Tuberculosis physical examination and management

Tuberculosis physical examination and managementCreated OnMay 29, 2020Last Updated OnMay 29, 2020byadmin You are here: Main Clinical Examination Tuberculosis physical examination and management < All Topics Table of Contents General examination: Vital signs Temperature (fever, night sweat) Pulse rate of tachycardia/bradycardia (rate,rhythm,volume) Respiratory rate of >30 breath/min if severe Blood pressure (normotensive? Hypotensive?) SpO2 <95 % Observation Assess the level of consciousness – Indicate the severity Note the build of the patient, thin build, muscle wasting may suggest malignancy (Mesothelioma(rare), secondary metastasis) or Tuberculosis Note whether patient can speak in words/ phrases/ sentences/ couldn’t speak Dyspnea, count respiratory rate Observe for any signs of distress Pleuritic chest pain Respiratory distress Diaphoresis Cyanosis Current oxygen therapy – Nasal prongs/ Simple face mask/ High flow mask/ Venturi mask, connected to oxygen (how many litre/min) Bedside Sputum culture container – suspected TB Waste bin to look for hemoptysis Skeletal muscle Look for cachexia Neck Look for cervical lymphadenopathy (firm, fixed, non-tender) Look for neck stiffness (TB meningitis) Look for cold abscess Spine Look for cold abscess Ask for any backaches (Pott’s disease) Eye Phlycten Choroid tubercle (ocular TB) Skin Lichen scrofulosorum Erythema nodosum Lupus vulgaris Systemic examination (Right pleural effusion) Inspection Decreased movement at the right side of chest Chest tube/injection mark seen Look for BCG scar* Palpation Trachea shifted to opposite side Apex beat shifted Chest expansibility reduced on right side Vocal fremitus reduced Percussion Stony dull on right side Auscultation Reduced/absent breath sound Reduced vocal resonance Bronchial breath sound over effusion area Cardiovascular Examination Inspection Visible apex beat Palpation Shifted apex beat (Cardiomegaly) Ausculation Listen to heart beat, any murmur, S3 gallop Abdominal Examination Inspection Abdominal distension Palpation Palpable mass? -Liver? Pelvic mass (ovarian mass)? Percussion Liver span (any hepatomegaly? Ascites? Investigation : Sputum AFB (min. 3 sputum in 2mths) Ziehl-Nielsen stain Mycobacterium C&S Lowenstein Jensen medium – 10x more sensitive CXR (symptomatic + risky patient) TB serology- Not for dx PTB or extrapulmonary TB ESR Mantoux test: Preferred in latent TB infection Quantiferon gold test (99% specificity, unaffected by previous BCG) Bronchoscpe (take a better sample of sputum, if you see a mass you can cut it straight) Patchy opacity in right upper segment of the lung Ziehl Neelsen stain Acid fast bacilli Lowenstein Jensen medium Small buff coloured colonies Mantoux test/tuberculin test: Intra-dermal injection of a standardised amount of TB protein (no living bacilli!) Measure reaction at 72 hours < 5 mm = neg 5 – 10 mm = could be due to BCG > 10 mm = suspicious But ~ 40% of sputum +ve PTB cases are <10 mm TB prophylaxis: *screening for asymptomatic contact: Mantoux, CXR, Sputum AFB   Contact tracing >8hr contact (any person staying under same roof) Family Friends/work CXR & Mantoux test Symptomatic Evaluate for active TB (CXR, Mantoux, Sputum AFB)   Asymptomatic (do mantoux test first) +ve Mantoux test, normal chest x-ray, no symptoms: TB prophylaxis (LTBI) +ve Mantoux test, normal chest x-ray, with symptoms: TB prophylaxis All -ve: no prophylaxis, follow up in 2 months   TB prophylaxis Isoniazid 6-9months Vitamin B6 Follow up 2 months Treatment: Notify & tracing procedure (From Dato’ Dr. Abdul Razak- IPR, bedside teaching) Notify PKD within 2 days (if failed to do so: RM500 fine) Then PKD will notify PHI. Contact tracing will be conducted for the patient’s close contact at the nearest KK for screening **Malaysia target 80% contact to be screen. 1-2% become positive**   AntiTB 6-month regimen (daily 2-month of EHRZ followed by daily 4-month of HR) if not compliance: drug-resistant TB Drug Daily maximum dose in mg Side effects Isoniazid (H) 300 Vitamin B6 deficiency Hepatitis Peripheral neuropathy Rifampicin (R) 600 Orange colour urine Hepatitis Pyrazinamide (Z) 2000 Hepatitis Hyperuricemia Ethambutol (E) 1600 Optic neuritis Colour blindness Streptomycin (S) 1000 Renal failure Deafness *Ethambutol can be replaced by streptomycin if drug resistance/toxicity TB drugs and common investigation needed Ethambutol FBC, RBS Isoniazid RP, CXR Rifampicin LFT, HIV screening test Pyrazinamide Mycobacterium tuberculosis C&S 6 months treatment flow chart Visits Duration Regime Investigations 1 Start of Tx EHRZ/SHRZ FBC, RBS, RP, LFT, HIV, Sputum AFB direct smear Sputum MTB C&S, CXR 2 2 – 4 weeks EHRZ/SHRZ LFT...

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