Internal medicine clerkship case presentation on
RVI, Pulmpnary TB and Pyrogenic meningitis
By : Shikur Yasin HSR/0031/11
Submitted to: Mr. Teshale (assist. Professor )
Tikur Anbessa

Contents
 Patient demographics
 patient history
 physical examination
 labolatory finding
 diagnostic imaging
 working diagnosis
 current medication
 progression
 pharmaceutical care
 reference
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Patient demographics
 Name : M.K
 age: 59 years old
 sex: F
 ward: B-8
 card No: 224794
 bed No: 806/3
 Date of admission:
08/02/2023
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History
 CC:
 Presented with fever and
headache for 3 days.
 HPI:
 Presented with 3day history of
globalized throbbing type headache ,
fever, and neck stiffness.
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PMH
 Known RVI patient for the past 2 month and a week and she
is on HAART(1J) but unknown CD4 count and viral lode
status.
 She had also diagnosed with pulmonary TB before 2 month
ago and on anti TB(RHZE).
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Family history:
 there was no family member with TB
case.
SH,FH
Social history
 She is a merchant and lives with
her family
 She has no history of smoking and
dinking much.
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Medication History
 POM:
 HAART(1J) 1 tab po/day
 RHZE, 4 tabs po/day
 pyridoxine 25 mg po/day
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Cont.d
 OTC: paracetamol 1g PRN
 CAM (complementary alternative medicine): no known CAM
taken.
 Allergies and ADRs: she had no known allergy and no ADR
has been reported until this time.
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Physical examination
 GA: well looking
 HEENT: pc, NIS
 Neck and lymph node: Nucheal rigidity, no palpable LAP
 CVS: s1and s2 weal heard , no gallop and murmur sound.
 R/S :Bilateral few creptation on the back 1/3 rd of posterior chest.
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Cont.d
 ABD: flat, moves with respiration, No signs of palpable
organomegally.
 GUS: no CVAT
 MSS: Grade one bilateral pitting edema.
 CNS: COTPP
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vital signs
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signs At
admission
08/02/2023
10/02/2023 13/02/2023 14/02/2023 23/05/15 24/05/15
BP 127/63 112/99 107/61 122/68 148/90 130/82
PR 94 100 103 104 111 112
RR 26 24 22 20 21 24
Temp 37.8 37.4 ....... 36.7 ........ 36.5
SPO2
ON INO2
%
88 92 ……….. …… 90 off o2 99 off o2

pertinent laboratory finding
test 01/02/2023 07/02/2023 10/02/2023 COMMENT range unit
WBC 6.0 5.08
5.2
4.8 - 9.07 10^3/uL
RBC 3.55 3.37 2.8 L 4.63 - 6.08 10^6/uL
HGB 10.1 10.2 8.4 L 13.7 - 17.5 g/dL
HCT 31.7 29.8 25.2 L 40.1 - 51.0 %
MCV 89.3 88.4 90.0 79.0 - 92.2 fL
MCH 28.5 30.3 30.0 25.7 - 32.2 pg
MCHC 31.9 34.2 33.3 32.3 - 36.5 g/dL
PLT 143 136 120 L 163.0 - 337.0 10^3/uL
NEUT 81.8 86.2 80.2 H 34.0 - 67.9 %
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Cont.d
tests 01/02/23 07/02/23 10/02/23 commen
t
range unit
MONO 3.7 5.4 5.3 - 12.2 %
EOS 0.2 1.3 0.8 - 7.0 %
Baso 0.8 0.8 0.2 - 1.2 %
LYMPH 8.1 9.1 12.3 low 21.8 - 53.1 %
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Cont..
RFT (12/02/2023)
Cr = 0.49 (0.51 - 0.95 )
ESR = 100(0-20)
LDH=475.0 (240.0 - 480.0 Iu/l )
HBSAG =negetive
HCV = negetive
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Serum electrolyte
tests 01/02/23 07/02/23 12/02/23 comment Range unit
Na+ 126 129.3 128.0 L 136.0 - 145.0 mmol/l
K+ 3.5 2.44 2.42 L 3.5 - 5.1 mmol/l
Cl - 92 88.7 93.5 L 98.0 - 107.0 mmol/l
ca - 6.93 -
Organ function tests
AST 51.3 78.7 49.1 H 0.0 - 32.0 Iu/l
ALT Iu/l
ALP 116 140 101 H 35.0 - 104.0 Iu/l
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Urine analysis (10/02/2023)
 PH- 7.5 (5-8)
 Sg- 1.01(1.0 - 1.02 )
 Blood- no
 Protein – Trace
 Ketone-negative
 Glucose-negative
 WBC – 1-4/ HPF (3.6 - 10.2/ HPF)
 RBC – 1-4 / HPF ( 4.06 - 5.63 / HPF )
 Bacteria- many
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Diagnostic imaging
ABDOMINALULTRASOUND
 Hepatomegaly + borderline Splenomegaly
Multiple well defined hypoechoic splenic nodular lesions ddx Lymphoma ,
Disseminated TB
Multiple intra and retroperitoneal lymphadenopathy (Periportal, paraaortic,
paracaval) -
 Bilateral mildly increased renal echogenicity + right upper pole simple
renal cortical cyst
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Current diagnosis
 P1: RVI (stage IV)
 P2:Pulmonary TB
 p3: Phyrogenic meningitis( R/O TB meningitis)
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Current drug therapy during hospitalization
 For RVI: (started before 2 month
and a week)
 1J 1 tab po/day
 For P.TB (started before 2 month )
 RHZE 4 tabs po/day
 Pyridoxine 25 mg po /day
 For Pyrogenic meningities: (16 th day)
 Vancomycin 1g 1V BID (discontinued in 15th day)
 ceftriaxone 2g IV BID (discontinued in 15th day)
 Ampiciline 2g IV QID
 For depresion : (3rd day) Floxetine 20 mg /day
 For pain and headache: (16 th day) Tramadol 50
mg IV PRN and PCM 1gm po PRN respectively
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Patient progression
 The patient have good progression in symptoms.
 The fever were relieved.
 Neck stiffness and signs of infection were subsiding.
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Pharmaceutical care
 Subjective data: night mare and delusion .
 Objective data: k+ = 2.42,cl- = 93.5 Na+ =128
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Assessment
Drug related
need
Indication DTP Comment Plan
Indication Hypokalemia Needs additional
drug therapy
Since the patient
is severe
hypokalemic she
needs kcl
Initiate KCL
Indication Opportunistic
infection
Needs additional
drug therapy
Since she is
stage Iv RVI
patient she needs
cotrimoxazole for
prevention of
opportunistic
infections like
PCP, and
Toxoplasma gondi
Initiate
cotrimoxazole
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Pharmacy Assessment
Drug related need Indication DTP Comment Plan
Effectiveness INH induced
peripheral
neuropathy
Dose too low The dose of
pyridoxine in this
scenario is 50mg
po/day
Make the dose of
pyridoxine 50 mg
po/day
Effectiveness RVI Dose too low Since Rifampcin is
liver enzyme
inducer it
increases The
metabolism of
DTG
Make the dose of
DTG 100 mg po
/day or 50 mg po
BID
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Therapeutic alternatives
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Desired therapeutic outcome
 Eradication of infection (meningities and PTB)
 Making viral lode undetectable < 50 copies/ml
 maintain normal serum electrolyte.
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pharmacotherapeutic plan
 Initiate KCL 40 ME IV TID
Iniciate Cotrimoxazole double strength (960 mg) 1 tab po/day
Make the dose of pyridoxine to 50 mg po/day
Make the dose of DTG 50 mg BID
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Parameters to evaluate the outcome
 Improvement in symptoms
 vital signs
 CBC especially WBC differentials.
 serum electrolyte
 CD4 count and viral lode status
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Patient education
 Adhere to PO medications( because there is series resistance issues
specialy for TB medications ).
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Communication and implementation of the
pharmacotherapeutic plan
 The plan has communicated and some of them has been
implemented and some are on progress.
 KCL 4o ME iv TID (accepted and implemented)
 DTG 100 mg po/day (acepted and implemented)
 Cotrimoxazole 960 mg po/day (on progress)
 Pyridoxine 50 mg po/day (on progress)
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References
1. STG 2020:
2. Guidelines for clinical and programmatic management of TB ,
TB/HIV, DR-TP and leprosy in Ethiopia 2021
3. American clinical practice guidelines for treatment of drug susceptible
diseases 2016
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