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PULMONARY TUBERCULOSIS

A case Presented by
LEVEL III, BLOCK 3
The term tuberculosis was first used in 1839; it was derived from the Latin word
tubercula, meaning small lump, referring to the small scars seen in tissues of infected
individuals. TB reappeared in Europe and the United States in epidemic form during the 19th
century. In 1882 German physician Robert Koch discovered the bacteria that caused TB. Using
simple but precise observations and experiments, Koch demonstrated the presence of the bacteria
and how it was transmitted.

Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It
also may be transmitted to other parts of the body, including meninges , kidneys, bones and
lymph nodes. The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that
grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and
mycobacterium avium have rarely been associated with the development of a TB infection.

TB spreads from person to person by airborne transmission. An infected person release s


droplet nuclei through talking, coughing, sneezing, laughing. Most infections in humans result in
an asymptomatic, latent infection, and about one in ten latent infections eventually progresses to
active disease, which, if left untreated, kills more than 50% of its victims.

The primary cause of TB, Mycobacterium tuberculosis, is a small aerobic non-


motile bacillus. High lipid content of this pathogen accounts for many of its unique clinical
characteristics. It divides every 16 to 20 hours, an extremely slow rate compared with other
bacteria, which usually divide in less than an hour. Since M.
tuberculosis has a cell wall but lacks a phospholipid outer
membrane, it is classified as a Gram-positive bacterium.
However, if a Gram stain is performed, M. tuberculosis
either stains very weakly Gram-positive or does not retain
dye due to the high lipid & mycolic acid content of its cell
wall. M. tuberculosis can withstand weak disinfectants and
survive in a dry state for weeks. In nature, the bacterium
can grow only within the cells of a host organism, but M. tuberculosis can be cultured in vitro.

The signs and symptoms of pulmonary tuberculosis are insidious. Most patients have
low-grade fever, cough, night sweats, fatigue, and weight loss. The cough may be non-
productive, or mucopurulent sputum may be expectorated. Hemoptysis also may occur. Both
systematic and the pulmonary symptoms are chronic and may have been present for weeks to
months. Elderly patients usually present less pronounced symptoms than younger patients.
PATIENT’S PROFILE

Name: Patient A

Age: 80 years old

Gender: Male

Address: Prado, Umingan, Pangasinan

Birthday: February 8, 1931

Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: High School Graduate

Civil Status: Married

Date of Admission: July 29, 2010

Time of Admission: 8:30 AM

Chief Complaint: Difficulty of Breathing

PATIENT’S HISTORY

Patient A, is a 80 year old male, a Filipino citizen who resides in Prado, Umingan. His
religious affiliation in Roman Catholic and he was married once and their union produced four
children. He used to work abroad as construction worker. He used to work long extended hours,
about 10-12 hours, in order to have money to send back to the country. He usually sleeps for just
7 hours a day. He usually sleeps at 9 in the evening and rises up at 4 am to get his act together.
He usually have pandesal and coffee as his meal for breakfast. After eating his meals, he lits up
a cigarette every single time. Smoking was his vice ever since he was a teenager. He is
hospitalized for the nth time; and for the same reasons, for PTB. All of his children are married
and have completed their studies. His eldest child is the one who stands watch on him most of
the time. He has health insurance card, and is willing to undertake everything necessary for him
to get well.

13 AREAS OF ASSESSMENT

I. GENERAL SOCIAL STATUS

Patient A is an 80 year old male with four children and used to work as a construction worker
abroad. His family belongs to the middle class group.

II. MENTAL AND SOCIAL STATUS

Patient A is admitted to the hospital conscious and responds to verbal stimuli.

III. EMOTIONAL STATUS


Patient A is experiencing depression because of his illness.
IV. SENSORY STATUS
Patient A is wearing reading eyeglasses. He has poorer sense of taste.
V. MOTOR STATUS

Patient A can’t walk without assistance and is experiencing fatigue.

VI. NUTRITIONAL STATUS

Patient A has poor appetite and weight loss.

VII. ELIMINATION STATUS

Patient A has normal bowel movement and pattern.

VIII. FLUID AND ELECTROLYTE STATUS

Patient A is currently experiencing night sweats.

IX. CIRCULATORY STATUS

Patient A’s cardiac rate is 84 beats per minute and has a blood pressure of 120/70 mm Hg.

X. RESPIRATORY STATUS

Patient A has productive cough, dyspnea and crackles upon auscultation and changes in
respiratory rate and depth. His respiratory rate is 28breaths/min.

XI. TEMPERATURE STATUS

Patient A has fever with 38.2 ˚C

XII. INTEGUMENTARY STATUS

Patient A is experiencing clubbing of fingers and toes and enlarged or tender lymph nodes in
the neck.

XIII. COMFORT AND REST STATUS

Patient A is irritable and restless.

ANATOMY AND PHYSIOLOGY OF LUNGS

The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight
chamber with distensible walls. Ventilation requires movement of the walls of the thoracic cage
and of its floor, the diaphragm. The effect of these movements is alternately to increase and
decrease the capacity of the chest. When the capacity of the chest is increase, air enters through
the trachea (inspiration) because of the lowered pressure within and inflates the lungs. When the
chest wall and diaphragm return to
their previous positions (expiration),
the lungs recoil and force the air out
through the bronchi and trachea.

The lungs and wall are lined


with a serous membrane called
pleura. Each lung is divided into
lobes. The right lung has upper,
middle and lower lobes, whereas the
left lung consists of upper and lower
lobes.
There are several divisions of the bronchi within each lobe of the lung. First are the lobar
bronchi (three in the right lung and two in the left lung). Lobar bronchi divide into segmental
bronchi. Segmental bronchi then divide into subsegmental bronchi. The subsegmental bronchi
then branch into bronchioles, which have no cartilage in their walls. The bronchioles contain
submucosal glands which produce mucus that covers the inside lining of the airways. The bronci
and bronchioles are lined with cells that have surfaces covered with cilia. The bronchioles then
branch into terminal bronchioles, which do not have mucus glands and cilia. The respiratory
bronchioles then lead to alveolar ducts and alveolar sacs and then alveoli. Oxygen and carbon
dioxide exchange takes place in the alveoli.

PATHOPHYSIOLOGY

M. tuberculosis

Inhalation

Irritation of airway
Alveoli

Inflammation Occluded the Increased mucus


airway production

Phagocytes
(neutrophils and
macrophages) Cough Crackle
Engulf many of the s
bacteria
Hyperventilatio Airway
n constriction
GRANULOMAS TB-specific
Surrounded by lymphocytes destroy Increase work
macrophages the bacilli and normal in breathing DOB
tissue

Transformed to a
fibrous tissue Accumulation of
mass exudates in the alveoli Impaired O2 and
ulceration
CO2 exchange
Spread
GHON TUBERCLE of the
bronchi
Bronchopneumonia Ventilatory demands
Necrosis

Scar formation

Calcified and formed


a collagenous scar

Bacteria become dormant


Reactivate and reinfect
DIAGNOSTIC PROCEDURES

Diagnostic Procedure Findings


1. Chest X-Ray  Reveals lesions in the upper lobes

2. Mantoux skin test  6 mm wheel

3. Acid-fast bacillus smear  Contains M. tuberculosis

4. Sputum Culture  Contains M. tuberculosis

INTERPRETATION

In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the
upper lungs. However, lesions may appear anywhere in the lungs. A reaction of 5 mm or greater is
defined as positive in those persons with nodular or fibrotic changes on CXR consistent with old healed
TB. An acid-fast smear and sputum culture that contains M. tuberculosis is an indication for pulmonary
tuberculosis.

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