GRIFFINExpress

Urgent Care Clinics

Patient Record

Healthcare Provider: Kiana Murdock

History and Physical Examination

Patient Name: Patient A

Date: September, 25th 2017

Referral Source: Self

Data Source: Patient

Chief Complaint: Severe Cough and Nocturnal hyperhidrosis

Introduction and Presenting Concerns:

The patient age 40, came into the doctors office complaining about having a cough that

kept her up at night along with having nocturnal hyperhidrosis. Previously in March, the patient

had developed lingering bronchitis from a cold. The patient recently went through some

emotional trauma and has been under extreme stress. Working as a nurse in hospice care she

works extended hours and has little down time. She had previously worked as a nurse working in

an urban area visiting with many patients that were immigrants from southeast Asia. The patient

has multiple concerns create a high risk of developing tuberculosis. The first risk is the patients

close contact with people who have immigrated from an area with high rates of tuberculosis, and

a second risk is her occupation in a hospital. (CDC-TB Risk Factors, 2017) She has also been

working with people who have become immunocompromised due to their health. The patient has

not been practicing good self-care including adequate sleep, food, or exercise. The patient has

also been showing signs of a lung infection for over six months. While at the doctors office, an
x-ray was taken that revealed unusual cavitary lesions in her right upper lobe. A sputum sample

which was taken and stained revealed pink bacillus-shaped bacteria. The lesions observed in the

x-ray are a sign of tuberculosis. Since tuberculosis is a Mycobacterium, it stained pink by

Carbolfuchsin in an acid-fast stain. The stain also showed the typical bacillus shape of

Mycobacterium tuberculosis.

Clinical Findings:

In lab, an Acid Fast Stain and Microscopic Analysis was done. When using this process,

the bacteria have to be dry-fixed for four hours before staining. This time-consuming nature of

this process slows down the diagnosis which is important since sometimes a fast diagnosis can

be crucial. Also, when Acid Fast staining is used, the sample has to be heated while applying the

Carbolfuchsin stain for five minutes because the mycolic acids found in the cell walls of the

Mycobacterium give them a waxy coating. It was difficult to make sure that that Carbolfuchsin

was on the sample for the appropriate duration of time to obtain proper staining. The

Mycobacterium stained pink but under the microscope the bacilli shape was hard to see until

100x objective.

Results of Sputum Acid Fast Stain and Microscopic Analysis:

A sputum sample was obtained from the patient, and then Acid Fast Stained and analyzed

under the microscope. While looking at the stain under the microscope there were multiple pink

bacilli. The presence of large amounts of pink bacilli means that the patient has been very

infected by Mycobacterium.
Diagnostic Focus and Assessment:

Based on the results found and the patients signs and symptoms that patient is most

likely infected with Mycobacterium tuberculosis. When a patient develops tuberculosis in

their lung, they typically develop a severe cough that lasts around three weeks or longer.

When coughing, they typically cough up blood or sputum. Along with the cough, the patient

usually experiences chest pain, weakness or fatigue, fever, and chills. Some patients may

have a loss of appetite and weight. (Tuberculosis (TB), 2017)

Tuberculosis is an airborne illness that can be spread through inhalation of the

Mycobacterium tuberculosis bacteria. When a person coughs or sneezes he releases droplets

into the air which then can infect another person (Tuberculosis (TB), 2017) Because

tuberculosis is an airborne illness multiple precautions should be taken to protect others from

getting the illness. The patient should be placed in an Airborne Infection Isolation Room that

provides negative pressure, has at least six air exchanges per hour, and has exhaust that goes

through high efficiency particulate air filtration. Often times these rooms are not available in

many hospitals; therefore, other precautious must be taken. For example, the patient should

be provided a mandatory facemask that should be changed if it becomes wet. He should also

have a private room that has a closed door (Tuberculosis (TB), 2017).

Since tuberculosis is easily transmitted, anyone who has come in contact with the patient

is at risk of developing the illness; therefore, each person should be notified. The incubation

period for tuberculosis can be between two and twelve weeks, and it can only be spread once

the disease is active (Tuberculosis (TB), 2017). Once in the body, tuberculosis can take up
 to three years to cure although symptoms usually last around four to five weeks. Tuberculosis

is a curable disease if the proper measures are taken; however, it can also result in death.

Medications such as Isoniazid, Rifampin, Ethambutol, and Pyrazinamide are given to patients

for at least six to nine months. If patients develop multidrug-resistant Mycobacterium

tuberculosis, then they are often administered fluoroquinolone antibiotics and intravenous

medication for twenty to thirty months. Most previously healthy patients are able to make a

recovery and the recurrence rate is low. However, in elderly and immunocompromised

patients the recovery rate is much lower because their immune system is unable to fight off

the bacteria as easily. (Tuberculosis-Treatment, 2017). The Bacille Calmetter-Gurin

vaccination is available to vaccinate against tuberculosis.

Therapeutic Focus and Assessment:

Since the patient has Mycobacterium tuberculosis in an active form, she will most likely

have to take multiple antimicrobial drugs. The most common medications for treatment of

tuberculosis are Isoniazid, Rifampin, Ethambutol, and Pyrazinamide. These antibiotics are used

in combination for a six to nine month period (Tuberculosis-Treatment, 2017). The patient

should be monitored for cardiac toxicity, hepatotoxicity and renal toxicity while taking these

medications. Therapeutic drug monitoring should be performed to monitor serum drug levels to

minimize risk of acquired drug resistance. A monthly sputum specimen should be submitted

throughout and at the end of treatment to culture for microbiological monitoring. Other side

effects of the drugs should be assessed weekly such as nausea, headache, hemoptysis, chest pain,

arthralgia, and rash (Tuberculosis (TB), 2017).

 If the patient has a multi-drug resistant strain of Mycobacterium tuberculosis a

combination of injectable medications such as Amikacin, Kanamycin, or Capreomycin and

fluoroquinolones antibiotics would be used. Also, for drug-resistant Mycobacterium tuberculosis

Bedaquiline or Linezolid would be used in combination with the other medications. The same

patient pre-cautions should be taken for these drugs (Tuberculosis-Treatment, 2017). The

patient will be still contagious for a couple weeks after starting the medication and, therefore, she

should be in isolation and wearing a face mask. Anyone who comes in contact with her should

also being wearing a face mask. It is important that the patient continues to take her full course

of drug therapy to prevent the bacteria from reemerging and becoming resistant. After the patient

is done the full course of drug therapy, she should get a chest x-ray to determine that the

treatment has worked.

References

CDC | TB | Basic TB Facts | TB Risk Factors. (2017). Cdc.gov. Retrieved September 2017, from
https://www.cdc.gov/tb/topic/basics/risk.htm

Tuberculosis (TB) | CDC. (2017). Cdc.gov. Retrieved September 2017, from

https://www.cdc.gov/tb/topic/basics/signsandsymptoms.htm),

Tuberculosis - Treatment. (2017). Mayo Clinic. Retrieved September 2017, from

http://www.mayoclinic.org/diseases-conditions/tuberculosis/diagnosis-treatment/treatment/txc-
20188961