CCS - Tuberculosis (cough)

Question 1

PRESENTATION

Common Features of Tuberculosis

Answer 1

• Middle-age
• Immigrant (South-East Asia and Western Pacific regions, African, Latin Amer.), Homeless, or Incarcerated
• Hx of Cough (3 - 6 weeks)
• Low-grade Fever
• Yellow Sputum (for a week prior to appt.)
• Smoker
• Hemoptysis
• Weight Loss
• Night Sweats and Chills

Question 2

PHYSICAL EXAMS

Physical Exams for Tuberculosis

Answer 2

• General Appearance - Thin with Cough
• HEENT - normal
• Lymph Nodes - normal
• Lungs - Rales and Rhonchi heard over Apex
• Heart - normal
• Abdomen - normal
• Extremities/Spine - normal

Question 3

DIAGNOSIS

Orders for Tuberculosis

Answer 3

1. CXR (PA/Lateral) - apical cavity w/ small pleural effusion & hilar adenopathy
2. Sputum
   
   • AFB smear (+)
   • Mycobacterial culture
   • PCR mycobacterial RNA
3. PPD (+) & HIV Ag, ELISA
4. CBC, BMP, LFT, Uric acid

Question 4

TREATMENT

Therapy for Tuberculosis

Answer 4

Location:

• Inpatient
• Reverse isolation - until 3 sputum AFB smears are negative

Medications:

• Rifampin
• Isoniazid (+ Pyridoxine)
• Pyrazinamide
• Ethambutol
• Management should be instituted within the 1st day

Directly observed therapy

Notify public health department

Question 5

MONITORING

Follow-up Management for Tuberculosis

Answer 5

• Sputum AFB smear daily while on isolation - until 3 negative results
• At 1 month - TB PCR RNA
• At 2 months
  
  • TB PCR RNA
  • CXR (PA/Lat)

Question 6

SEQUENCING

CCS Order Sequence for Tuberculosis

Answer 6

1. Physical Exams - General Appearance, HEENT, LNs, Lungs, Heart, Abdomen, Extremities/Spine
2. Orders - CXR (PA/Lat)
3. Clock - advance to CXR results (apical cavity)
4. Location - Inpatient w/ Reverse Isolation
5. Orders - Sputum studies, PPD, HIV test/ELISA, CBC, BMP, LFT, Uric acid
6. Clock - advance to Sputum results (positive AFB)
7. Orders - Rifampin, Isoniazid (+ Pyridoxine), Pyrazinamide, Ethambutol, Directly observe therapy, Notify public health department
8. Clock - advance to additional lab results, patient updates and case end.
9. End Orders - Sputum AFB smear daily until 3 negative results.