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History was taken from her aunt Daw Moe Thi and her father U Win
Aung.
II. Summary of Relevant Social and Community
Aspect
1. Personal History
-NSVD at home with traditional birth attendant
-Since childhood, she has health problems such as diarrhea,
epistaxis and fever
-Her mother died when she was 1yr and 7mth old
-cared by her father and her aunt
2. Family history
-Extended or joint family
-size of family - 6 members
-Head of family - U Win Aung
Family Tree
U Aung Chi Daw Myint Aye
80yrs 65yrs
U Win Aung Daw Nwe Nwe Soe Daw Moe Thi U Lin Aung
45yrs 45yrs 43yrs 35yrs
- General condition - fair, not dysponoeic, not irritable, thin for her age
- Temperature is raised
- Oral thrush absent
- BCG scar is present
Systemic Examination
- CVS - pulse rate is 100/min
- BP - 120/70 mmHg
- Heart sound - normal first heart sound followed by second
heart sound
- Respiratory system - Respiratory rate is 28/min. VBS, added
sounds and cerpitations (-)
- Abdomen is soft.
- Liver and spleen - not palpable.
- cervical, Axillary, Inguinal lymph node englargements.
3. Provisional diagnosis is retro positive with pulmonary tuberculosis.
4. Investigations
27.11.16 - Haematological report
WBC - normal, Hb - reduced, platelet - normal
ESR - 15+
MP - not seen
ICT malaria - negative
Widal test - Negative
28.11.16 - USG (Abd) intraabdominal lymphadenopathy
CXR-NAD
29.11.16 - HIV (Ab-NHL) positive
HBs Ag-Negative
HCV Ab-Negative
GAS microscopy specimen for TB - 2+
Gene Expert result - MTB detected medium
Rif resistance not detected
11.12.16 - tuberculin test - negative
21.12.16 - Indian ink preparation (C.S.F)
No cryptococus
-CD4 count is still pending.
5. Diagnosis
- Retro positive with pulmonary tuberculosis.
Social eitology Social Implication
Personal factors
IV. Problem Analysis Individual
-lack of health -social problems
knowledge -depression
-child -poor health
-passive smoker
Family factors Family
-retro contact -risk of infecting others
-lack of awareness of -increase burden on
disease family
Retro+ with pulmonary
Sociodemographic tuberculosis
Community
factor
-increase TB cases
-low income
-increase retro cases
-large family size
-increase workload for
-overcrowded
hospital
Service factors
-Poor access and National
utilization to health -Detoriation of human
care services resources and decreased
productivity
-increase burden of TB
and retro
V. Discussion of Possible Solution for Patients
Immediate Managemet
Clinical
-Anti TB drugs
Ethambutol 300mg, Isoniazid 150mg, Rifanpicin 225mg,
Pyrazzinamide 450mg
-ART
Lamivudine and Zidobudine
-Paracetamol 250mg qid
-Zytee gel
Long term Management
Individual level
- regular taking of drugs
- regular follow up
- good nutrition and hygiene
- Morale support and awareness of her health problem
Family level
- to take care of the patient
- HE to increase awareness of pulmonary TB and HIV and how to
prevent
- to do screening tests on other family members
Community level
- giving knowledge about TB and HIV
- HE about transmission
- Collaborative TB and HIV services
- Provision of counselling services
National level
- HE through mass media
- Implementing ART services
- Implementing STOP TB strategy up to gross root level
- Making adequate health facilities and services to the village