regular rhythm with normal character and
volume.
Respiratory rate: 16 bpm
Inspection
No peripheral cyanosis, no Osler's node, no jane ways lesion.
The periphery was cold. No conjunctival pallor and scleral
jaundice, oral hygiene acceptable, no central cyanosis.
JV not distended. No any visible pulsation of neck.
Chest: no any chest deformities, no any surgical scars and no
visible pulsation
6
Palpation
Trachea is not deviated
The cricosternal distance is 3 fi nger breadths
Apex beat is felt at 5th intercostal space along midclavicular line
Chest expansion was good
Tactile vocal fremitus- increased on the right area
Percussion
Anterior
Dull sound heard on right lower zone
Posterior
Dull sound heard on right lower zone
Auscultation
PROVISIONAL DIAGNOSIS
Pleural Tuberculosis
Positive fi ndings
Previous history of pleural eff usions
shortness of breath,
decreased eff ort tolerance
lethargy,
loss of weight
Percussion revealed dull sound heard on right lower zone on
both anterior and posterior chest wall
Auscultation revealed bronchial breathing, decreased air entry
on the left compartment and tactile vocal fremitus- increased
on the right area
DIFFERENTIAL DIAGNOSIS
1. Pneumonia
Signs of lobar or atypical pneumonia such as dyspnoea.
Generally, shorter duration of symptoms compared with TB.
2. Sarcoidosis
Other features of sarcoidosis, such as intrathoracic
lymphadenopathy and arthralgias, may be present.
3. Fungal infection
Potential fungi include histoplasmosis, coccidioidomycosis,
and blastomycosis. Travel history may help narrow the
diff erential diagnosis
10
INVESTIGATION
Blood investigations
FULL BLOOD
RESULT
REFERENCE RANGE
COUNT
Hb
10.3g/dL
11.5-15.5
TRBC
3.6 x 10 /uL
3.8-5.8
PCV
31.8 %
37-47
MCV
88.8 fL
76-96
MCH
28.6 pg
27-32
MCHC
32.2 g/dL
30-35
PLT
284 x103/uL
150-400
TWBC
8.1 x 103/uL
4-11
Neutrophil
63.6 %
5.15%
2-7.5
Lymphocyte
24.2 %
1.96%
1.5-4
Monocyte
5.5 %
0.45%
2-10
Eosinophil
5.7 %
0.46%
1-6
Basophil
1.0%
0.08%
0.02-0.1
11
LIVER FUNCTION
RESULT
TEST
TOTAL PROTEIN
ALBUMIN
GLOBULIN
A/G RATIO
TOTAL BILIRUBIN
ALKALINE
REFERENCE
RANGE
73 g/L
39 g/L
34 g/L
1.1 g/L
7 umol/l
84 U/L
65-85
35-50
20-35
1.0-2.2
UP TO 22.2
30-120
15 U/L
UP TO 32
Normal results of
Liver Function Test.
PHOSPHATASE
ALANINE
TRANSAMINASE
RENAL
RESULT
REFERENCE
PROFILE
SERUM
70 umol/l
RANGE
53-100
CREATININE
UREA
SODIUM
8 mmol/l
134
2.5-8.3
135-145
POTASSIUM
mmol/l
4.0
3.5-5.0
CHLORIDE
mmol/l
95 mmol/l
98-108
Normal results of
Renal Profile.
12
CARDIAC ENZYMES
RESULT
REFERENCE
CREATINE KINASE
LACTATE
53 U/L
254 U/L
RANGE
25-200
110-248
DEHYDROGENASE
ASPARTATE
13 U/L
UP TO 40
TRANSAMINASE
CALCIUM
INORGANIC
2.16 mmol/l
1.0 mmol/l
2.1-2.6
0.87-1.45
RESULT
REFERENCE
PHOSPHATE
COAGULATION
RANGE
PT
INR
APTT
11.70
1.14
36.20
9.56 11.05
29.5 40.9
Normal results of
Coagulation Profile
13
Gross appearance
Microscopic fi ndings
WBC
: Blood stained
: Packed with RBC, unable to count
14
15
Ta ke n o n 26 / 4 / 2 0 16
Fin d i n g s
PA v ie w C h es t X- r a y.
Ta ke n i n ere ct p o s it io n w i t h n o ro t a t i o n a n d t h e fi l m i s a d e q u a t e l y
p e n e t r a t ed .
T h e fi l m is a d eq u a t ely i n s p ire d a n d t h e l u n g fi e l d i s cl e a r.
T h e ca rd ia c th o r a c ic r a t i o i s < 5 0 % .
B il a t e r a l lu n g h ila r v is ib l e w i t h b l u n t e d r i g h t c o s t o p h re n ic a n g le w it h
r a d i o - o p a c it y lo w er z o n e o f r ig h t lu n g .
Lu n g i s h y p er in fl a t ed a n d t h e t r a c h e a i s ce n t r a ll y lo ca t e d a n d n o
d e v i a t i o n . N o c o n s o lid a t io n a n d n o s i g n o f a i r u n d e r d i a p h r a g m .
T h e re i s n o Ao r t ic A n eu r y s m , n o d i l a t e d p u l m o n a r y t r u n k , n o rm a l
h e a r t o r ien t a t io n , n o d ext ro - c a rd ia a n d t h e a p ex i s l o c a t e d i n t h e l e ft .
I m p re s s i o n
Due to blunted costophrenic angle and radioopacity, there might be a fl uid
collection (pleural eff usion) up to the medial border at the right lung.
No cardiomegaly.
16
17
Ta ke n o n 27 / 4 / 2 0 16
Fin d i n g s
PA v ie w C h es t X- r a y.
Ta ke n i n ere ct p o s it io n w i t h n o ro t a t i o n a n d t h e fi l m i s a d e q u a t e l y
p e n e t r a t ed .
T h e fi l m is a d eq u a t ely i n s p ire d a n d t h e l u n g fi e l d i s cl e a r.
T h e ca rd ia c th o r a c ic r a t i o i s < 5 0 % .
B il a t e r a l lu n g h ila r v is ib l e w i t h b l u n t e d r i g h t c o s t o p h re n ic a n g le w it h
r a d i o o p a c it y lo w er z o n e o f r ig h t lu n g .
Lu n g i s h y p er in fl a t ed a n d t h e t r a c h e a i s ce n t r a ll y lo ca t e d a n d n o
d e v i a t i o n . N o c o n s o lid a t io n a n d n o s i g n o f a i r u n d e r d i a p h r a g m .
T h e re i s n o Ao r t ic A n eu r y s m , n o d i l a t e d p u l m o n a r y t r u n k , n o rm a l
h e a r t o r ien t a t io n , n o d ext ro - c a rd ia a n d t h e a p ex i s l o c a t e d i n t h e l e ft .
I m p re s s i o n
Due to blunted costophrenic angle and radioopacity, there might be a fl uid
collection (pleural eff usion) at the lower zone of the right lung.
No cardiomegaly.
18
COMPARISON
26/4/2016
27/4/2016
19
IMAGING (CECT)
20
Taken on 16/2/2016
Findings
Image quality is degraded by breathing artefact.
There is moderate amount of pleural eff usion noted in the
right
hemithorax.
The fl uid is homogenous in density, which measures <20HU.
No pockets of air or soft tissue mass within the eff usion.
The pleural lining is homogenously thin and non-enhancing.
There is a collapse consolidation of the medial segment of the right
middle lobe and basal segment of the right lower lobe with air
bronchograms.
21
MANAGEMENT PLAN
PHARMACOLOGICAL:
23
24
26
27
28
29
30
IMAGING IN EPTB
Pleural TB
I n c l i n i c a l p r a c t i c e , u l t r a s o n o g r a p h y ( U S ) ca n b e u s e d t o d e m o n s t r a t e
p l e u r a l c o l l e c t i o n a n d g u i d e d i a g n o s t i c o r t h e r a p e u t i c p ro c e d u re s s u c h a s
p l e u ro s c o p y.
M u s c u l o s ke l e t a l T B
T h e i m a g i n g m o d a l i t i e s u s e d i n d i a g n o s i s a re p l a i n r a d i o g r a p h y , C T a n d
MRI.
C T a n d M R I i m a g i n g a re o f g re a t v a l u e i n d e m o n s t r a t i n g a s m a l l f o c u s o f
b o n e i n f e c t i o n a n d a l s o t h e ex t e n t o f t h e d i s e a s e p ro c e s s .
M R I i s t h e p re f e rre d i m a g i n g m o d a l i t y i n t h e a s s e s s m e n t o f t u b e rc u l o u s
s p o n d y l i t i s b e c a u s e o f i t s s u p e r i o r a b i l i t y t o d e m o n s t r a t e s o ft t i s s u e
a b n o rm a l i t i e s .
Central Nervous System TB
T h e m o d a l i t i e s t h a t a re u s e d t o i m a g e t h e b r a i n a n d s p i n e a re C T a n d M R I .
C T b e t t e r d e m o n s t r a t e s h y d ro ce p h a l u s w h i c h i s a c o m m o n c o m p l i ca t i o n
o f T B m e n i n g i t i s . I t m a y a l s o s h o w a b n o rm a l m e n i n g e a l e n h a n c e m e n t a n d
p a re n c h y m a l c h a n g e s .
In addition to the above, MRI better demonstrates the involvement of the
31
s p i n a l c o rd a n d c r a n i a l n e r v e s .
Abdominal TB
T h e i m a g i n g m o d a l i t i e s m o s t l y u s e d i n t h e i n v e s t i g a t i o n a re U S , C T a n d
barium studies.
T h e d i a g n o s t i c y i e l d s f o r t h e d i ff e re n t m o d a l i t i e s a re 8 3 % f o r b a r i u m
m e a l f o l l o w t h ro u g h , 80 % f o r C T a n d 7 7 % f o r U S .
Fe a t u re s s u g g e s t i v e o f a b d o m i n a l T B a re a s c i t e s ( 7 9 % ) , e n l a rg e d L N
( 3 5 % ) o m e n t a l t h i c ke n i n g ( 2 9 % ) a n d b o w e l w a l l t h i c ke n i n g ( 2 5% ) .
Genitourinary TB
I n v e s t i g a t i o n i n c l u d e s i n t r a v e n o u s u ro g r a p h y ( I V U ) , U S , C T a n d M R I .
IVU can demonstrate the moth-eaten calyx which may be the earliest
e v i d e n c e o f re n a l T B . I t c a n a l s o d e m o n s t r a t e u re t e r a l a b n o rm a l i t i e s .
U S , C T o r M R I c a n d e m o n s t r a t e t h e re n a l p a re n c h y m a a n d u r i n a r y
bladder better than IVU.
U S a n d C T a re u s e d i n g e n i t a l T B t o e v a l u a t e t h e u t e r u s a n d a d n ex a i n
f e m a l e s a n d t h e p ro s t a t e i n m a l e s b u t t h e i m a g i n g f e a t u re s a re n o n s p e c i fi c .
Head and Neck TB
CT and MRI can be used to evaluate head and neck TB.
C a s e a t i o n a n d c a l c i fi c a t i o n o f c e r v i c a l l y m p h a d e n o p a t h y m a y b e h i g h l y 32
suggestive but is not pathognomonic of TB
THANK YOU
33