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Chief Complaint I have this constant cough thats getting worse, and I have no energy History of Present Illness (HPI) Big Boy (BB) is a 50 year-old man who presents to the Medicine Clinic complaining of a 1-month history of a persistent cough that has become productive over the past 2 weeks. He also complains of malaise, fever, night sweats, and a 9.1 kg weight loss over the past 2 months. Past Medical History (PMH) Seizure disorder since age 10 HTN-5 years Family History (FH) His mother and father died in an MVA 10 years ago; one brother, age 37, is HIV (+) and lives with the patient; one sister, age 47, is alive and has no known medical problems.

Social History (SH) Patient is single, no children. He worked as an aide in a local nursing home but was laid off 6 weeks ago when the home was purchased by a regional chain. He denies smoking or IV drug use. He had a 20-year history of alcohol abuse, but has been sober for 10 years. His brothers HIV infection, attributed to IV drug abuse, is in the early stages with a CD4 count of 280 and a low viral load. Medications (Meds) Phenytoin 300 mg p.o. QHS Hydrochlorothiazide 25 mg p.o. QD Patient reports that he tries to be compliant with his therapies and takes them regularly except when he is unable to get his refills; over the past 2 months, he has gone 3 or 4 days without medication.

Allergies (All) Not known drug allergies (NKDA) Review of Systems (ROS)

Unremarkable except for complaints of recurrent headaches and intermittent abdominal pain; No seizures for 8 months Physical Examination (PE) General appearance (Gen) Thin, emaciated African American man who appears older than stated age; Appears fatigued, but otherwise in no acute (or apparent) distress (NAD); Vital signs (VS) BP 138/88; P 84; RR 16; Temp 38,3oC; Wt 51 kg Chest Diffuse rhonchi in upper lobes, decreased breath sounds on left, with pleural rub. Skin Cool to touch; multiple bruises on extremities; moles on trunk. Cardiovascular (CV) RRR; no m/r/g Labs AST 72 IU/L

ALT 56 IU/L Etc. Other Consent for HIV testing obtained

Chest X-Ray Profound bilateral upper lobe infiltrates with questionable cavitation on left, bases spared; small left pneumothorax with effusion. CT Chest Small posterior peritracheal and hilar nodes; left pleural thickening and small pneumothorax; Cavity (3-4 cm) in left posterior segment, no air fluid level.

Clinical Course The patient was admitted and placed on respiratory isolation. Three separate sputum Gram stain specimens were reported to contain 3+ AFB. An intermediate-strength PPD tuberculin skin test (Mantoux method) was placed. Candida and mumps were used as controls. Sputum samples were sent for AFB, fungi, and bacteria. After 48 hrs, the PPD skin test was read as a 12-mm area of induration.

Assessment Active pulmonary tuberculosis

Problem Identification 1. a. Create a list of the patients drug-related problems. b. Which signs, symptoms, and other findings are consistent with active TB infection? c. What factors place this patient at increased risk for acquiring TB?

Desired Outcome 2. What are the goals of therapy for this patient with active TB?

Therapeutic Alternatives 3. a. What non-drug therapies might be useful in this patient?

b. What drug therapies are available for the treatment of active TB? c. What economic and social considerations are applicable to this patient?

Optimal Plan 4. a. What drug, dosage form, dose, schedule, and duration of therapy are best for this patient? b. What alternatives to daily administration of medicines exist? Outcome Evaluation 5. Which clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

Patient Counseling 6. What information should be provided to the patient to

enhance compliance, ensure successful therapy, and minimize adverse effects?

Clinical Course The patient is treated with the regimen you recommended under respiratory isolation in the hospital. The results of his HIV test were negative. After 10 days, his presenting symptoms have improved, and three consecutive sputum specimens have been negative for AFB. Because he had three negative smears, he was removed from respiratory isolation and subsequently discharged to home. After 6 weeks, the results of these initial cultures are available. Mycobacterium tuberculosis is present, and the sensitivity report indicates INH-resistant organisms. The organism is sensitive to all other agents.

Follow-Up Question 1. How should the presence of INH resistance influence the drug therapy? 2. After 3 months of therapy, an increase in the patients AST and ALT are noted (AST 160 IU/L; ALT 190 IU/L). Other liver enzymes and total bilirubin are normal. The patient

reports no new complaints. What changes would you make to the current therapy and monitoring plan? 3. What potential drug interactions should be evaluated? How should they be managed? 4. How should other close contacts of the patient, including the brother, be evaluated and treated (considering that the patient has INH-resistant organisms)?

Clinical Pearl All patients receiving treatment for active TB should be considered for directly observed therapy (DOT). With adequate drug therapy for TB, nearly all patients with drug-susceptible organisms will become bacteriologically negative, recover, and remain well. For people who are candidates for serial tuberculin skin test (e.g. health care workers) an initial two-step test should be considered. With this strategy, an initial negative skin test is repeated in 2 weeks to prevent confusion in interpreting results in subsequent years.

For HIV-positive patients, rifabutin can be substituted for rifampicin to reduce the potential for drug interactions.