CASE 2:
A 60 year old male presents to the emergency room with a two
month history of a 20 lb. weight loss, loss of appetite, low grade fever and night sweats.
The patient has a chronic cough that is productive of yellow, blood-tinged sputum. The
patient denies shaking chills, or chest pain. PMHx: Alcoholic liver disease, hospitalized 1 year ago with alcoholic
hepatitis and alcohol withdrawal. (+)PPD (tuberculin skin test) one year ago not treated with prophylactic isoniazid because of the presence of hepatitis.
Chronic obstructive pulmonary disease
Meds: Albuterol and ipratropium inhaler
Social: Drinks 6-12 beers / day, lives at the YMCA, has been homeless
and lived in a shelter two years ago.
Physical examination: Wasted malnourished patient, T: 37.5° C orally, HR 80, R 20, BP 110/60. Nodes: none. Chest: increased AP diameter Lungs: diminished breath sounds, rales in (R) upper lung field. CV: S,andS2NLnoS3/S./M. Abd: Scaphoid, liver span 13 cm firm, no spleen felt, no masses or ascites, nl bowel sounds. Ext: WNL. Neuro: WNL
Laboratory: CBC - Hgb 11.0 gms WBL 15,000/mm3, 60 P. 35 L, 5 M, platelets 250,000/mm3. BUN, Creatinine, Lytes-WNL Liver function - WNL CXR: cavitary lesion (R) upper lobe with surrounding infiltrate, flat diaphragms. Sputum: many acid fast bacilli on smear
QUESTIONS:
1. Create a problem list from the history. Answer
2. Identify and explain the significance of each pertinent physical finding. Answer
3.Review the lab data and explain the findings. Answer
4. What is diagnosis based on History, physical and lab data. Answer
5. Describe succinctly, the magnitude of problem this disease represents Answer6. Describe the offending organism, its morphological, cultural characteristics and their normal habitat. Answer
7. How do these organisms gain access to humans? Answer
8. How do they invade and spread in humans? What is the pathogenesis of M. tuberculosis infection in this patient? Is this a primary or reactivation infection? How might the patient have acquired the primary infection? Answer
9. What type of infection does this patient have? Answer
10. What defenses humans have against these organisms? Answer11. How do these organisms able to overcome human defenses? Answer
12. What is the end result of this battle between organisms and humans? Answer
13.How do you diagnose this infection? Answer
14. What will be your therapeutic strategy? . Propose a treatment regimen for this patient. Answer
15. How can you prevent it from spreading to others? Prevent its occurrence? How is this infection spread? How do you prevent the spread of this infection while the patient is hospitalized? Answer
16. What are other clinical infections with these organisms? Answer
17. What does a positive PPD mean? Answer
18. Does a positive sputum smear with acid fast organisms imply that the patient has a Mycobacterium tuberculosis infection? What information do you need to confirm the diagnosis? Answer
19. Name other mycobacteria sp. which are important in the pathogenesis of human disease. Answer