I.

Overview of the case

TB is caused by a bacterium called Mycobacterium tuberculosis. TB bacteria are spread
from person to person through the air. The TB bacteria are put into the air when a
person with TB disease of the lungs or throat coughs, speaks, or sings. People nearby
may breathe in these bacteria and become infected.
People with TB disease of the lungs or throat can spread bacteria to others with whom
they spend time every day. However, children are less likely to spread TB bacteria to
others. This is because the forms of TB disease most commonly seen in children are
usually less infectious than the forms seen in adults.
If TB bacteria become active in the body and multiply, the person will get sick with TB
disease.
Persons with TB disease:

 Usually have a skin test or blood test indicating TB infection;

 Are sick from TB bacteria that are active (meaning that they are multiplying and
destroying tissue in their body);
 Usually have symptoms of TB disease; and
 Must be given medicine to treat TB disease.

Once infected with TB bacteria, children are more likely to get sick with TB disease and
to get sick more quickly than adults.
Confirming the diagnosis of TB disease in children with a laboratory test can be
challenging. This is because:

 It is difficult to collect sputum specimens from infants and young children; and
 The laboratory tests used to find TB in sputum are less likely to have a positive
result in children; this is due to the fact that children are more likely to have TB
disease caused by a smaller number of bacteria (paucibacillary disease).

For these reasons, the diagnosis of TB disease in children is often made without
laboratory confirmation and instead based on combination of the following factors:

 Clinical signs and symptoms typically associated with TB disease,

 Positive tuberculin skin test (TST) or positive TB blood test (IGRA),
 Chest x-ray that has patterns typically associated with TB disease, and
 History of contact with a person with infectious TB disease.

Signs and symptoms of TB disease in children include:

 Cough;
 Feelings of sickness or weakness, lethargy, or reduced playfulness;
 Weight loss or failure to thrive;
 Fever; or
 Night sweats.

The most common form of TB disease occurs in the lungs, but TB disease can affect
other parts of the body as well. Symptoms of TB disease in other parts of the body
depend on the area affected. Infants, young children, and immunocompromised children
(e.g., children with HIV) are at the highest risk of developing the most severe forms of
TB such as TB meningitis or disseminated TB disease.
REQUIRED VIEWING
Students wishing to gain a better understanding of tuberculosis should take time
to watch this video

III. Instructions
1. Convene the team, choose a Team Leader and assign among members the specific
assignment as per components of case presentation discussed during the orientation.
2. Read the case scenario carefully and confine your responses within this case. Do not
assume any facts not present in the case scenario.
CASE SCENARIO:
CASE SCENARIO:
An 8 year old male named RB from Sta. Barbara, Baliwag, Bulacan consulted at
the OPD section of the BDH for the first time on January 31, 2022 due to anorexia. He
is the 2nd among the 4 children of Mr. X and was born on January 25,2014. Her mother
told the nurse" Halos wala syang gana sa pgakain kaya halos sobrang payat na nya".
Two years prior to consultation, Patient RB was diagnosed to have Primary
Complex since he has chronic cough, with positive result in PPD and Chest Xray. He
was treated with Rifampicin and PZA for two months and allegedly with good
compliance. During the contact investigation at that time, the grandfather who was
staying with them was also diagnosed with active PTB and treated with quadruple anti-
Koch's, however this was only taken for three (3) months. Since then, Patient RB
completed his treatment and was apparently improved with weight gain and good
appetite and sense of well being and has been asymptomatic.
Two months prior to consultation, Patient RB was noted to be anorexic, with
gradual weight loss but he does not manifested cough or fever. On the day of his
consultation, the result of repeat Chest Xray shows progression of infiltrates. At this
point, upon verification, the grandfather who still has chronic cough is not living with
them anymore but visits occasionally.

Hematology Result:

Blood Components Normal Value Results

Hemoglobin 110-165 g/l 127 g/l
Hematocrit 35-50 % 42 %
WBC count 3.5-10.0 x 10 g/l 5.0 x 10 g/l
Platelet count 150-390 x 10 g/l 200 x 10 g/l
Segmenters 43-76% 80%
Lymphocytes 17-48% 20%

Urinalysis Result

Urinalysis Components Normal Value Results

Appearance Yellow (light pale to dark amber) Yellow
Characteristic Clear Slightly turbid
urine pH 4.5-8 3.8
Specific Gravity 1.002-1.030 1.015
WBC 0-2/hpf 6-8/hpf
RBC 0-2/hpf 0-3/hpf
Epithelial Cells None few
Bacteria None few

Chest X-ray revealed : progressive fibronodular infiltrates at the lower lung and the inner
zone of the left lung
Upon interview, Patient RB was fully immunized as verbalized by the mother. His usual
illness was cough, fever and colds and didn't have history of mumps nor chicken pox.
He has no allergies on foods and medication. RB is not a picky eater. Her mother
mentioned that RB's father is a chain smoker and can consumed about 6-7 packs of
cigarettes a day and was diagnosed to have prostate problem as well. Both side of the
family has incidence of high blood pressure and pulmonary tuberculosis. RB's blood
pressure was read as 100/70 mm Hg , his body temperature registered at 36.7 degrees
celsius per axilla, with pulse rate of 84 beats per minute and respiratory rate of 20
breaths/minute. No abnormal lung sound were heard , with equal chest expansion and
No rales or wheezes. RB's father is a36 year old factory worker while his mother is a 32
year old food server/waitress. Patient RB eats 3x a day an usually consumes only half
of cup of rice with usual viands as tinola, nilaga or sinigang and consumes about 4
glass of water only within the entire day. His urine is dark yellowish in color and urinates
approximately 3 times a day approximately 200 cc per urination. He defecates once
every other day with no difficulty and described the consistency as brown formed stool.
Patient RB takes a bath daily and changes clothes twice every day and brushes his
teeth once in the morning upon waking up and when he retires in the evening.
According to RB's mother, he usually sleep at around 11 in the evening after playing
Mobile Legend and doing his module in school and usually wakes up at around 9:00 in
the morning since his online class starts at 1:00 PM every Wednesday and Thursday
and the rest of the days, they are on asynchronous mode doing the module. Patient RB
is very close to his mother and able to share whatever matters that bother him just like
the other siblings since the mother make it to the point of asking their situation during
the day; usually during the dinner time since the mother is a waitress. When ask to
described their home environment, they live in a simple bungalow house made of wood
and cement with own kitchen, bathroom and living room. They have good water and
electric source in their area and the drainage and sewage systems are cleaned weekly
while their garbage is being collected weekly. Presence of mosquitoes, cockroaches
and mice around their house were mentioned in the interview. Their house is just 5-10
minutes tricycle ride away from school, Barangay hall, health center, market, hospital
and church.
When Patient RB was interviewed by Nurse Michael , he was in sitting position,
appears pale, wearing a clean shirt and pajama. He has a short hair, straight and black
in color. There were no scars, wounds, lesions noted and was free from nits, lice and
dandruff. The skull has round contour and was normocephalic with no masses or
tenderness upon palpation. He didn't have any mannerism, and not able to maintain eye
contact and seems to be shy during the interview, shown when he looks to his mother
when asked of questions, usually responds to question through nodding. His facial
expression is appropriate to his mood, with no involuntary muscle movements and facial
muscles can move freely and no pimples, whiteheads or blackheads noted. His face
was somewhat oval is shape, He has pinkish conjunctiva, with clear sclera and
transparent cornea. Pupillary size ranges from 3-7 mm, equal, round and reactive to
light and accommodation. RB's eyebrows are symmetrical, evenly distributed and in line
with each other. His upper eyelids cover the small portion of the iris, cornea and sclera
and meets completely with the lower eyelids when he closes her eyes. Pinna of RB
recoils when folded and has no tenderness, with bean shaped ears and were
symmetrical and the upper attachment is in line with the outer canthus of the eye as
noted by Nurse Michael. His lips were pink in color, moist upper and lower lips, no
wounds, lesion, cracking or inflammation as well as gums. The teeth of RB were slightly
yellowish in color, properly aligned but have several dental caries specifically on the
upper central incisor, lower lateral incisor , canine and lower first molar. There are
presence of submandibular lymph nodes, no jugular vein distention noted. Patient RB
was able to flex, extend and rotate his neck freely, the trachea was in midline and
thyroid gland is not palpable. The uvula is located midline of the soft palate, pink in color
and not inflamed and was able to stick her tongue out. Nurse Michael even noticed that
shoulders of Patient RB are symmetrical and in level with each other, can shrug his
shoulder and no use of sternocleidomastoid muscles when breathing as well as
intercoastal retractions. There was no tenderness felt upon palpation or lesions seen on
the nose however with presence of nasal discharge on both nares and not patent with
flaring noted on both nostrils. Both ears have cerumen along the auditory canal though
there is no problem noted on hearing. Range of motion was within normal limits except
for his right arm due to the IVF inserted, both extremities are symmetrical and equal in
length and in proportion to the body length, no scars, wounds, stiffness noted. Nails are
clean and cut, with capillary refill within 2 seconds and no clubbing of fingers. Patellar
reflex was present, no cracks on the surface of the soles of the feet with range of motion
within normal limits as well. Patient RB mentioned of slight pain felt upon urination. The
contour of the abdomen is flat, no tenderness felt upon palpation with normal bowel
sound heard about 10-12 bowel sounds per minute and there is no pain upon palpation
of quadrants of the abdomen.
At the end of the assessment and consultation with the attending physician, Dr. Robert
Mendoza. Patient RB was placed on a curative chemotherapy for 6 months; to
take HRZE for first 2 months and to take HR in the remaining 4 months
(H) Isoniazid with Pyridoxine HCL (200 mg/10 mg per 5 ml) to give 5
ml once a day P.O
(R) Rifampicin (200 mg/5 ml) to give 5 ml once a day P.O
(Z) Pyrazinamide (250mg/5 ml) to take 5 ml P.O. once a day
(E( Ethambutol (150 mg capsule) 1 cap once a day
And Bactrim (400mg/200mg) 5 ml BID for 7 days and then to repeat urinalysis after 7
days.
The mother was properly advised on nutrition, rest , compliance to treatment regimen
and other important measures to improve condition and was sent home with emphasis
on possible signs and symptoms to look for to bring back the child to the hospital.