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A Tuberculosis Patient History

Dr. Sunitha Mathew Dr. Sunitha Mathew Jun 23, 2020 / 4 mins read

A 45 yr old female patient presented to the outpatient department following a six weeks history of productive cough and low-grade fever in the evenings. She noted several episodes of haemoptysis during this period and also experienced slight right-sided chest pain.

So let’s have a look at how this patient’s Arintra interview goes.

BASIC PROFILE
Age: 45yrs
Gender: Female
Height: 150 cm
Weight: 50 kg

VITALS
RR: 22bpm
Blood pressure: 120/80 mmHg
Temperature: 38𝇈C
Pulse: 80 bpm
SpO2: 98%
Hb: 11g/dl
RBS: 280 mg/dl

RISK FACTORS:
Do you have diabetes? - Yes
If yes, additional details: currently taking medication; for 5 years

Do you have hypertension? - Yes
If yes, additional details: currently taking medication; for 5 years

Any other history (to be selected from the list) - Loss of appetite
Additional Details: going on for 4 weeks

CHIEF COMPLAINTS Productive Cough
Additional Details: Sudden onset, Constant over time, staying the same.

Blood in Cough
Additional Details: Sudden onset, comes and goes, getting worse

Fever between 100.4 and 104𝇈F
Additional Details: Sudden onset, comes and goes, staying the same

Cough, productive
How long has it been going on? - Going on for 1 month 14 days
Colour of sputum: green, yellow
Consistency: Thick
Does your cough affect your daily activities? - Severe and sudden coughing attacks
When do you experience cough - occurs in the morning
Do you have a family history of any of TB/asthma/other? - Nil

Haemoptysis
How long has it been going on? - Going on for 1 month
How often do you cough up blood? - occurs often
How much blood-stained mucus would you estimate it to be? - could fill a tablespoon
How does the blood you coughed out appear? - Blood mixed with mucus
When do you cough up blood more? - All-day
Do you experience any other symptoms while coughing out blood? - chest pain, sweating at night

Fever
How long has it been going on? - Going on for 14 days
Other symptoms experienced during fever - shivering, sweating too much, feeling tired
When do you usually get the fever? - night
Does your fever occur in a pattern? - occurs throughout the day with minimal change in temperature
What is your body temperature during fever? - mild fever less than 100.4F
Do you experience any of the following that caused your fever? - recent travel to visit son at Kolkata
Any history of recent surgery/cancer/organ transplant/hyperthyroidism/other? - No

LAB REPORTS
All reports that have been gathered will be entered here Haemoglobin : 11g/dl
WBC Count : 17,000 cells/cumm
Platelets : 9,00,000 platelets/microlitre
Lymphocyte : 55%
Neutrophil : 70%

REVIEW OF SYSTEMS
Swollen glands Tiredness

MEDICATION HISTORY
Tab. Metformin P/O 500mg BiD (taking regularly for 5 years)
Tab. Olmesartan Medoxomil P/O 40mg OD (taking regularly for 5 years)

OCCUPATION HISTORY
Housewife


This patient history provides us with an example of what an initial presentation of pulmonary TB looks like.

Her risk factors flag diabetes which could be compromising her immune system.

She presents with the typical symptoms of a TB patient: a cough that lasts for more than three weeks, haemoptysis, and chest pain. Other symptoms like tiredness, loss of appetite, fever, chills, and night sweats were also mentioned by the patient.

While collecting additional details about her fever, she was provided with a few possible causes. She reminisces her recent travel to Kolkata at her son’s place and reveals it to her doctor.

Increased WBC count with lymphocyte predominance denotes an infection.

Finally, during the review of systems, she identifies two other symptoms which she hadn’t mentioned before - enlarged lymph nodes and tiredness.

These bits of her history serve as clues to her provisional diagnosis of TB. Further confirmation can be made by performing diagnostic tests like the tuberculin skin test, sputum smear test and chest radiograph.