Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.

Subjective

Questions: Have you taken a Tuberculosis test? Have any family members been ill recently? or diagnosed with TB? How many people live in your household? Where did you move from? Do you have a dry or productive cough? Do you smoke? Have you had a change in your appetite? Weight loss?

History of present illness: 29-year-old female immigrant has been having weakness, shortness of breath, cough and night sweats for the past month.

Past medical history: hx of any conditions? Diabetes? HIV? Asthma?

Family history: hx of TB?

Allergies: n/a

Medication: ask about any medications

Social history: does the patient smoke? lifestyle? high-risk behaviors? What do you do for a living? Where has the patient resided for the past few years? Country of origin?

Objective

Vitals: Temp 100.9 F, HR 98, RR 24, BP 140/84, Pulse Ox: 96%

Observe for anorexia, fatigue, anemia, weight loss, fevers, night sweats, productive cough, and dyspnea, (Jarvis, 2015).

Perform focused assessment: Skin: pale, cold. HEENT: Eyes: pale conjunctiva related to low RBC, Nose: nasal discharge, inflammation, Throat: tender lymph nodes, Chest: labored breathing, chest symmetrical, no masses or abnormal findings, abnormal crackles or rales are audible in the posterior lungs.

Assessment

Thorough assessment and lab work should be done to rule out pneumonia or any other illnesses. Physical assessment and medical history should be obtained followed by isolation until test results confirm or deny the diagnosis. Usually, Tuberculosis presents with no symptoms but this patient is showing clinical signs and symptoms consistent with TB. The patient’s clinical and nutritional status should be assessed, as well as psychological, behavioral, and emotional well being to assess the capability of understanding and compliance with the treatment plan. Identify barriers before the treatment plan.

Diagnosis: Pulmonary Tuberculosis

Differential diagnosis: bacterial pneumonia, atypical pneumonia, bronchogenic carcinoma, sarcoidosis

Plan

The treatment plan for TB is specific for each patient. The plan is to order a sputum test for Acid Fast Bacilli, chest x-ray, Mantoux test, CBC, and an HIV test since most patients that have TB are at high risk for HIV. Cultures should be taken at monthly intervals until the culture connects to the negative. Upon a positive diagnosis, isolation is necessary.

The first line of treatment for Tuberculosis is treated using an intensive regimen for four months followed by a continuation phase, (Carr, 2022). Isoniazid, Rifampin, Moxifloxacin, and Pyrazinamide are initially started with interval testing to check clinical response. The patient needs to be educated about medication compliance and antibiotic resistance which is very common with TB. The patient should be encouraged to rest, avoid exertion, increase fluid intake, and monitor vitals. The patient should control the spread of infection by covering the mouth and nose, and understanding how TB is transmitted. The patient should be educated on eating a nutritious diet to promote healing, monitoring weight is important, and use of additional vitamin supplements. Follow-ups should include sputum cultures should be done at monthly intervals until two consecutive specimens are negative, (Carr, 2022). The patient should also be educated about the side effects of the medication, for example, Rifampin can cause urine to turn orange or reddish.

Reference:

Carr, W. (2022, February 24). Interim Guidance: 4-Month Rifapentine-Moxifloxacin Regimen . . . Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/71/wr/mm7108a1.ht…

Jarvis, C. (2015, March 18). Physical Examination & Health Assessment (7th ed.). Saunders.

Case 1: A 9-year-old female

presents with her mother complaining of a dry cough that “wakes up

everyone in the house” each night for the last two weeks.

Questions to ask:

• When did the symptoms start?
• During what time does the cough feel worse?
• Any allergies?

Subjective

The 9-year-old patient was accompanied by her mother presenting a complaint of a dry cough that “wakes up everyone in the house”.

Chief Complaint

The patient presented complaints of dry cough at night for the last two weeks.

History of present illness

The patient came in with her mother with complaints of dry cough for the last two weeks which she rated as 5 out of 10 in terms of severity. The mother explained that her daughter’s symptoms are worsened at nighttime when she is lying down flat. She also claimed that she can hear a squeaky sound upon exhaling.

Past medical history

Chronic illnesses: Eczema/ Respiratory Syncytial Virus (RSV) at 10 months

Hospitalizations/Surgeries: None

Allergies: No known allergies

Social history: Patient is currently attending elementary school

Family history: She lives with her parents and has one older brother.

Medications: None

Immunization: Immunizations are up-to-date.

Objective

V/S: BP 100/60mmHg, HR 70 bpm, SpO2 98%

Upon the initial assessment, the patient is alert and oriented and appears as her stated age. She has dressed appropriately for the occasion and is well-groomed. Her lungs are clear to auscultation and breath sounds are equal. Symmetrical chest wall expansion as well. Positive bowel sounds in all quadrants. The patient has warm, dry, and pink skin. No rashes or itching present.

Labs/diagnostic studies: chest x-ray, CBC with differential, spirometry

Assessment

Working diagnosis: New onset asthma

Asthma is a chronic inflammatory airway condition characterized by recurring occurrences of airflow restriction caused by edema, bronchospasm, and increased mucus production (Lizzo & Cortes, 2021). Moreover, to diagnose asthma, various indicators should be present including recurrent episodes of cough, wheezing, difficulty breathing, or chest tightness, symptoms that occur at night or disrupt sleep, as well as other symptoms that appear to be triggered by exposure to animals, dust, stress, etc.

Differential diagnosis: allergic rhinitis, hay fever, sinusitis, cystic fibrosis

Plan

2.5 – 5 mg of nebulized albuterol will be given as initial management for her asthma and can be re-dosed every 20 minutes. However, since the patient is already 9 years old, 5 mg is the recommended dose. Patient education (in this case, including her parent) will include instructions on how to store the medication properly and teach some points to breathe out fully before taking the medication as well as remind her to wait one minute before the second puff.

Follow-up: The patient will be scheduled to return in 2-4 weeks for a follow-up check-up. Patient is also advised to seek emergency care if symptoms worsen.

Reference:

Lizzo, J. M., & Cortes, S. (2021). Pediatric asthma. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551631/