CASE PRESENTATION

A male patient of age 52 years was admitted in pulmonary

department on 25th September with the major complaints
of fever, cough with expectoration, weight loss, polyuria
& polydipsia

PATIENT DETAILS
NAME

Mr:XYZ

AGE

52 yrs

SEX

IP No:

201010380

Wt

59 Kg

Ht

56

BMI

21

Dept

Pulmonary

DOA

25.9.12

DOD

31.9.12

S - SUBJECTIVE
O - OBJECTIVE
A - ASSESSMENT
P - PLAN

PROBLEM LIST

PROBLEM LIST

Pulmonary Tuberculosis
Diabetes Mellitus

SOAP ANALYSIS FOR TB

SUBJECTIVE
REASON FOR ADMISSION

Weight loss since 1 month

SOCIAL HISTORY
Alcoholic : Y
Tobacco:Y

(65kg to 59 kg)

Smoker :Y

Allergies: Not known

Cough with expectoration x 3 wks

C/o Fever > 2 wks

Martial status: Married

Children-2

Hemoptysis x 2 wks

Chest pain x 1 wk

Cotton industry
Father: TB-3 Yrs

PAST MEDICAL HISTORY

K/C/O T2DM

PAST MEDICATION HISTORY

Inj. insulin 30/70 bd

OBJECTIVE
PHYSICAL EXAMINATION
General examination : P I C CL+E
Vital signs : Pulse rate:72/min
CVS

: S1S2 +VE

Chest : Not clear on auscultation

GIT : Soft
EXT :N
CNS :N

VITAL SIGNS

Days

Day1

Day2

Day3

Day4

Day5

Day6

Day7

Temp

101.5

100.5

100

99

98.5

98.5

98.5

BP

130/90

130/80

130/80

120/90

130/80

130/90

130/80

Pulse

72

72

72

72

72

72

72

BLOOD COUNT
Hb

13.5 gm/dl

TLC

6500 cells/cumm

ESR

20 mm/hr

Polymorph

74 %

Lymphocytes

34 %

Basophils

1%

Eosinophils

2%

Monocytes

2%

OTHER INVESTIGATIONS
Chest X-ray :Right lower lobe opacity
CT Scan of Thorax : Large consolidation with formation in right lower
lobe & upper lobe, Nodular lesion present
Sputum Examination: Presence of acid fast bacilli
Gram stain: Plenty of gram + ve cocci & occassionaly gram ve bacilli
Sputum Culture :
Organism isolated:
Staphylococcus species

SENSITIVE TO

RESISTANT TO

Amikacin

Cotrimoxazole

Cefuroxime

Netilmycin

Ceftriaxone

Ofloxacin

Clindamycin

ASSESSMENT
DIAGNOSIS

TUBERCULOSIS

ASSESSMENT
Etiology
Alcohol use
Heavy smoking
Diabetes mellitus
Family history : father
Malnutrition
Close contact with people infected with TB
Immunosuppressed patient
Indication for therapy
To control TB either by

Preventing the development of infectious forms

Reducing the period of infectivity of people with infectious disease

DRUGS PRESCRIBED
DRUGS

DAYS OF TREATMENT

S.No

DOSE
T.Name

G.Name

D1

D2

D3

D4

D5

D6

D7

T.Monto 3

INH,Rifampin,
Ethambutol

300+450 +800mg
1-0-0

T.Pyzina

Pyrazinamide

750 mg
1-01

Neb.Duolin

Ipratropium Br/
Levosalbutamol

20+100 mcg q4h

Inj.Oframax

Ceftriaxone

1gm bd

C.Yogut

Pre pro biotic

1-0-1

T.Dolo

Paracetamol

650 mg 1-1-1

Syp.Linctus
codeine

Codeine
phosphate

2tsp tds

C. Becosules

Multivitamin

1-0-0

ALTERNATIVE THERAPY

DRUGS

DOSE

Cyclosporin

250 mg od

PAS

200 mg od

Amikacin

500 mg od

Kanamycin

500 mg od

Capreomycin

1 g od

PLAN
Discharge Medications
DRUGS

DOSE

T. INH,Rifampin,Ethambutol

300+450+800 mg1-0- 0

T.Pyrazinamide

750 mg

C.Multivitamin

1-0-0

1-01

GOALS OF THERAPY
General goals
To cure patient
Restore QOL
Prevent relapse
Reduce transmission
Patient specific goals
Reduce fever, cough, chest pain, hemoptysis.
To maintain normal weight
Goals achieved
Temperature reduction
Symptoms relieved
Patients conditions improved

Monitoring parameter
THERAPEUTIC MONITORING & TOXICITY MONITORING
Chest radiography
Isolation of mycobacterium

Hepatitis
Rashes

CT scan of thorax
Hematological test
Tuberculin test
Thoracotomy
Interferon gamma release assay
DNA based testing

Constipation
Hyperuricemia

Points to physician

Points to patient

Discuss the condition &

treatment given

Cessation of smoking &

alcohol consumption

Assess adherence to
regimen

Rifampin-orange colouration

Check the LFT

Uric acid level

About disease
About drugs

LIFE STYLE MODIFICATION

Resume activity in life
Avoid alcohol & smoking
All fruit diets
Fresh air, breathing
Light exercises & yogas
Follow up
Review after 15 days

SOAP ANALYSIS FOR

DIABETES

SUBJECTIVE
Polyuria
Polypdipsia
Fatigue

OBJECTIVE
Blood sugar
mgs/dl

Day 1

Day 3

Day 5

Day 7

FBS

160

145

144

90

RBS

200

195

185

170

PPS

180

170

175

163

OBJECTIVE
RENAL FUNCTION TEST
Urea

25

Scr. Creatine

0.8
ELECTROLYTES (m.Eq/L)

Sodium
Potassium

135
4

Chloride

99

Bicarbonates

26

URINE EXAMINATION

URINE EXAMINATION

Colour

Pale yellow

Sugar

++ ve

Bile salts

-ve

WBC

Nil

Bile pigment

-ve

RBC

Nil

Albumin

++ ve

Casts

Nil

Pus cells

2-3

Epithelial cells

2-3

ASSESSMENT
Diagnosis: Diabetes
Etiology
Family history-mother (5yrs)
Indication for therapy
Normalize the blood glucose level
Symptoms to be controlled
Assessment of therapy
DRUGS

DOSE

DAYS

Inj. Insulin

30/70 1-0-1

D1- D7

T. Glimeperide

1mg od

D1- D7

PLAN
Discharge medications
Inj. Insulin
-30/70 units
T.Glimeperide - 1mg od
Goals of therapy
Eliminate symptoms
Prevent long term complications
Patient specific goals
To reduce fatigue, polyuria, polydipsia
Goals achieved
Blood glucose level reduced
Improvement in patient condition

Monitoring parameter

Therapeutic monitoring & Toxicity monitoring

Monitor RBS,PPS,FBS

Hypoglycemia

Glycosylated Hb

Diarrhea, nausea,vomiting

Protein & sugar in urine

Serum creatine & urea

 Points to physician

Life style modification

Carry Candy

Glimiperide + rifampin
Consult the current references
For normal values

Exercise
Foot care

Points to patient

Diet
Hygiene
Blood sugar monitoring
About disease
About drugs

Go for eye check up

Follow up
Review after 15 days-test

THANK YOU