Patient examination protocol

Student’s name__khan areeba 59d-________________________

Course, 5th
Patient's john
Age____38 years ______ Professional - Teacher __Weight____60 kg_____ High___171 cm
Complaints
_Patient has febrile temp,had a rapid pulse-120b/ perminute,RR-28 BREATH PER MINUTE

Anamnesis of
life__Patient have diagnosed w ith HIV infection three years ago,history of
smoking .He had been started on ART one year ago and had complaints _with his medication
Epidemiology anamnesis___________No Data
Anamnesis of disease___No allergy and other history of illness

Objective data___ fever-38.5celsius,Pulse rate-120bpm,RR 28breath per minute ,BP-130/90mm Hg,He

appeared pale and loss weight,
examination of chest revealed bilateral crepitation ,hepatomegaly found on abdominal examination
_

Plan of laboratory and instrumental

investigation_BLOOD AND URINE TEST,ETIOLOGICAL ANALYSIS,,
_ACCERLATED METHOF MTB DETECTION,SKIN METHOD,X-RAY, _CT-SCAN
General blood account
test_Hb-8.5g/dl,TLC-12000 cells/mm3, Lymphocytes -

80%,ESR-120mm/hr
Biochemical L analysys______________NO Data

Urine
analysys___Appearance: ClearL___
Color: Yellow
pH: 7.0
Specific Gravity: 1.0 15
Protein: Positive
Sputum analysis at registration or admission (numbers, date, results

XpertMTB/Rif____Mycobacterium tuberculosis complex: Detected ____

Resistance to Rifampin: Not detected
Acid-Fast Bacilli (AFB): Positive
Microscopy___

_Quantity: 3+ (numerous)
Culture of sputum (BACTEC, Levenstein-Jensen а Days to Positivity: 14 _
Mycobacterium tuberculosis complex:
Detected

X-ray The chest X-ray show s diffuse infiltrates and miliary nodules throughout both lungs which are consistent
with disseminated tuberculosis. The mediastinum appears

normal, and there is no evidence of pleural effusion.

Clinical diagnosis Patient have disseminated tuberculosis

Complications miliary TB, tuberculosis meningitis, bone and
bone and joint TB
Accompanying diseases
 TreatmentThe standard treatment regimen for disseminated TB includes four drugs
initially - isoniazid, rifampicin, pyrazinamide, and ethambutol - for the first two
months. This is followed by a continuation phase of two drugs - isoniazid and
rifampicin - for at least four months. The duration of treatment may vary
depending on the patient's response to treatment and other factors.
_