grand round 3

1
GRAND ROUND PRESENTATION

• GROUP MEMBERS
• - ABDULRAHMAN IDARUS
• - IDA JOHN BUSHAIJA
• - CHANCE OCTORVIAN
• - FATEMA JAFFER
• - ALINANUSWE MPETA
• FACILITATORS
• - Dr. CATHERINE CHACHA
• - Dr. BILQIS NASSOR

2
PATIENT PARTICULARS

• PATIENT INITIALS KHS
• D.O.B 15/09/1993 (30 YEARS)
• SEX MALE
• ADRESS KINONDONI
• TRIBE MUHA
• OCCUPATION COOK
• RELIGION MUSLIM
• NEXT OF KIN MOTHER
• MARITAL STATUS SINGLE
• SELF REFFERAL
• DATE OF ADMISSION 27/11/2023 DATE OF
  CLERKING- 5/12/2023
• DAYS IN THE WARD- 8 DAYS
  INFORMANT- PATIENT

3
CHIEF COMPLAINT

• COUGH 2/12
• DIFFICULT IN BREATHING 4/7

4
HISTORY OF THE PRESENTING ILLNESS

• The patient was apparently well until 2 month ago
  when he started experiencing dry cough of gradual
  onset, more marked at night, aggravated when
  smoking cigarettes, partially relieved by
  medication.
• One month later the cough worsened which was
  associated with on and off fever, night sweats,
  fatigue and weight loss such that his clothes
  dont fit him anymore.
• It was also accompanied with sharp right sided
  chest pain radiating to the back and aggravated
  by deep breaths.

5
HISTORY OF THE PRESENTING ILLNESS

• He also presented with difficult in breathing for
  4 days which was of sudden onset which occurred
  through out the day aggravated by lying on the
  right side and relieved by changing to the left
  side or sitting upright and was not associated
  with wheezes.
• He denied awareness of heartbeat, shortness of
  breath and lower limb swelling.
• He was transferred from surgical ward where he
  was admitted for 3 days as he had abdominal pain,
  which was treated by medication and referred to
  medical ward due to difficult in breathing, cough
  and drenching night sweats.

6
REVIEW OF THE OTHER SYSTEM

• GASTROINTESTINAL SYSTEM
• No abdominal pain
• No vomiting
• No passage of loose stool
• No inability to pass stool

7

• URINOGENITAL SYSTEM
• No painful urination
• No blood in urine
• No waking up at night to urinate
• No overwhelming desire to urinate
• No change in frequency of urination
• No genital itching
• No urethral discharge

8

• NERVOUS SYSTEM
• No headache
• No blurry vision
• No dizziness
• No convulsion
• No loss of consciousness
• No numbness
• No tingling sensation

9

• ENDOCRINE SYSTEM
• No excessive hunger
• No excessive thrist
• No cold or heat intolerance
• No excessive hair growth
• No loss of libido.

10

• MUSCULOSKELETAL SYSTEM
• No joint or muscle pain
• No joint or muscular swelling
• No joint deformities
• HEMATOLOGICAL SYSTEM
• No easy bruising
• No bleeding tendencies

11

• INTEGUMENTARY SYSTEM
• No skin rashes
• No itching
• No hair loss
• HEENT
• No pain, discharge or swelling on eyes, ears or
  nose
• No throat pain or neck swelling.

12

• PAST MEDICAL HISTORY
• This is his 1st admission
• He had few OPD visits of which he doesn't
  remember the reasons
• Positive history for a minor surgical procedure
  on the thumb to remove an abscess, which was
  successfully done as an outpatient 5 years ago at
  a health dispensary.
• No history of blood transfusion
• No history of any chronic illness

13

• FAMILY HISTORY
• He is the 2nd child out of 3 children.
• Patients mother is known hypertensive patient
  and the patient's father was diabetic but is now
  deceased, the cause of his death was not
  determined.

14

• SOCIAL HISTORY
• He is cohabitting with his fiance , have no
  children
• Is a cook for 7 years.
• He is a smoker for the past 11 years and smokes
  17 cigarettes per day ( pack years- 9.35)
• Has a history of smoking marijuana in some
  ocassions. About 1- 2 pc every 1 week.
• He lives on a small house not well ventilated and
  is surrounded by friends who smoke Cigarretes
• No positive hx of TB contact.
• No history of alcohol use
• The patient exercises regularly by running more
  than 1 hour per day, every 3 days a week.

15

• DIETARY HISTORY
• The patient takes 3 meals
• Morning the patient takes cassava or buns with
  tea
• Afternoon he takes ugali, meat and vegetables
• Evening he takes potatoes and fruits.
• He also takes about 4 liters of water, as he
  spends more time near heat during cooking.
• His diet is satisfactory

16

• ALLERGY HISTORY
• The patient has no known allergy to food or drugs
  
• DRUG HISTORY
• Patient has no HX of using long term medications

17
SUMMARY 1

• I present to you a 30 years old male known smoker
  who presented with dry cough, pleuritic chest
  pain, difficult in breathing, night sweats, fever
  and weight loss with no wheezes.

18
Clinical diagnosis based on history

• 1. Pulmonary Tuberculosis
• Reason for a) cough
• b) night sweat
• c) weight loss
• d) fever
• e) difficult in breathing
• f) chest pain

19
DDX due to history

• 1. community acquired pneumonia
• reason for a) cough
• b) fever
• c) chest pain
• reason against a) No sputum production
• b) chronic cough
• Lung malignancy
• Reason for a) positive hx of smoking
• b) positive hx of B Symptoms

20
PHYSICAL EXAMINATION

• GENERAL EXAMINATION
• -The patient was conscious ,ill-looking, with a
  green cannula on his left hand and urinary
  catheter in situ which had 100mls of dark
  yellowish urine collected over 8hrs. The hair
  distribution ,texture and color was normal and
  was not easily pluckable, he was not pale, not
  jaundiced, not cyanosed, no angular chelitis.
• -The axillary lymph nodes were bilaterally
  enlarged/palpable about 2 cm, warm, mobile,
  tender and firm.
• -There was finger clubbing and presence of
  nicotine stain on finger tips,no splinter
  hemorrhages, no oslers nodes or janeway lesion,
  no palmar erythema,no dupuytren contracture, no
  koilonychia, no leukonychia.
• -No lowerlimb edema.

21

• VITALS
• Temperature 36.5 degrees centigrade
• pulse rate 88bpm
• respiratory rate 20 breaths per minute
• blood pressure 130/88mmHg
• spo2 97 on RA

22

• SYSTEMIC EXAMINATION
• Respiratory Examination
• On inspection
• Abnormal chest contour, the chest was inclining
  more towards the right.
• RR- 20 B/MIN
• Presence of traditional markings at the center of
  chest.
• Right sided of the chest below the axilla was
  expanded.
• - Respiratory pattern was normal
• - There was no sign of respiratory distress such
  as nasal flaring exhale through pursed lips or
  use of accessory muscles
• There was diminished chest movements on the right
  side
• Chest tube insitu at right side 5th intercostal
  space along axillary line, draining about 2000
  mls of pinkish frothy fluid.

23

• On palpation
• - The trachea was deviated to the left side.
• Tenderness on right sided of chest.
• Cardiac apex beat was at 5th ICS deviated lateral
  to the MCL
• - There was diminished chest expansion on the
  right side
• Tactile vocal fremitus was diminished on the
  right side.
• No palpable/ enlarged LN on supraclavicular and
  cervical area

24

• On percussion
• The right side of the chest was dull to
  percussion along the right lung fields.
• On auscultation
• There were diminished breath sounds on the right
  lung fields
• - There was decreased vocal resonance on the
  right side of the chest.

25

• 2. Cardiovascular system
• Capillary refill was less than 2 sec.
• The right radial pulse rate was 104 beats per
  minute with regular rhythm, normal character, non
  collapsing and synchronous with other arteries
  (radial, brachial, carotid, femoral).
• The blood pressure was 130/88 mmHg at Korotkoff
  phases 1 and 5.
• Neck veins were not distended.

26

• Precordial examination
• On inspection,
• - there were no surgical or traditional scars.
• - There was no precordial hyperactivity or
  bulging.
• - There was no prominent superficial veins.
• On palpation,
• - the apex beat was located on the left fifth ICS
  lateral to the mid clavicular
• line.
• - It was non tapping and non heaving.
• - There were no heaves and thrills.

27

• On auscultation,
• S1 and S2 were audible on the 4 valvular areas.
• - No added or abnormal sounds.

28

• 3. Gastrointestinal system
• On examining the mouth, there were no lesions in
  the oral cavity.
• The tonsils were not enlarged and not hyperemic.
• Grayish discolouration on the hard palate
• On per abdomen inspection,
• Normal abdominal contour.
• Abdomen moved with respiration.
• - The umbilicus was inverted and retracted.
• - There were no surgical or traditional scars.
• - There were no distended veins or visible
  pulsations

29

• On palpation,
• - there was no superficial or deep tenderness.
• - No palpable organomegaly or masses
• On percussion
• Dull note was heard at upper right quadrant
• Tympanic note on the rest of the abdomen
• On auscultation,
• - there were no renal or hepatic bruits.
• - Bowel sounds were heard 3 in a minute.

30

• 4.Nervous system

• CENTRAL NERVOUS SYSTEM
• Higher centers
• The patient had GCS of 15/15.
• He had good concentration
• He had normal speech and coherent language.
• Both long term and short term memories were
  intact.
• He was calm and oriented to person, place and
  time.

31

• Cranial nerves
• CN 1 (olfactory)
• The patient could smell an orange peel with each
  nostril.
• CN 2 (optic)
• The patient had normal visual field and visual
  acuity of 20/20 on both eyes.
• Pupil reflex was normal on both eyes.
• CN 3, 4 and 6 (oculomotor, trochlear, abducens)
• -The patient could move his eyes in all
  directions.

32

• CN 5 (trigeminal)
• - The patient sensed fine touch on his facial
  divisions of the ophthalmic, maxillary and
  mandibular branches on both sides.
• - The masseter and temporalis muscles were
  palpable on clenching his teeth.
• - He could open his mouth against resistance.

33

• CN 7 (facial)
• - The patient could taste on anterior two-thirds
  of the tongue.
• - He could raise his brows, close his eyes shut
  equally on both sides
• - could blow his cheeks with air and was able to
  hold when resistance was applied.

34

• CN 8 (vestibulocochlear)
• - Able to hear normal sound and whisper
• - Air conduction was better than bone conduction
  in both ears as demonstrated by Rinnes tests.
• - Webers test was negative as he heard equally
  on both ears.
• CN 9 and 10 (glossopharyngeal, vagus)
• - Patient could swallow.
• - Uvula was not deviated.

35

• CN 11 (accessory)
• - The patient could shrug his shoulders against
  resistance
• - Could turn his neck sideways against
  resistance.
• CN 12 (hypoglossal)
• The patient could protrude his tongue and move it
  side to side.
• - No deviations or tremors were present.

36

• PERIPHERAL NERVOUS SYSTEM
• Motor examination

R.U.L L.U.L R.L.L L.L.L
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movements NIL NIL NIL NIL
Gait - - - -
Tone NORMAL NORMAL NORMAL NORMAL
Power 5/5 5/5 5/5 5/5

1. Coordination Coordination was intact as
   performed by the finger nose test and Rapid
   alternating movements of the hand.

37

• 7. Reflexes

DEEP TENDON REFLEXES RIGHT SIDE LEFT SIDE
BICEPS REFLEX NORMAL NORMAL
TRICEPS REFLEX NORMAL NORMAL
PATELLA REFLEX NORMAL NORMAL
ACHILLES REFLEX NORMAL NORMAL
BABINSKI DOWNWARD DOWNWARD

• SUPERFICIAL REFLEXES Abdominal reflexes present.

38

• Sensory examination
• -He could sense pain, pressure and crude touch on
  both upper and lower left and right sides.
• -He could perceive vibrations and fine touch on
  both upper and lower limb.
• -Joint position was intact.

39

• Summary 2
• I present to you a 30 years old male known smoker
  who presented with dry cough, pleuritic chest
  pain, difficult in breathing, night sweats, fever
  and weight loss. However he denies awareness of
  heartbeat, lower limb swelling, wheezing.
• On physical examination the patient had
  bilaterall palpable axillary lymph nodes with
  finger clubbing and nicotine finger stains. On
  respiratory system examination there was abnormal
  chest contour, expanded on the right side with
  diminished movement, reduced tactile vocal
  fremitus, dull on percussion and decreased vocal
  resonance on the right side.

40

• Diagnosis based on history and examination.
• Right sided pleural effusion secondary to
  pulmonary TB.
• Reasons for
• Cough.
• Night sweats.
• Pleuritic chest pain.
• Fever.
• Diminished chest movements, decreased tactile
  vocal fremitus, dullness on percussion,
  diminished breath sounds on the right side of the
  chest.

41

• Differential diagnosis
• Community acquired pneumonia
• Reasons for
• Cough.
• Fever.
• Reasons against
• Night sweats.
• Weight loss
• 2. Lung malignancy
• Reason for a) positive hx of smoking for long
  time
• b) positive hx of B Symptoms

42
INVESTIGATIONS DONE

• Complete blood count
• S.creatinine

43

• Serum electrolytes

44

• 1st chest xray before treatment

45

• Control XRAY after Underwater Seal Drainage

46
(No Transcript)
47
(No Transcript)
48

• Treatment in the wards.
• IV ceftriaxone 1g od for 3 days.
• IV metronidazole 500 mg tds for 3 days.
• IM diclofenac 75 mg tds
• Anti-TB drugs rifampicin, isoniazid,
  pyrazinamide and ethambutol for two months.
  Followed by 4 months of rifampicin and isoniazid.
• Chest tube connected to underwater seal drainage.
• Chest physiotherapy

49
Further investigations required

• Stool for gene xpert
• Pleural fluid analysis including- ADA

50

• PULMONARY TUBERCULOSIS
• DISCUSSION

51
INTRODUCTION

• Its the oldest disease known to be affecting
  humans
• Caused by various strains of Mycobacteria,
• usually Mycobacterium Tuberculosis.
• Usually affects the lungs,
• but also other body parts like lymph nodes, bowel
  and brain.
• ( hematogenous, from adjacent organs).

52
Epidemiology

• Tuberculosis (TB) is the ninth leading cause of
  death worldwide and the leading cause from a
  single infectious agent, ranking above HIV/AIDS.
• In 2016, 2.5 million people fell ill with TB in
  the African region, accounting for a quarter of
  new TB cases worldwide.
• An estimated 417,000 people died from the disease
  in the African region (1.7 million globally) in
  2016. Over 25 of TB deaths occur in the African
  Region

53
Transmission

• Inhalation via aerosolized, infected droplet
  nuclei
• Expelled when the infected person cough, sneezes
  or speaks
• per cough , patient can release 3000 infectious
  nuclei.
• Sputum smear ve can give 105-107 AFB /ml
• Ingestion of unpasteurized milk( less frequent)
• Skin inoculation
• Transplacental route ( rare)

54
Risks from exposure to infection depends on

• Presence of co-morbid conditions like DM and HIV
• Use of immunosuppresants
• Age e.g in children and old
• Health care workers
• Duration of contact with infected person
• Crowding in poorly ventilated room
• Individual innate immunity
• Malnutrition
• Smoking

55
s/s of Active TB

• Chronic/persistent cough (gt14days) with
• low grade fever ( more in the night, excessive
  night sweats.)
• Weight loss
• Hemoptysis
• Fatigue
• Chest pain
• SOB
• Other symptoms depends on the affected site
• e.g. TB spine, pt presents with lower back pain.

56
Classification
PTB 80 EXTRA PTB 20
Primary disease LN TB
Secondary disease Skeletal TB
Pleural TB
TB of the upper air way
Genital urinary TB
Miliary TB
Tuberculous meningitis.
57
Pathogenesis

• Once inhaled the organism lodge in the lung
  alveoli and initiate
• recruitment of macrophages and lymphocytes,
• macrophages transform into epithelioid and
  Langerhans.
• Then aggregates with lymphocyte forms tuberculous
  granuloma
• ( primary lesion)
• The primary lesion/Ghons focus,
• Is pale yellow caseous nodule,
• Situated in the peripheral area of the lung,
• The same pathological reaction occurs to hilar
  LN.
• Combi of primary lesion regional LN form
  primary complex of ranke.

58
Pathogenesis cont

• Ghons complex
• Made up of primary TB lesion and the enlarged
  media sternal lymph node.
• i.e Tuberculous infection with an associated LN.
• Implantation of inhaled bacteria in lung (Ghons
  focus),
• followed by drainage of the bacilli to adjacent
  LN (usually hilar)
• Body ctrls this infection,
• and hence this focus almost always fibroses and
  eventually calcifies.
• Common in children
• they can retain bacteria and can be a source of
  infection later in life.

59
Pathogenesis cont

• Later calcification occurs
• Limit the spread of infection
• Become LATENT TB
• Risk of developing disease after primary inf is
  10
• Lymphatic and hematogenous spread can
• occur before established immunity.
• Affect other organs like liver and kidney

60
Investigations

• PTB
• Sputum/phlegm, (2 samples taken)
• For Ziehl-Neelsen /AF stain (AFB will stain
  bright red, and the background will stain blue)
• Gene- expert- PCR based rapid molecular assay
• Auramine stain (AFB visualized by fluorescence
  microscope will appear yellow or orange)
• Culture test
• Lowenstein- Jensen medium (mycobacterium
  tuberculosis appear brown)
• 8-14 days.
• Radiographic
• CXR
• CT scan
• Blood test i.e. interferon-gamma release assay/
  IGRA
• Other inv.
• WBC count
• ESR

61

• Pleural fluid analysis- ADAgt 40 IU/L Indicates
  lymphocytic pleural effusion
• Mantoux tuberculin skin test/ purified protein
  derivative
• Confirmatory diagnostic test
• For detection of latent TB
• For sputum smear ve cases
• It can have false ve for those who have received
  BCG
• Diagnosis based on the size of the wheal
• 0.1ml of tuberculin PPD injected at the forearm
• After 48-72hrs checked for induration
• gt10mm - ve

62

• Parenchymal findings of TB on CXR
• Consolidation/ area of opacity
• can have a lobar or segmental distribution ,
• Usually homogenous,
• mostly involves the upper zone and/or superior
  segments of the lower lobes.
• They later break down to form thick wall cavity
• that gt75 of the walls can be seen (as a ring).
• Infiltrates
• Tuberculomas ( small hyperdense nodules), it has
  the following
• Rounded outline
• Central caseous necrosis
• Epitheloid cells
• Lymphocytes, plasma cells and fibroblast

63

• Pleural findings of PTB
• Pleural effusion ( lemniscus, blurring of the
  costophrenic angle)
• LN findings
• Lymphadenopathy

64

• In CT scan
• Homogenous consolidation
• Fissures on the lobes
• Small cavities
• Tree in bud appearance
• Appearance of areas of centrilobular nodules with
  linear branching pattern

65

• Active PTB
• Consolidation/ cavitation
• Miliary mottling
• Lymphadenopathy
• Pleural effusion
• Healing/ healed
• Fibronodular scarring
• Traction bronchiectasis
• Calcified LN
• Lung volume loss
• Pleural thickening

66
Management

• Both pulmonary and extra pulmonary are Rx with
• Anti tuberculous agents for 6-12months
• 1st line streptomycin/S
• Isoniazid/H
• Rifampicin/ R
• Pyrazinamide/Z
• Ethambutol/E

67
STD regimen for TB Rx- STG 2017

• Rx for new cases is divided into 2 phases
• Initial / intensive phase
• RHZE for 2months
• Continuous phase
• RH for 4 months
• ReRx case is also divided into 2 phases
• Initial/ intensive phase
• SRHZE for 2 months then RHZE for 1 month
• Continuous phase
• RHE for 5 months

68
Prevention and control

• BCG vaccine
• Bacilli Calmette Guerin/1921
• Is a live attenuated vaccine derived from M.
  bovine
• Administered intradermally inj. 0.1ml
• Highly immunogenic
• Appear to prevent disseminated diseases
• In TZ, children are given soon after birth.
• Wearing of mask
• Improve ventilation
• Healthy life style

69
(No Transcript)