CASE SCENARIO

Maria is a 42-year-old single mother living in New York City with her three sons. She

immigrated to New York from Peru two years ago. About six months after she arrived, she began

developing night sweats and unexplained fevers. Most recently, she has developed a persistent,

worsening cough. Her illegal status has made her hesitant to seek medical treatment, but a

neighbor told her that the local community clinic would see her and would not check her

residency status.

Screening at the clinic included a questionnaire that addressed some of the problems she was

experiencing. The nurse explained to Maria that she might have TB. The physician treating

Maria performed a complete physical exam and discussed her questionnaire responses with her,

including her response that in Peru, she lived with her grandfather who she believes may have

died from TB.

Physical exam findings showed abnormal lung sounds in Maria’s upper lobes bilaterally. The

physician found cervical and axial lymphadenopathy. Maria was asked to leave sputum samples

to be tested for mycobacterium tuberculosis. A PPD was placed with instructions for Maria to

return in two days to have it read. When Maria returned two days later, the result showed a 10

mm raised, red reactive site. Maria was also screened for HIV at the time of initial exam because

it is often found in patients with TB. In this case, she tested negative for HIV. Her sputum

culture tested positive for M. tuberculosis.

The physician explained that given the findings on the chest x-ray and the clinical findings on

exam, he believed that she had reactivation TB. The physician informed Maria that he planned to

start her on a four-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol

(Myambutol) for two months. The physician then explained that a “continuation phase” would

follow, which would consist of isoniazid and a rifamycin (rifampin, rifabutin [Mycobutin], or

rifapentine [Priftin]) that is administered daily for four to seven months. He also informed her

that he would start her treatment at the hospital, where she would stay for least two days because

she was still considered contagious. Following the hospital stay, Maria would need to come to

the clinic for observed medication administration and to assure compliance.

Two months passed and Maria continued about her day-to-day life including going to the clinic

for her medication. She attempted to work full time and to take care of her three sons. She found

that her night sweats had become a nightly occurrence, and her cough had become productive

with blood along with intense coughing spells. Maria was compliant with the drug regimen but

called the clinic because her symptoms were worsening. Maria was scheduled for a visit the very

next day.

The follow up chest x-ray showed no improvement, and it was determined that Maria was

exhibiting signs of multidrug-resistant TB. Because multidrug-resistant and extensively drug-

resistant tuberculosis requires at least 18 to 24 months of therapy, depending on the patient’s

response to treatment, the physician decided to extend her therapy to 18 months, beyond the 4 to

7 month time period he had projected. He also stopped the ethambutol and started moxifloxacin.

Thoracic surgery for resection of lung lesions is often considered as adjunctive therapy, and this

was discussed with Maria at the time of the exam.

Maria was devastated to learn about her multidrug resistant TB because she needed to work.

Fortunately, the clinic was able to fund Maria’s drugs at a discounted rate. Nonetheless, the

entire situation has put Maria under stress to the point that it is unclear how she will meet this

challenge and adequately handle her health crisis.

DUE MAY 1 ST

ASSIGNMENT

Conduct an evidence-based literature search to identify the most recent standards of

care/treatment modalities from peer-reviewed articles and professional association

guidelines (www.guideline.gov (Links to an external site.)). These articles and

guidelines can be referenced, but not directly copied into the clinical case

presentation. Cite a minimum of three resources.

Answer the following questions:

1. What is the transmission and pathophysiology of TB?

2. What are the clinical manifestations?

3. After considering this scenario, what are the primary identified medical concerns for

this patient?

4. What are the primary psychosocial concerns?

5. What are the implications of the treatment regimen, as far as likelihood of

compliance and outcomes? Search the Internet to research rates of patient

compliance in treatment of TB, as well as drug resistant TB.

6. Identify the role of the community clinic in assisting patients, particularly

undocumented patients, in covering the cost of TB treatment. What resources exist

for TB treatment in community health centers around the United States? Compare

the cost for treatment between subsidized and unsubsidized.

7. What are the implications of TB for critical care and advanced practice nurses?

The use of medical terminology and appropriate graduate level writing is expected.