Tuberculosis

Clinico-Social Case Study

Department of Community Medicine

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• Name : Mrs.X
• Age : 22 years
• Sex : Female
• Religion : Hindu
• Education : 10th Standard
• Occupation : Home maker
• Address : Shanthi Nagar, Nalgonda
• SES : Lower middle class (as per modified
Kuppuswamy’s socio economic status scale, 2016)

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 Chief complaints

• Cough of 3 weeks
• Shortness of breath of 3 weeks
• Chest pain of 3 weeks

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 History of presenting illness
• Patient was apparently normal till November
2016 when she developed cough of 3 weeks,
insidious in onset, progressive in nature,
continuously present associated with yellowish
mucoid copious sputum, not blood stained, not
foul smelling, aggravates on doing mild
household work, relieves on medication.
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• H/o SOB since 3 weeks on and off which is mild
and associated with walking/ house hold
activities (Grade II MMRC).
• H/o chest pain since 3 weeks of left sided and
aching type, aggravates after bouts of cough.
• H/o fever since 3 weeks of low grade
continuously present, relieves on medication.
• H/o weight loss present. 5
• K/c/o Hypothyroidism since 6 months on 50µg
of Thyroxin tablets.
• Patient’s HIV status is negative
• Not a k/c/o Bronchial Asthma/ DM/ HTN/
Epilepsy
• No H/o Surgeries/ previous hospitalizations
 History of past illness
• Patient had similar illness one and half year back
before her marriage, while she was working in a
cotton mill near by her house at Narayanapur,
Choutuppal Mandal, Nalgonda District.
• The symptom of cough started early followed by
fever, 4 days after starting of symptoms patient visited
a local RMP (Patient delay), she had treatment for
fever and cough from local RMP for 2-3 weeks.
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• Since the symptoms were persisting after
treatment from local RMP, Patient visited
Narayanpur PHC, Choutuppal mandal,
Nalgonda district where she was diagnosed of
Pulmonary tuberculosis by 2 sputum samples
(Diagnosis delay) and patient had been
initiated on Anti-Tuberculosis Treatment (ATT)
immediately.
 H/o past illness contd……
• Patient had taken treatment for 2 months
regularly from ANM (DOTS Provider)
• At the end of the 2 months of ATT treatment
(intensive phase) patient was advised to get
sputum tested by the ANM.
• Patient visited Choutuppal Community Health
Centre (CHC) and given a sputum sample.
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• The first follow up sputum result came out to
be negative and conveyed the report to ANM.
• Later neither the patient went to Primary
Health Centre (PHC) to get Continuation Phase
(CP) medication nor the ANM revisited the
patient for follow up.
 Social factors in discontinuation of
treatment
• Patient thought that she was cured of TB and so
• Patient has not visited PHC to get Continuation
Phase (CP) medication
• ANM who supposed to revisit the patient for
follow up did not turn up.
• Patient is not aware of duration of treatment for
Tuberculosis.
• Marriage proposals has started and patient
thought that it was social stigma to reveal her
status and she discontinued the treatment.
 H/o past illness contd……
• Patient was asymptomatic for one and half year after
she stopped the treatment then she developed cough
with expectoration, SOB and Chest pain.
• Patient consulted a private general physician initially,
who treated for 1 week and referred the patient to
District Tuberculosis Centre (DTC), in District Hospital
(DH) Nalgonda after seeing the Chest X-Ray.

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• Patient attended OPD of DTC, in District
hospital Nalgonda where advised for 2 sputum
samples (Spot & early morning), both came
out to be positive (1+).
• Patient was diagnosed as PTB (Treatment after
loss to follow up) and had been put on ATT
Category II regimen

[(2HRZES) 3+ (1HRZE) 3] + [5(HRE) 3].

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• Patient is on Intensive Phase (IP) of Category II Anti
Tuberculosis Therapy (ATT) regimen, consuming oral
medications and Streptomycin injection from
ANM/Local RMP 3 days per week.
• Sputum samples has been sent to Intermediate
Reference Laboratory (IRL) for Line Probe Assay
(LPA) for diagnosis of MDR-TB and the report came
out to be sensitive for both Isoniazid (H) and
Rifampicin(R)
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 Contact history
• Patient’s sister in-law who stays along with the
patient’s family (before her marriage) was
diagnosed of PTB 2 years back and had ATT
treatment (Treatment completed) (H/o
Contact present)
• Patient’s paternal uncle was diagnosed PTB
10 years back and had ATT treatment
(Treatment completed). He visits the family
once in a while.
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 Personal history
• Pt. appetite is good , but could not be able to
take food after initiation of ATT treatment due
to nausea.
• Follows mixed diet
• Normal sleep pattern
• Bowel and bladder habits are regular
• Occasionally consumes Toddy
• Non-smoker
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 Menstrual history
• Attained menarche at the age of 14 years
• H/o regular periods since menarche for 3/30
days.
• But h/o irregular periods since 18 months –
2 months once for 3-5/30 days cycle.
• Nulli gravida

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 Immunization status
• No H/o Immunization
• Parents are not aware of Immunization

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 Diet History
(24 hour recall method)
S.NO Food item Quantity Calories (K.Cal) Protein (gms)
Morning 1. Rice 1 cup 170 6
9 AM 2. Beans Curry ¼ cup 80 2
3. Boiled Egg 1 90 6
4. Coffee 1 cup (100 ml) 110 2

Afternoon 1. Rice 1 cup 170 6

2PM 2. Beans Curry ¼ cup 80 2
3. Upma 1 cup 270 6
4. Curd 1 cup 100 3

Evening 1. Coffee 1 cup (100 ml) 110 2

6 PM
Night 1. Jowar Roti ½ roti 40 2
9 PM 2. Curd 1 cup 100 3
Total 1320 K.Cal 40 grams
Deficit 580 K.Cal 2 grams
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 Environmental history
• Cross ventilation is inadequate
• Open field disposal of solid wastes present
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Kitchen

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Sump Water Supply

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Psychosocial environment in the family
• The family is well adjusted with community but
the Community and the patient relatives does
not know that the patient is diagnosed of
Tuberculosis. The patient and her husband feels
it is a social stigma to disclose her condition to
others.
• There is psychological stress in the family, the
patient is depressed as she was diagnosed of TB
for the second time.
• Problems due to financial difficulty and debts
• Husband is the care giver to the patient
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 Personal hygiene
• Hair & Teeth – NAD
• Bath – once daily
• Clothes – tidy
• Uses foot wear
• Hand hygiene practices – uses soap before
eating food and after using toilet.

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 General physical examination
• Pt. is conscious, coherent and cooperative,
well oriented to time, place & person
• Thin built and ill nourished
• Height – 145 cms.
• Weight – 42 kgs.
• BMI – 19.97 kg/m2 (Normal range)
• No Pallor, no icterus, no cyanosis, no clubbing,
no lymphadenopathy, no edema
• Skin – NAD
• JVP – not raised 32
 Vital signs
• Temperature: afebrile
• Pulse rate: 98/min regular, normal in rhythm
and character, no radio-radial delay, no radio-
femoral delay, all peripheral pulses felt.
• Respiratory rate: 20/min regular thoraco-
abdominal
• Blood pressure: 110/70 mmHg right upper
limb in sitting position.

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 Systemic examination
Respiratory system:
• Inspection:
• Trachea appears to be in midline.
• Chest bilaterally symmetrical
• Apical impulse in the midline 5th Inter coastal
space
• No scars, no sinuses

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Palpation:
• Tracheal position is in the midline
• Chest expansion is 2cms
• Apex beat is in the midline 5th Inter coastal
space.
Percussion: a dull note is heard at left
subclavicular region.
Auscultation :
• Bilateral air entry present
• Normal vesicular breath sounds heard
• Crepitations present left subclavicular area
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Cardiovascular system:
• S1 & S2 heard, No murmurs
Abdominal examination:
• Soft, No organomegaly, Bowel sounds heard
Central Nervous system examination:
• No focal neurological deficit

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 KAP REGARDING HEALTH AND DISEASE

Knowledge:
• Patient is not aware about cause, mode of
transmission and prevention of Tuberculosis.
• Patient believes that she acquired the
Tuberculosis disease due to someone had done
witchcraft on her and dust exposure and not able
to eat properly for 5 months due to having a
teeth clip.

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Attitude:
• Couple believes offering animal sacrifices to the
God cures the disease.
• Patient is willing to follow the same system of
medication for treatment and willing to consult the
doctor at regular intervals and follow his/her advice.
Practice:
• Patient spits sputum in open washing area and in
the surroundings of the house
• Patient is following Allopathic system for treatment
and consulting doctor at DTC at regular intervals
and taking her medications regularly
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 Final Clinical Diagnosis
• A 22 year old female with left upper lobe
fibro-cavitary lesion due to Pulmonary
Tuberculosis on Anti-Tuberculosis Therapy,
Category II regimen of RNTCP with no drug
resistance.
 Social Diagnosis
• Female patient of 22 years from rural background
migrated to urban area belonging to Lower middle
class according to Modified Kuppuswamy socio-
economic scale 2016, adequately nourished, non
compliant to treatment of Tuberculosis due to relief
of symptoms & marriage proposal, improper disposal
of sputum, ignorance about cough etiquette, belief in
witch craft and worked at Cotton based industry.
 Levels of prevention failed
Levels of prevention Level Reasons for failure
failed

Health Promotion Failed 1. Lack of awareness

2. Misconceptions
Primary
Specific protection Failed 1. Absent BCG vaccination

1. Patient delay
2. Diagnosis delay
Secondary Early diagnosis &
treatment Failed 3. Belief in visiting RMP
4. Non compliance of the
patient

Disability limitation Failed

Tertiary
Rehabilitation ---
Advice:
1. To the patient:
• Adherence to ATT medications by DOT i.e., thrice
weekly (Monday, Wednesday and friday) 4 tablets
and Streptomycin injections I.M. till first two
months followed by 4 tablets thrice weekly for
one month, followed by 3 tablets thrice weekly
for next 5 months.
• Complete the course of treatment within 8
months.
• Cough out sputum in a newspaper/tissue and
burn the paper or deep burial of the paper.
• Regular visit to the nearest DMC / DOTS
centres for follow up check up, monitoring
weight, and collect follow up medications.

• At the end of 3rd and 8th month of treatment

the sputum to be given for testing at the
nearest DMC/DOTS centre.

• Regular counseling from the DOTS

provider/health worker to adhere to
treatment.
• 6 frequent meals are advised.
• Personal hygiene to be improved,
• Contraceptive measures to prevent pregnancy
can be followed till 2nd month of ATT
treatment.
Advice:
2. To the family on the whole:
• Regular counseling and motivation for the
family members in each visit by the trained
health worker.

• Support of the family to the patient -

accompanying to the health centre,
reminding about medicines, giving meals .

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• Contact tracing i.e., children below 6 years in
contact with the case in the family has to be
identified and Isoniazid Prophylaxis therapy
(IPT) has to be initiated by Senior Treatment
Supervisor (STS) at the earliest.

• Family members in the house has to be

subjected to screening for TB.
Advice:
3. To the community at large
• Conducting effective awareness programs
and campaigns regarding TB with the help of
IEC materials by STS and other trained field
staff.

• Cough >2 weeks should be suspected of

Pulmonary TB, can be diagnosed by sputum
examination.

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• The diagnosis & treatment is free of cost
available at the nearest DOTS centre.
• TB is a curable and preventable disease
• There is effective programme (RNTCP).
• Notification of cases by the private sectors
Thank you