AUDIT KEMATIAN PESAKIT

TIBI 2015

Name: Kho Beng Siong

IC: 770413-13-5183
No daftar TB: 130424/17/15
38-year-old Chinese male staying at Lot
490, jln 2 C Pujut
Underlying mental retardation & flat foot
with calluses

Pre-diagnosis
Coughing for 2 weeks; fever x1/52, loose
stool x1/12, visit to KK Miri on 6/1/15,
Referred to MGH on 6/1/15 and admitted
for infective AGE and hyponatremia

HIV NR
? body weight
BCG scar unknown
Mantoux test not done
SAFB +4 (scanty)
sputum TB CS NG
CXR moderately advanced
VDRL negative
Diagnosis: PTB smear positive new case & extra
PTB - TB ileocaecal

 admitted on 6/1/15, diagnosed on 12/1/15,

notified on 12/1/15
forecox 4tabs OD on 12/1/15
died on 23/1/15 at 1.28pm at ICU, Miri
Hospital (11 days on intensive phase)
Cause of death: Extensive pulmonary and
extrapulmonary TB

TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 ada
Borang 10A-3
Borang 10C-1 ada
Borang 10C-2
Borang 10D-1
Borang 10J ada

CONCLUSION
Pesakit TIDAK lewat datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Suding Hartani

Passport No: AF 626213
No daftar TB: 130424/42/15
44-year-old Indonesia lady staying at Niah
Plantation
HIV NR

Pre-diagnosis
30.1.15 coughing for one week; SAFB done
3.2.15 noted SAFB 3+x1; called up pts relative;
promised to come cm
4.2.15 noted lethargic and POI, ; pale, BP 90/60
PR 108 weak pulse, T afebrile RR 20 SPO2 99%
under RA; wear mask; IVF 1 pint over one hour
S/T Physician : for admission through A&E
On admission on 4.2.15, coughing for 1 month
LOA, LOW, night sweats
No TB Contact
Loose stool for one week

 HIV rapid test negative

BCG scar unknown
Started on EHRZ (EOD PZA and
Ethambuthol) on 4.2.15
Body weight 46kg
Diagnosis: PTB smear positive new case
Cause of Death: unknown

 19.2.15 at 8.20am pt requested to be discharged

as his manager had bought him flight ticket to
Indonesia
Absconded on 19.2.15 (16 days of intensive
phase) at 12.30pm with IJC and branula in situ
Police and Health Inspector were informed
Suddenly collapsed and Died at home on
20.2.15 at 8pm

TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 tiada
Borang 10A-3 tiada
Borang 10C-1 ada
Borang 10C-2 ada
Borang 10D-1 tiada
Borang 10J ada

CONCLUSION
Pesakit TIDAK lewat datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Looi Yee Yien

IC: 810825-13-5730
No daftar TB: 130424/285/14
33-year-old Chinese lady staying at 616a,
Desa Pujut

Pre-diagnosis
Patient was found alive 1day before. Her
friend called her and she complained of
chest pain.
Her brother found out that patient was
dead in living room
noted there was a poison bottle and beer
can.

HIV rapid test negative

body weight 46kg
BCG scar unknown
Mantoux test not done
SAFB negative
sputum TB CS NG
CXR clear
VDRL NR
Diagnosis: Extra PTB - TB Lymphadenitis

 Notified on 22/9/2014, died on 18/5/15

Started forecox 3tabs on 22/10/2014, on
maintainance phase 7HR
cause of death: BID

TBIS

Borang health 1 (notifikasi) Ada

Borang 10A-1 Ada
Borang 10A-3 tiada
Borang 10C-1 tiada
Borang 10C-2
Borang 10D-1
Borang 10J ada

CONCLUSION
Pesakit TIDAK lewat datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Alau Pada

IC: 860809-52-6286
No daftar TB: MD/15/03
29-year-old Penan lady staying at Long
Pakan, sungai Patah, Marudi
HIV NR

Pre-diagnosis
Productive cough x1/12, worsening SOB
x3/7, night sweat, nocturnal fever
Admitted to Hospital Marudi on 17/1/15
and then transferred to MGH on 19/1/15
for septic shock secondary to PTB
H/o PTB contact (mother)
was diagnosed TRO TB lymphadenitis in
2011 but defaulted f/up in SGH

HIV rapid test negative

body weight: 50kg
BCG scar No
Mantoux test not done
SAFB +3
sputum TB CS NG
CXR moderately advanced
VDRL NR
Diagnosis: PTB smear positive new case

 admitted on 17.1.15, diagnosed on

17.1.15, notified on 18.1.15 ; died on
20.1.15 at 5.05am
FORECOX 3Tab OD on 17.1.15,
Pyridoxine 20mg OD
Cause of Death: Septic shock with severe
metabolic acidosis secondary to PTB

TBIS

Borang health 1 (notifikasi) Ada

Borang 10A-1 tiada
Borang 10A-3 tiada
Borang 10C-1
Borang 10C-2 ada
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit LEWAT datang mendapatkan
rawatan
Pesakit LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Sahari Bin Adnan

IC: 760420-13-5203
No daftar TB: 130424/95/15
39-year-old Penan male staying at Kg Ogos
Jambatan Suai
Risk factors:
Ex IVDU
Strong Smoker 1pack/day
Alcoholic
Hepatitis C +

Pre-diagnosis
Abdominal distended x1/12, SOB x1/12,
fever on and off x1/12, no cough
No altered bowel habit
No PTB contact

HIV rapid test negative

BCG scar unknown
BW 54kg
Mantoux test not done
SAFB x3 positive; Pleural fluid AFB on 20/3/15 1+
sputum TB CS NG; Sputum MTB C&S negative
CXR far advanced
VDRL negative
Hepatitis C reactive
Diagnosis:
UGIB with severe metabolic acidosis
Possible pulmonary hemorrhage
U/L PTB with pleural TB

 Admitted to MGH on 18.3.15, diagnosed

on 20.3.15, notified on 24.3.15; died on
6.6.15 at 8.39pm
started forecox 3tabs on 20/3/2015
Cause of death:
Upper GI bleed with metabolic acidosis
U/L PTB

TBIS

Borang health 1 (notifikasi) Ada

Borang 10A-1 Ada
Borang 10A-3 ada
Borang 10C-1 ada
Borang 10C-2 tiada
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit LEWAT datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Besi AK Chambo

IC: 610201-13-5349
No daftar TB: 130424/50/15
54-year-old Ibanese male staying at Lot
1583-Lorong 4, Permyjaya
k/c right lung Ca, Hepatitis B +

Pre-diagnosis
cough x1/52, no hemoptysis, LOW, LOA
History from relative (son)
Patient c/o hemoptysis at night before he
died.
unable to sought any medical treatment

HIV rapid test negative, smoker

body weight 37kg
BCG scar unknown
Mantoux test not done
SAFB 3+
CXR moderate advanced
VDRL NR
Diagnosis: Smear positive PTB

Diagnosed on 9.2.15, Notified on 9.2.15

died on 17.4.15
started forecox 2tabs on 9.2.15
cause of death: unknown

TBIS

Borang health 1 (notifikasi) Ada

Borang 10A-1 Ada
Borang 10A-3
Borang 10C-1 tiada
Borang 10C-2
Borang 10D-1
Borang 10J ada

CONCLUSION
Pesakit TIDAK LEWAT datang
mendapatkan rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Sahlan
Passport No: A 3821626
No daftar TB: 130425/14/15
46-year-old Indonesian male staying at
Samling Plywood Sdn Bhd, Tebanyl
Veneer Mill, Ulu Baram

Pre-diagnosis
Abdominal pain x1/52, altered bowel habit
x1/12.
POI x5/7, LOA,LOW x2/52, feverx1/7
went to KK Tudan on 11/5/15 and referred
to MGH

DM, HIV NR
EBW: 52kg
BCG scar unknown
Mantoux test not done
SAFB +3
CXR moderate advanced
sputum TB CS NG
VDRL negative
Diagnosis: Intrabdominal TB with
enterocutaneous fistula, PTB smear positive new
case

 Admitted on 11.5.15, diagnosed on

13.5.15, notified on 13.5.15; died on
12.6.15 at 9.46am
started forecox 3tabs on 13.5.15
Cause of death: Intrabdominal TB with
sepsis

TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 ada
Borang 10A-3 tiada
Borang 10C-1 ada
Borang 10C-2 ada
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit LEWAT datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
subptimal
Pesakit PATUH rawatan tibi

Name: Usun Ngau

IC: 590608-13-5804
No daftar TB: 130424/148/15
56-year-old Kayan lady staying at 4s 3A,
Pujut, Padang Kerbau Tanjung

 k/c hard palate squamous cell carcinoma

under ENT clinic f/up
latest CECT neck (20/5/15): suggestive of
tumour recurrence with agressive local
infiltration to left mandibular region &
extensive cervical nodal metastasis

Diagnosis: TB lymphadenitis
started forecox on 22/5/15
died on 17/6/15 at home
cause of death: unknown

Borang health 1 (notifikasi) Ada

Borang 10A-1 ada
Borang 10A-3 ada
Borang 10C-1 ada
Borang 10C-2
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit TIDAK LEWAT datang
mendapatkan rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Adzmer Ahalil

No passport
No daftar TB: 130424/178/15
24-year-old Filipino male staying at Lot
4938, Permyjaya
HIV NR, smoker

Pre- diagnosis
Body weakness x2/52, vomiting x2/52, ~5
episodes/day, a/w loose stool x2/52
Abd pain, RIF, burning sensation, x1/52
cough x3/52, LOW x1/12, no night sweat
No PTB contact

HIV rapid test negative, smoker

? body weight
BCG scar unknown
Mantoux test not done
SAFB +3
sputum TB CS NG
CXR moderately advanced
VDRL negative
Diagnosis: PTB smear positive new case &
extra PTB - TB ileocaecal

Started anti TB on 15/6/15

- INH 250mg OD
- RIF 600mg OD
- ETH 800mg EOD
- PZA 1250mg EOD
Admitted to MGH 13/6/15, notified 15/6/15, died
on 17/6/15 @ 11.12am
Cause of death: Severe shock 2 PTB
complicated with multiorgan failure

TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 ada
Borang 10A-3 tiada
Borang 10C-1 tiada
Borang 10C-2
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit LEWAT datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
suboptimal
Pesakit PATUH rawatan tibi

Name: Saifuddin Bin Seri

IC: 641121-13-5383
No daftar TB: 130424/179/15
51-year-old Malay male staying at 7235-128 Permyjaya

Pre-diagnosis
Productive cough x1/12, fever on and off
x1/12, worsening SOB x1/7, cough with
yellowish sputum and haemoptysis x1/7,
pleuritic chest pain, night sweat x1/12

no DM, HIV NR, ? smoker

EBW: 40kg
BCG scar unknown
Mantoux test not done
SAFB +3
CXR moderate changes
sputum TB CS NG
Diagnosis: PTB smear positive new case

 Admitted on 16.6.15, diagnosed on

16.6.15, notified on 21.6.15; died on
20.6.15 at 4.56pm
started forecox 3tabs on 16.6.15
Cause of death: Severe sepsis secondary
to PTB

TBIS

Borang health 1 (notifikasi) tiada

Borang 10A-1 tiada
Borang 10A-3 tiada
Borang 10C-1 ada
Borang 10C-2 ada
Borang 10D-1 tiada
Borang 10J belum

CONCLUSION
Pesakit LEWAT datang mendapatkan
rawatan
Pesakit bukan kontak tibi
Pesakit TIDAK LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
subptimal
Pesakit PATUH rawatan tibi

Name: Mohd Zabani

IC:130424-202-15
No daftar TB: KKT/15/58
61-year-old,melanau, male staying at RH
lot 1646 Tudan Fasa 1
HIV NR , non DM,no Smoker

Pre-diagnosis
Sign and Symptom:
-Coughing more than one month
-low of appitite
-lose of weight
- no hemoptysis
Body weight: 49kg
No BCG scar
Mantoux test not done
SAFB positive
TB CS pending

CXR moderate changes

Diagnosis: PTB smear positive New
Case
Start treatment on 8.7.15 at TBCP Tudan
a) intensive phase
-started on forecox 3 tablets OD
-Pyridoxine 20mg OD
-Tab multivitamin 1 tablet OD
(9 days on intensive phase)

 19.7.15 Pt died at home @ 8am

(informed by relative pt)

Borang TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 ada
Borang 10A-3 ada
Borang 10C-1 ada
Borang 10C-2 ada
Borang 10J belum

Pesakit LEWAT datang mendapatkan

rawatan
Adakah pesakit dikenalpasti sebagai
kontak pesakit tibi tetapi tidak disaring?
Pesakit LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
subptimal
Pesakit PATUH rawatan tibi

Name: Serian anak pengabang

IC: 350708-13-5235
No daftar TB: SA /14/113
79-year-old IBAN male staying at RH
Langgau ,Jungkong,95000 Sri Aman
HIV NR , non DM, EX Smoker

Pre-diagnosis
Sign and Symptom:
-Coughing for two weeks
-giddness (on& off)
-Generalised bodyweakness
26.12.14 :Admit male medical ward hospital sri
aman
28.12.14 pt discharges from hospital.
Relative pt request follow up at tbcp miri
Folder pt sent to miri and tbcp miri received on
27 januari 2015

Body weight: 39.5kg

BCG scar
Mantoux test not done
SAFB negative
TB CS NG
CXR moderate changes
Diagnosis: PTB smear negative New
Case

Treatment
A) intensive phase
-started on forecox 3 tablets OD
-Pyridoxine 20mg OD
-Tab multivitamin 1 tablet OD
-Complete intensive phase @26.2.15(60 days)
B) Maintainance phase

27.2.15 @ started on :
-Tab INH 200mg OD
- Cap. Rifampicin 450mg OD
- Tab. Pyridoxin 20mg OD
-Tab multivitamin 1 tablet OD
- 115 days on maintainance phase

History from relative

4.6.15 @ 11 am :patient nearly fainted at

home and sent pt to Columbia Hospital
Miri then admited till 11.6.15
Pt discharge and back home
On 12.6.15 his son bring pt back home
town at Sri Aman
20.6.15 pt died at home
Family pt put OPD card pt inside coffin

Borang TBIS

Borang health 1 (notifikasi) ada

Borang 10A-1 ada
Borang 10A-3 ada
Borang 10C-1 ada
Borang 10C-2 ada
Borang 10J belum

Pesakit LEWAT datang mendapatkan

rawatan
Adakah pesakit dikenalpasti sebagai
kontak pesakit tibi tetapi tidak disaring?
Pesakit LEWAT dilakukan diagnosa
Pesakit TIDAK mendapat rawatan
subptimal
Pesakit PATUH rawatan tibi