CLINICOSOCIAL CASE PRESENTATION

TUBERCULOSIS
A 50 years old male named Mr. Devaraj coming from Gundumedu presented to outpatient clinic in
Saveetha UHTC following a 1 month history of cough with expectoration and low grade fever in the
evenings. He also noted several episodes of haemoptysis within this time period and was
experiencing right sided chest pain. He is also known case of Type – 2 Diabetes Mellitus on regular
treatment for the past 15 years and a chronic smoker for the past 20 years and he used to smoke
about 10 cigarettes per day and now for the past 2 months he stopped smoking.

Mr Devaraj is a security guard in an apartment. He earns about Rs. 15, 000 per month. His wife is a
home maker. She has two daughters, the older daughter is 17 years and she is studying in Class 11
and her younger daughter is 10 years and she is studying in Class 5.

He consumes mixed diet; his bladder and bowel habits are normal. Yesterday he had 1 cup of tea
with 3 spoons of sugar in the morning at 6 am. At 8.30 am he had four idlis and sambar. For lunch,
he had a cup of rice, a cup of rasam and a cup of spinach. In the evening he had a cup of tea with 3
spoons of sugar. At night he had a cup of upma with chutney.

They live in a kutcha house with a two rooms. There is a window in each room. The house is
illuminated only with artificial source of light. They do not have a separate kitchen. They use LPG as
their cooking fuel. There are few cats in their house. Vegetables are kept in open baskets in the
kitchen. The disposal of kitchen water is indiscriminate. Breeding places for mosquitoes are
present. They throw their solid waste in an open bin provided by the corporation. The drinking
water supply is from a public tap which is placed in front of their house and the supply is for 2
hours in the morning every day. Water is stored in covered pots. They do not boil the water before
consuming it. They do not have a toilet at home and hence they practice open air defecation.

On examination he was found to have BP (120/80 mmHg); tachycardia (108 bpm); tachypnoeic (26
pm) and on auscultation decreased breath sounds with crepitations was audible on right side of the
chest. His chest X-ray showed cavitary lesions and infiltrates in his left upper lobe. Sputum sample
contained small amount of blood and numerous acid-fast bacilli.
DEMOGRAPHIC DETAILS:
NAME: MR.DEVARAJ

AGE: 50

GENDER:MALE

OCCUPATION: SECURITY GUARD

ADDRESS: GUNDUMEDU

PER CAPITA INCOME: RS 3750 (RS.15000/4 MEMBERS)

CHIEF COMPLAINTS:
PATIENT PRESENTS WITH COMPLAINTS OF COUGH WITH EXPECTORATION AND LOW GRADE
FEVER FOR THE PAST MONTH, ASSOCIATED WITH EPISODES OF HAEMOPTYSIS AND RIGHT
SIDED CHEST PAIN.

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY NORMAL 1 MONTH AGO AFTER WHICH HE DEVELOPED COUGH
WITH EXPECTORATION AND LOW GRADE FEVER ASSOCIATED WITH EPISODES OF HAEMOPTYSIS
AND RIGHT SIDED CHEST PAIN.

>FEVER PROGRESSED THROUGH THE DAY AND PRESENTED AS AN EVENING RISE IN

TEMPERATURE.

>COUGH WITH EXPECTORATION – COPIOUS IN AMOUNT, MUCOID CONSISTENCY, BLOOD

STAINED SPUTUM

>CHEST PAIN WAS A RIGHT SIDED SHARP TYPE OF PAIN WHICH WAS INSIDIOUS IN ONSET AND
INTERMITTENT IN NATURE AGGREVATED BY EXERTION AND PHYSICAL ACTIVITIES WITHOUT
RELIEVING FACTORS

HEMOPTYSIS - FRANK BLOOD

NO H/O NIGHT SWEATS

NO H/O LOSS OF WEIGHT

NO H/O LOSS OF APPETITE

NO H/O BREATHLESSNESS

NO H/O WHEE ZING

NO H/O CARDIAC SYMPTOMS

NO H/O RENAL SYMPTOMS

NO H/O ABDOMINAL SYMPTOMS

NO H/O RIGHT HYPOCHONDRIAC PAIN

PAST HISTORY:

PATIENT IS A KNOWN CASE OF TYPE 2 DIABETES MELLITUS ON REGULAR TREATMENT FOR THE
PAST 15 YEARS

NO H/O CONTACT WITH OPEN CASE OF TB

NO H/O SIMILAR COMPLAINTS IN THE PAST

NO H/O TREATMENT FOR TB IN THE PAST

NO H/O EXANTHEMOUS FEVER

NO H/O RECURRENT LOWER RESPIRATORY TRACT INFECTION

NO H/O HYPERTENSION / ASTHMA / EPILEPSY

TREATMENT HISTORY:
PATIENT HAS BEEN RECEIVING TREATMENT FOR DM FOR THE PAST 15 YRS

NO TREATMENT FOR COUGH OR FEVER, NO H/O TB IN THE PAST

FAMILY HISTORY:
NUCLEAR FAMILY,4 MEMBERS

NO H/O SIMILAR COMPLAINTS IN FAMILY MEMBERS

NO H/O CONTACT WITH OPEN TB CASE

Name Age Relationshi Education Occupation Income Health

p status

Devaraj 50 Head Middle Security 15,000 TYPE 2 DM

school gaurd

Mrs devaraj 60 Wife Middle Home -

school maker

Aarti 17 Daughter High school Student -

Lata 10 Daughter Middle Student -

school

Per Capita income/ month = Total income of family/ Total no. of family members = 15000/4 = Rs
3750
 Socio economic status (According to modified Kuppuswamy scale), the family belongs to Upper
Lower class.

[Middle school – 3, Acc to ficci he is semiskilled – 3, Income – 2 (2018)]

CONTACT HISTORY

NO CONTACT WITH OPEN TB CASE IN THE PAST

OCCUPATIONAL HISTORY

HE WORKS AS A SECURITY GUARD IN AN APARTMENT

PERSONAL HISTORY:
HE CONSUMES MIXED DIET

H/O SMOKING : 200 PACK YEARS [FOR THE PAST 20 YEARS, 10 CIGARETTES PER DAY, STOPPED
SMOKING FOR THE PAST 2 MONTHS]

HAS NORMAL SLEEP PATTERN

HAS NORMAL BOWEL AND BLADDER HABITS

NO H/O ALCOHOLISM

NO H/O BETEL NUT CHEWING

NEARBY HEALTH FACILITIES: SMCH URBAN HEALTH CENTRE PRESENT NEARBY

IMMUNIZATION STATUS OF THE FAMILY MEMBERS - BCG VACCINATION

DIET HISTORY:

Name Morning Afternoon Evening Night Energy (K cal) Protein (Gms)

DEVARAJ 1 CUP TEA 1 CUP RICE + 1 CUP TEA 1 CUP UPMA 1199 22
WITH 3 1 CUP RASAM WITH 3 WITH
SPOONS + 1 CUP SPOONS CHUTNEY
SUGAR + SPINACH SUGAR
4XIDLI +
SAMBAR

Energy Requirement Energy intake Energy deficit

1.0 CU = 2,400 Kcal 1199 Kcal 1201 Kcal

Protein Requirement Protein intake Protein deficit

 1g/kg body wt = 70g 22 gms 48gms

ENVIRONMENTAL HISTORY:
INTERNAL ENVIRONMENTAL HISTORY:

TYPE OF HOUSE: KUTCHA

OVERCROWDING: ABSENT

TOILET: ABSENT, NON SANITARY - OPEN AIR DEFECATION

VENTILATION: NOT SATISFACTORY

LIGHTING: SATISFACTORY

KITCHEN: NOT SEPARATE, FUEL FOR COOKING: LPG, EXHAUST FOR SMOKE: NOT PRESENT

SOURCE OF DRINKING WATER: PUBLIC TAP, STORAGE:COVERED POTS, DISINFECTION METHOD:

NONE, THERE IS NO BOILING OF WATER BEFORE DRINKING

PRESENCE OF CATS

EXTERNAL ENVIRONMENT HISTORY:

WASTE DISPOSAL: OPEN BIN DISPOSAL

WASTE WATER DISPOSAL: INDISCRIMINATE

BREEDING PLACES FOR MOSQUITOS ARE PRESENT

GENERAL EXAMINATION:

The patient was conscious, oriented, well nourished, well built.

No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalised Lymphadenopathy, Pedal oedema.

Vitals:

Pulse rate: 108/minute (Tachycardia)

Respiratory rate: 26 cycles per minute (Tachypnoeic)

Blood Pressure: 120/80 mmHg

Height: 175cm

Weight: 70kgs

BMI = 24.1 (Weight/height in metre square) (normal)

SYSTEMIC EXAMINATION:

CVS- S1S2 heard, No murmur

RS- decreased breath sounds and crepitations on right side

Abdomen- No Scar, Sinus, Organomegaly, Free fluid

CNS- No focal neurological deficit, Reflexes Present

INVESTIGATIONS:

XRAY - cavitary lesions and infiltrates in left upper lobe

Sputum culture - blood and numerous acid fast bacilli detected

SUMMARY:

50 year old male Mr Devaraj working as a security guard in an apartment , came with chief
complaints of cough with expectoration and low grade fever in the evenings. He also had episodes
of haemoptysis and right sided chest pain. He is a known case of type 2 Diabetes Mellitus for 15
years for which he takes medication regularly. He belongs to upper lower class and nuclear type
family living in a kutcha house where there is no overcrowding, no toilet, no disinfection of drinking
water, no proper waste disposal and cats present. On investigation his BP is 120/80mmhg, BMI:
24.1, energy intake: 1199Kcal, energy deficit: 1201Kcal, Protein intake: 22gms , protein
deficit:48gms

PROVISIONAL DIAGNOSIS:

Tuberculosis

Q)Comment on the environmental risk factors

ENVIRONMENTAL RISK FACTORS –

 Overcrowding
 Inadequate ventilation
 Recirculation of air containing infectious droplets
 Poverty
 Poor sanitation
Q)Mention the management :

Investigations –

Sputum culture and sensitivity testing – acid fast bacilli detected .

X- ray chest - cavitary lesions and infiltrates in left upper lobe .

CBC including ESR , CRP

HIV – ELISA

Blood sugar testing – RBS , Oral glucose tolerance test.

Urine examination .

Treatment –

First line drugs –

 Bactericidal drugs – rifampicin , INH, streptomycin ,pyrazinamide

 Bacteriostatic drugs – ethambutol.

Second line drugs – includes ciprofloxacin , bedaquiline , amikacin , kanamycin , ethionamide ,

azithromycin , delamanid .

 Cessation of smoking
 Modification in diet -
Avoid intake of sugar, reduce fried oily foods , increase the intake of ragi , boiled green gram
sprouts , peanuts , spinach , palak and other green leafy vegetables , khichdi , bitter gourd
sabji , chicken and fish can be taken for protein , wheat dosa , snacks can include cucumber ,
chickpeas , ragi balls , moong dhal,
Intake of low glycemic index foods – chappati , barley, chickpeas , jowar

ADVICE :

Individual level (self care measures ) -

 Emphasis on regular medications to control diabetes and tuberculosis

 Maintain hygiene –
wash hands after coughing and sneezing .
Always cover the mouth with tissue when coughing or sneezing and seal the tissue in a
plastic bag and dispose it .
Avoid spitting in public places.
Wash hands before eating .
 Avoid crowded places .
 Avoid sweets and sugar intake .
 Spend only a short time in rooms that other family members use
Family level –

 Screening of family members .

 Drug and diet monitoring to avoid further complications .
  Ventilate the rooms .
 Don’t let visitors come to house except health care workers .
 BCG vaccination – provides protection against the complications of TB

Community level –

 Health education mainly for target risk groups.

 Knowledge about the mode of transmission , symptoms and complications of TB.
 Awareness about the health programmes – RNTCP, National strategic plan ,India ,The end
TB strategy
Levels of prevention –
Primary prevention - health education , awareness about the modes of transmission and associated
complications , BCG vaccination to prevent complications and progression of disease ,
Environmental controls include proper ventilation , reducing overcrowding of homes and places,
negative pressure patient isolation rooms , high efficiency particulate air filtration systems (HEPA).
Secondary prevention- screening of target risk groups , detection of latent TB infection by
tuberculosis skin test and its treatment, regular medications and diet should be followed .
Tertiary prevention- aims to prevent disability and complications and measures taken include –
specialized clinics in towns and cities , maintaining local and national registries for tb cases.

Health programs –
Revised national tuberculosis control program , 1993 – adopted the DOTS strategy .
The End TB strategy, 2016
National strategic plan,India, 2017
The Stop TB strategy, 2006