Index Case Presentation

TUBERCULOSIS
NANDINI SINGH
B AT C H 2 0 1 6
 PATIENT DETAILS
•NAME: Mohsina
•AGE: 18 years
•SEX: Female
•EDUCATIONAL STATUS: Passed class 10th
•OCCUPATION: Unemployed
•MONTHLY INCOME: Nil
•MARITAL STATUS: Unmarried
•RELIGION: Muslim
•ADDRESS: Nayanagar
 CHIEF COMPLAINTS
At present the patient is asymptomatic, but 6 months ago she
presented to the primary healthcare centre with the chief complaints
of:
• COUGH for nearly a month (6 months ago)
• LOW GRADE FEVER WITH NIGHT SWEATS for nearly 20 days ( 6
months ago)
• Loss of weight
 HISTORY OF PRESENT ILLNESS
•The patient was apparently well 6 months ago when she started developing
cough.
•Initially the cough was mild but gradually it became severe.
•It was associated with excessive sputum production and difficulty in breathing
on doing heavy exercises.
•Each episode of coughing was associated with mild chest pain.
•The sputum was mucoid in consistency.
•The cough was consistent but there was no history of haemoptysis.
•After a week of developing cough, the patient started developing fever which
was mild in character and initially managed it by taking paracetamol at home for
a few days.
•However the fever continued for subsequent days and was accompanied by
excessive sweating at night. Fever was not associated with rigor.
•The entire episode was marked by loss of weight as the patient informed that
the clothes had become loose to her.
 PAST HISTORY

•There is no significant past surgical history.

•No history of any significant previous medical condition.
 TREATMENT HISTORY
•After having experienced the above stated symptoms for almost a month with no improvement,
the patient visited the Primary Healthcare Centre, Mehuwala from where she was referred to
Community Health Centre, Premnagar and diagnosed with pulmonary tuberculosis.
•Since then the patient has been regularly taking the medicines (3 tablets daily) recommended
for drug sensitive tuberculosis.
•The regime consists of
I. INTENSIVE PHASE: 2 months : HRZE
II. CONTINUATION PHASE: 4 months : HRE
THE COURSE WILL BE COMPLETED IN ONE MONTH’S TIME.
 PERSONAL HISTORY
There is no history of epilepsy or diabetes.
 FAMILY HISTORY
•There is no significant family history.
•None of the family members have ever had
tuberculosis.
 SOCIAL HISTORY
•The patient belongs to a middle class family( B G Prasad
Scale) consisting of 6 other members all of which share a
single room measuring nearly 10ft x 12ft x 14ft.
•The hygiene maintained is moderate.
•There is no history of any substance abuse.
 MENSTRUAL HISTORY
•AGE OF MENARCHE: 12 years
•DURATION OF EACH CYCLE AND BLEEDING: 30 days; 5 days
•REGULARITY: Regular
•SEVERITY OF FLOW: Moderate flow ( 2 pads used per day)
•ANY ASSOCIATED FACTOR: Occasional painful bleeding
(dysmenorrhea)
Detailed nutritional history
 GENERAL EXAMINATION
•PULSE: 78/min
•RESPIRATORY RATE: 18/min
•PALLOR: Mild
•ICTERUS: Absent
•WEIGHT: 46 kg
•HEIGHT:1.63m
•BMI: 17.31kg/𝑚2
THANK
YOU