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Urgent Care Clinics


Patient Record

Healthcare Provider: Alexandra Barbera

History and Physical Examination

Patient Name: Patient A

Date: September 25, 2017

Referral Source: Self

Data Source: Patient

Chief Complaint: Prolonged bronchitis accompanied by night sweats

Introduction and Presenting Concerns:

The patient is a 40-year-old female. She worked for a large medical center about a year

ago and currently works for the hospitals home health agency in New York City in an

area with a large southeast Asia immigrant population. She has a family history of lung

cancer; her father died from it last year. She has been under intense prolonged stress

and grief with family and financial issues. In March 2017, she presented a cold which

developed into bronchitis. This persisted with sleepless nights and drenching night

sweats and in September 2017 a chest X-ray was preformed and showed cavitary lesions

in her right upper lobe.

Presenting concerns from the patient were that of lung cancer.


Clinical Findings:

An acid-fast stain was preformed on the patients sputum on September 25, 2017. Acid-

fast stains differentiate microbes with a waxy coat, such as the genus Mycobacterium,

from from those without a waxy coat (2). The sputum was heat fixed onto a slide and

carbolfushin was used to stain the slide for five minutes while heat was applied. The

slide was then rinsed with water, acid alcohol for two minutes, water again and then

counterstained with methylene blue stain for one to two minutes. The slide was rinsed

with water and allowed to air-dry before observation. The sample presented with large

numbers of pink bacilli cells and light blue cocci cells. The pink cells represent that of the

Mycobacterium species (2). The presence of Mycobacterium cells in the sputum of a

patient is abnormal (2). Mycobacterium cells were present. The Mycobacterium cells

seem to be responsible for the illness

Diagnostic Focus and Assessment:

The patient presented with signs and symptoms of tuberculosis, TB. The microbe most likely

responsible for the infection is that of Mycobacterium tuberculosis. Tuberculosis disease is

characterized by a bad cough that persists for three weeks or longer, chest pain, coughing up

blood or sputum, fatigue, weight loss, lack of appetite, chills, fevers, night sweats, and an

abnormal chest X-ray and positive sputum smear or culture (1). The patient presented with
many of these signs including a bad cough, night sweats, and both an abnormal chest X-ray and

a positive sputum smear.

People who are at high risk for tuberculosis are those who have been infected with

Mycobacterium tuberculosis and those with conditions that weaken the immune system (1).

One could become infected by people who have immigrated from areas of the world with high

tuberculosis rates, or by working with people who are at a high risk for tuberculosis such as in

hospitals, nursing homes, homeless shelters and correctional facilities (1). The patient worked

in a hospital and now works for the hospitals home health agency in an area with a high

population of southeast Asia immigrants. Southeast Asia is an area with a high prevalence of

TB. India and China are accountable for almost 40% of tuberculosis cases and the southeast

region accounts for 40% of tuberculosis cases worldwide (3). These immigrants then come into

the hospitals, where tuberculosis is already at a higher risk of infection, and could potentially

infect others. Patient A worked in the hospital about a year ago and now goes into the

community for home health. Not only was she potentially exposed to the microbe in the

immigrant rich hospital, she is going out into the community where the high probability

immigrants are and treating those who are sick. In addition to her work environment, she is

also under stress to pay bills and provide for her family. This stress could potentially lower the

immune system resulting in a patients increased susceptibility to tuberculosis (4).

The incubation time for tuberculosis is two to twelve weeks, but the actual duration of the

disease could vary based on the disease and treatment options (1). Most patients who become

infected are able to be cured; however, those who contracted a resistant strain, didnt take

their medications correctly, or fail to treat entirely may not be cured. If treated correctly, the
disease may persist for 6 to 9 months; however, some strains may be antibiotic resistant and

take much longer, and need more expensive drugs to treat (1). If left untreated, the disease

could progress until death. Complications of the disease could arise during and after the

symptoms are present. These complications include a vascular compromise, metabolic

abnormalities, inflammatory responses, sepsis, impaired pulmonary function, or neurologic

defects (5).

Tuberculosis could infect a person but it may not be active. Those who are infected but not

active can not spread the Mycobacterium (1). Tuberculosis is spread through the air by coughs,

sneezes, speaking and singing, and can infect others through the respiratory route (1). Those

who are in prolonged and/or repeated exposure should receive annual testing either by skin or

blood tests (1). Those who travel outside of the United States should also be tested before

departure and eight to ten weeks after their departure (1). Patients with HIV have an impaired

response to tuberculosis tests (1).

Therapeutic Focus and Assessment:

Tuberculosis can be treated by taking drugs for six to nine months (1). The 4 most

common and effective medications are Isoniazid (INH), Rifampin (RIF), Ethambutol (EMB) and

Pyrazinamide (PZA), but there are a total of ten drugs approved by the Food and Drug

Administration (1). These drugs are taken heavily in the first eight weeks and then lesser in the

following eighteen weeks (1). The drugs must be taken exactly how they are prescribed and the

medication must be taken fully to ensure that they work. If the drugs are not taken accordingly,

the Mycobacterium tuberculosis can mutate and become resistant to the drugs (1). The patient
should be treated for the first eight weeks with INH, RIF, PZA and EMB for 7 days a week and

continuing treatment 7 days a week for 18 weeks with INH and RIF (1). Additional treatment

may be required if tested positive for tuberculosis after the initial treatment.

Latent tuberculosis, or tuberculosis in which the patient does not present symptoms can also be

treated. The medications used to treat latent TB are Izonazoid, Rifapentine, and Rifampin (1).

The patient would not be treated for latent tuberculosis because her symptoms are present.
References

1. Tuberculosis (TB). Centers for Disease Control and Prevention. 2016 Mar 20

[accessed 2017 Oct 2]. https://www.cdc.gov/tb/topic/basics/default.htm

https://www.cdc.gov/tb/topic/basics/default.htm

2. Foster J, Aliabadi Z, Slonczewski J. 2015. Microbiology: The Human Experience. 16th

ed. Norton.

3. Progress in Tuberculosis in South-East Asia. South-East Asia Regional Office.

[accessed 2017 Oct 2]. http://www.searo.who.int/tb/topics/health_concerns/en/

4. Stress Weakens the Immune System. American Psychological Association. [accessed

2017 Oct 2]. http://www.apa.org/research/action/immune.aspx

5. Shah M, Reed C. Complications of Tuberculosis. Current Opinion in Infectious

Diseases. 2014;27(5):403410. https://www.ncbi.nlm.nih.gov/pubmed/25028786