IM27.1-18 | Tuberculosis — Assignment

CLINICAL SCENARIO

This assignment asks you to produce a structured case report for a patient with presumptive or confirmed pulmonary tuberculosis, integrating history, examination, diagnostic workup, and a full management plan aligned with current NTEP (National Tuberculosis Elimination Programme) 2020 guidelines. You will also write a patient counselling plan demonstrating your ability to communicate the diagnosis and management empathetically and in plain language. The assignment tests your ability to apply the full clinical TB pathway — from the NTEP four-symptom screen through to Ni-kshay notification and treatment outcomes — as a final-year MBBS student who will shortly be working as an intern in TB-endemic settings.

Section 1: Patient History and Risk Factor Assessment

Guidance: Present the history of a real or constructed case of presumptive pulmonary TB. Include: (a) the presenting complaint with duration; (b) the full NTEP four-symptom screen (cough ≥2 weeks, fever ≥2 weeks, weight loss, night sweats) — specify duration and severity for each; (c) haemoptysis; (d) contact history — specify relationship to contact, smear status of index case if known, and duration of exposure; (e) prior TB treatment history and outcome (treated/defaulted/cured); (f) HIV status and DM history; (g) occupation and housing conditions as social determinants; (h) current medications including immunosuppressants or steroids. Approximately 250 words.

Section 2: Physical Examination and Differential Diagnosis

Guidance: Describe the systematic physical examination using the four examination domains relevant to TB: (a) general examination — nutritional status, pallor, clubbing, lymphadenopathy (site, size, consistency, matting), BCG scar; (b) chest examination — inspection (chest wall asymmetry, respiratory rate), palpation (tracheal position, chest expansion, vocal fremitus), percussion (dull, stony dull, hyper-resonant), auscultation (breath sounds, added sounds including post-tussive crepitations); (c) lymphatic system — cervical, axillary, inguinal nodes; (d) CNS examination if features of TB meningitis. After presenting findings, construct a prioritised differential diagnosis with at least three conditions ranked by probability. For each, state the specific clinical feature supporting it. Approximately 300 words.

Section 3: Diagnostic Workup — Selection, Results, and Interpretation

Guidance: Present the diagnostic workup for your case in the correct NTEP sequence. Start with CBNAAT as the mandatory first-line test and explain why smear microscopy alone is no longer sufficient under NTEP. For each investigation, state: (a) the test ordered and the clinical rationale; (b) the result (you may use typical results for a smear-positive case); (c) your interpretation with clinical significance. Include: CBNAAT (MTB detection and RIF sensitivity result), sputum AFB smear (with Ziehl-Neelsen grading), chest X-ray PA view (described using standard radiological terms), CBC, Mantoux (with correct cut-off applied), HIV test, and random blood glucose or HbA1c. Approximately 250 words.

Section 4: Management Plan — NTEP Regimen, Adverse Effects, and Notification

Guidance: Write a complete management plan: (a) State the NTEP treatment category and regimen with precise drug names (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol), phase durations, and daily dosing. Specify the weight band your patient falls into. Do NOT cite thrice-weekly dosing. Do NOT write the continuation phase as HR — it is HRE under current NTEP. (b) List the key adverse effects of each drug and the monitoring schedule: INH (peripheral neuropathy, hepatotoxicity — give pyridoxine 10 mg/day prophylactically), RIF (hepatotoxicity, orange discolouration of body fluids, CYP450 drug interactions), PZA (hepatotoxicity, hyperuricaemia, arthralgia), EMB (optic neuritis — Snellen chart baseline and monthly for doses >15 mg/kg). (c) State the NTEP ATT-DILI threshold for stopping treatment (ALT >5x ULN asymptomatic, or >3x ULN with symptoms/jaundice). (d) Describe the mandatory Ni-kshay notification step and the Ni-kshay Poshan Yojana nutritional support entitlement. (e) State the treatment outcome criteria for 'Cured' vs 'Treatment completed'. Approximately 350 words.

Section 5: Patient Counselling Plan

Guidance: Write a structured counselling plan as you would deliver it to a real patient and family member. Address: (1) Explaining the diagnosis in plain, non-stigmatising language; (2) Treatment duration, daily tablet schedule, and the importance of not missing doses; (3) Specific side effects the patient should self-report (yellow eyes/urine, vision change, numbness in hands/feet); (4) Infectivity — explain that the patient is infectious until sputum converts (typically 2–4 weeks into treatment) and advise household precautions (sleep in a separate, ventilated room, cover mouth when coughing); (5) Contact investigation — all household members must be screened; (6) Ni-kshay Poshan Yojana — the patient is entitled to INR 500/month nutritional support; explain how to access it. Write in the style you would speak to a patient (plain language), not in clinical notes. Approximately 250 words.

Section 6: Reflection — Social Determinants and the NTEP Goal

Guidance: In 150 words, reflect on: (a) what social or occupational factor in your patient's history most increased their risk of acquiring TB; (b) what specific step in this clinical encounter contributes directly to India's TB elimination goal (target: incidence <1 case per million population by 2025); and (c) what you learned from this case that changed how you will approach future patients with cough in an outpatient setting. Approximately 150 words.

PEER REVIEW

Review your peer's case report using the rubric. For each section, assign a score and write one specific comment — do not simply copy the rubric descriptor. In Section 4 (Treatment Plan), specifically check: (a) Is the continuation phase written as HRE or HR? HR alone is incorrect under NTEP. (b) Is the Ni-kshay notification step included? (c) Is the ATT-DILI stopping threshold correctly stated? In Section 5 (Counselling), check that the infectivity precaution and the Ni-kshay Poshan Yojana entitlement are both mentioned. Complete your peer review within 72 hours.