INSTITUT LATIHAN KEMENTERIAN KESIHATAN

MALAYSIA JOHOR BAHRU

PROGRAM DIPLOMA PEMBANTU PERUBATAN

TAHUN 2 SEMESTER 2

PENEMPATAN WAD SURGIKAL

CASE STUDY

TAJUK TUGASAN:
PNEUMONIA TUBERCULOSIS

NAMA PELATIH : MOHAMAD NUR HAIRIE BIN

BINDFGDFGDFG KAMAROLZAMAN
NO MATRIK : BPP2019-0176
NO IC : 950415-03-5555
KUMPULAN : JANUARI 2019

UNTUK MEMENUHI KEHENDAK KURIKULUM PROGRAM

DIPLOMA PEMBANTU PERUBATAN
TABLE OF CONTENT

NO TOPICS PAGE
1. Introduction 1
2 Problem statement 2
3. Literature review 3
4 Discussion 5-11
5. Conclusion 12
6. References 13
7. Attachment 14
INTRODUCTION

The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne

infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily

attacks the lungs. However, it can spread from there to other organs. Pulmonary TB is curable

with an early diagnosis and antibiotic treatment.

Pulmonary TB, also known as consumption, spread widely as an epidemic during the 18th

and 19th centuries in North America and Europe. After the discovery of antibiotics like

streptomycin and especially isoniazid, along with improved living standards, doctors were

better able to treat and control the spread of TB.

Since that time, TB has been in decline in most industrialized nations. However, TB remains

in the top 10 causes of death worldwide, according to the World Health Organization

(WHO)Trusted Source, with an estimated 95 percent of TB diagnoses as well as TB-related

deaths occur in developing countries.

That said, it’s important to protect yourself against TB. Over 9.6 million people have an

active form of the disease, according to the American Lung Association (ALA). If left

untreated, the disease can cause life-threatening complications like permanent lung damage.

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PROBLEM STATEMENT

Name : Patient A

Age : 30 Tahun

Race : Melayu

R/N : 1430031 / 690107-08-5325

CHIEF COMPLENT :

Patient A is a 30-year-old male who was admitted to the hospital from home after 1

week of cough, profuse nocturnal sweating, loss of appetite and hyposomnia.

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LITERATURE REVIEW

 Tuberculosis, not long ago the number one killer of humans, appeared to have been conquered in

developed countries in the twentieth century by biomedicine armed with powerful antibiotics.

This downward trend of tuberculosis cases began to reverse, however, in the late 1970s. For

example, cases of tuberculosis in the United States increased by 20.1 percent between 1985 and

1992 (NewYork City Department of Health, 2000).

 Globally, tuberculosis remains the leading infectious killer of adults, killing an estimated

three million people per year (WHO, 2001).

 The dominant biomedical explanation of tuberculosis was fifirst introduced in 1882,

when Robert Koch reported the isolation and cultivation of the tuberculosis-causing

bacteria, Mycobacterium tuberculosis. However, germ theory was based on laboratory

experiments and did not explain why only 25–50 percent of the humans exposed to M.

tuberculosis become infected, or why only 10 percent of those infected developed

fullblown tuberculosis (Dutt & Stead, 1999, p. 6)

 Furthermore, treatment of tuberculosis progressed slowly after the discovery of M

tuberculosis. Effective antibiotics were not available until 1943 with the discovery of

streptomycin. Although an appropriate combination of antibiotics could cure 95 percent

of tuberculosis (Iseman, 1985)

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 Drug susceptibility testing, the reference method for DR-TB detection, is based on the

proportional agar method on Lowenstein-Jensen medium (Canetti et al., 1969).

 TB is associated with poverty and, on this basis, its epidemiological burden is

heterogeneous, with high TB incidence rates mainly recorded in low income countries.

During the last decade, migration flows from low- to high-income countries (e.g., those

in EU/EEA) have significantly increased. Consequently, some high-income countries

have shown relevant changes of their TB epidemiology (Coker et al., 2006, Davies et al.,

2008)

 Many misconceptions about transmission, cause and risk factors for the disease are

present, perhaps because TB is not openly discussed in homes and communities

(Brassard, Anderson, Menzies, Schwartzman, & Macdonald, 2008)

 Another study Sreeramareddy et al. (2013) found that 32.4% knows TB is transmitted

through food, 18.2% knows sharing utensils and 12.3% knows touching a person with

TB. Their study also found that knowledge of TB transmission was lower among women,

illiterate and rural residents who demographically comprise the majority of the

population and knowledge of TB disease was higher among literate persons and urban

populations

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DISCUSSION

Tuberculosis (TB) is a contagious infection that usually attacks your lungs. It can also spread

to other parts of your body, like your brain and spine. A type of bacteria

called Mycobacterium tuberculosis causes it.

Signs and symptoms

The signs and symptoms of active TB (disease) are coughing, sometimes with sputum or

blood, chest pains, weakness, weight loss, fever and night sweats. TB most often affects the

lungs. It can cause serious damage to the lungs and other organs.

TB is curable and preventable. The vast majority of people with TB can be cured, if rapidly

and accurately diagnosed; and if appropriate medicines are provided and are taken properly.

But without proper tuberculosis treatment up to two thirds of people ill with TB may die.

TB infection is spread from person to person through the air when people with lung TB

cough, sneeze or spit. When a person develops the disease TB, the symptoms may be mild for

many months. This can lead to delays in seeking care, and results in transmission of the

bacteria to others. An individual with undiagnosed and untreated lung TB disease may infect

ten to fifteen other people through close contact.

Signs of active TB disease include:

 A cough that lasts more than 3 weeks

 Chest pain

 Coughing up blood

 Feeling tired all the time

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 Night sweats

 Chills

 Fever

 Loss of appetite

 Weight loss

Tuberculosis Tests and Diagnosis

There are two common tests for tuberculosis:

 Skin test. This is also known as the Mantoux tuberculin skin test. A technician injects a

small amount of fluid into the skin of your lower arm. After 2 or 3 days, they’ll check for

swelling in your arm. If your results are positive, you probably have TB bacteria. But

you could also get a false positive. If you’ve gotten a tuberculosis vaccine called bacillus

Calmette-Guerin (BCG), the test could say that you have TB when you really don’t. The

results can also be false negative, saying that you don’t have TB when you really do, if

you have a very new infection. You might get this test more than once.

 Blood test. These tests, also called interferon-gamma release assays (IGRAs), measure

the response when TB proteins are mixed with a small amount of your blood.

Those tests don’t tell you if your infection is latent or active. If you get a positive skin or

blood test, your doctor will learn which type you have with:

 A chest X-ray or CT scan to look for changes in your lungs

 Acid-fast bacillus (AFB) tests for TB bacteria in your sputum, the mucus that comes up

when you cough

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Tuberculosis Treatment

THE AIMS OF TREATMENT ARE:

1. To cure patients and render them non-infectious 

2. To reduce morbidity and mortality 

3. To prevent relapse and emergence of resistant tubercle bacilli. 

  

FIRST LINE DRUGS

Five drugs are considered essential to the treatment of tuberculosis. They are:

1. isoniazid (H) 

2. rifampicin (R) 

3. pyrazinamide(Z) 

4. streptomycin(S) 

5. ethambutol €

BASELINE INVESTIGATIONS:

Sputum D/S x 3, sputum culture AFB if D/S negative, renal profile, liver functions, visual

test *, blood sugar, HIV test when indicated.

* If ethambutol is used

** Recommended to be done where facilities are available

*** Routine follow up is optional.

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PATIENT MONITORING

To monitor treatment outcome, it is recommended that all patients with pulmonary

tuberculosis have repeat sputum smears performed at the end of the second month of

treatment. To verify treatment success, additional sputum examinations should be done at the

end of the 6-month treatment period.

Where culture facilities are available, sputum cultures should be obtained at the start of

treatment. Sensitivity tests for all available drugs if possible should be performed for new

patients whose sputum is still positive at the end of the intensive phase of treatment, and for

any patients suspected to be at risk of being drug resistant eg. relapsed cases, defaulters,

immigrants from high prevalence countries.

PATIENT SUPERVISION

As far as possible, all patients must be on Directly Observed Treatment, Short course

(DOTS).Local arrangements for supervision must be arranged either at the nearby health

facilities, family practitioner or by a responsible person / relative. Patients not on directly

observed therapy should be followed up more regularly.

The patient must be made aware of his follow up appointments to ensure compliance with

treatment. To strengthen patient adherence, the following factors should be considered:

1. Patient education on his illness and treatment. 

2. Education of immediate members of the patient_x0019_s family. 

3. Regular motivation during the course of treatment to the patient. 

4. Ensuring direct supervision by health service staff. 

5. Prompt defaulter tracing. 

6. Socio-economic assistance and advice.

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    In certain situations today, hospitalisation has been one of the critical elements in

achieving nearly 100% patient compliance during the intensive phase of short course

chemotherapy, how ever, it must be emphasised that routine hospitalisation of tuberculosis

patients is not required.

INDICATIONS FOR HOSPITALISATION

1. Gravely ill patients with far advanced disease or respiratory distress.

2. Cases of acute disseminated TB such as miliary TB or tuberculous meningitis.

3. Tuberculosis involving central nervous system, pericardium, adrenals and spine.

4.Multidrug-resistant tuberculosis.

5. Patients who default treatment frequently or whose compliance is suspect.

6. Patients with complications such as haemoptysis, pneumothorax and empyema.

7. Patients who have associated diseases such as uncontrolled diabetes mellitus and renal

failure.

8. Patients who develop severe side-effects such as severe skin reactions or jaundice.

9. Patients who need to be desensitised to anti-tuberculous drugs.

10. Initial intensive chemotherapy- if daily ambulatory treatment proves difficult eg.

homeless patients, drug addicts and alcoholic

DRUG TOXICITY MONITORING AND MANAGEMENT

(A) MONITORING

Where facilities are available,adult patients should have baseline measurements of :

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1. liver function tests. 

2. renal function including blood urea nitrogen and/or serum creatinine 

3. full blood count 

4. visual acuity if ethambutol is used

All patients should be monitored clinically for adverse reactions during the period of

chemotherapy. They should be informed about symptoms of common adverse reactions to the

medications they are receiving.

(B) MANAGEMENT

MINOR SIDE EFFECTS:

Minor side effects, such as gastrointestinal intolerance, mild skin rash, pruritus or flushing are

best managed by reassurance and symptomatic treatment and the patient should be

encouraged to continue anti tuberculosis treatment. Treatment with non steroidal anti

inflammatory drugs (NSAID)provide symptomatic relief of pyrazinamide related arthralgia.

Skin rashes can usually be managed by withholding the causative drug and if it is really

necessary to reintroduce the drug, the patient should undergo desensitization.

MAJOR SIDE EFFECTS:

Severe skin reaction and Steven-Johnson syndrome must be managed by physicians. Other

common serious drug toxicity is hepatitis. Patients who develop jaundice or other signs of

liver dysfunction during therapy should have treatment stopped immediately. Although many

patients with drug-induced hepatotoxicity can be successfully rechallenged, this is best done

in a where liver function can be carefully monitored. Thus, patients with this problem should

be sent to a referral centre for management.

The development of the following conditons contraindicates further use of the drug:

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-thrombocytopenia , shock and/or renal failure due to rifampicin.

-visual impairment due to ethambutol

-eighth nerve damage from streptomycin.

-Steven-Johnson syndrome.

If the period without drugs is likely to be prolonged, and the patient requires treatment, at

least two other drugs should be given until it is determined whether the offending drug can be

resumed. Drugs causing severe intolerance are best avoided and substituted with other drugs.

All patients who require alteration from the standard regimen should be referred to

experienced physicians.

MEDICATION ADVICE

 Take all of your medicines as they’re prescribed, until your doctor takes you off them.

 Keep all your doctor appointments.

 Always cover your mouth with a tissue when you cough or sneeze. Seal the tissue in a

plastic bag, then throw it away.

 Wash your hands after coughing or sneezing.

 Don’t visit other people and don’t invite them to visit you.

 Stay home from work, school, or other public places.

 Use a fan or open windows to move around fresh air.

 Don’t use public transportation.

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CONCLUSION

Tuberculosis, or TB, is still one of the major causes of preventable death in the world. TB is

an infectious disease caused by TB bacteria (Mycobacterium tuberculosis): a smart but

deadly survivor with the cunning ability to evade our immune system. The bacterium first of

all has a sort of harness: an almost impenetrable, unique surface which protects the bacterium

from attacks by our immune system and antibiotics. In addition, the bacterium comes armed

with a wide arsenal of proteins, secreted in order to manipulate and cunningly avoid our

immune system. Macrophages (literally ‘big eaters’) are part of our immune system. They are

specialized in consuming harmful microorganisms.

However, the TB bacterium manages to stay alive and multiply inside the macrophages. In

the end, the macrophage is so full of bacteria that the cell dies. Other macrophages rush in to

get rid of the dead cell and, in turn, are infected with TB bacteria and so on and so forth. A

healthy person will not immediately become ill. In fact, one quarter of the world’s population

is walking around with a ‘sleeping’ form of the TB bacterium. Things go wrong for people

with a weakened immune system, because this will allow the TB bacterium to gain the upper

hand and kill its host.

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REFERENCES

 NewYork City Department of Health. (2000). Tuberculosis in

New York city, 1999: Information summary, NewYork.

 World Health Organization. (2001). Global tuberculosis control:

WHO report 2001. Geneva: World Health Organization.

 American Thoracic Society: Treatment of Tuberculosis and tuberculosis infection in

adult and children. Rev.Respir.Dis.1986:134:355-363.

 The global tuberculosis situation and the new control strategy of the world Health
Organisation.Kochi A.Tubercle 1991, 72:1-6.

 Dutt, A., & Stead, W. (1999). Epidemiology and host factors. In D. Schlossberg (Ed.),
Tuberculosis and nontuberculosis Mycobacterial infections (4th ed). Philadelphia: W.B.
Saunders.

 Control and prevention of tuberculosis in the United Kingdom: Code of Practice

1994.Thorax 1994;49;1193-1200.

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 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE STUDY

Nama Pelatih: MOHAMAD NUR HAIRIE B KAMAROLZAMANNo. Matrik:

BPP20190176

Tahun: 2 Semester: 2 Kawasan Penempatan: HOSPITAL KULAI

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