A Tuberculosis Patient History

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

1. Productive Cough

Additional Details: Sudden onset, Constant over time, staying the same.

2. Blood in Cough

Additional Details: Sudden onset, comes and goes, getting worse

3. Fever between 100.4 and 104𝇈F

Additional Details: Sudden onset, comes and goes, staying the same

4. 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

5. 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

6. 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 Symtoms

  • 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

Report

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.