Tuberculosis - I.T. Pyatnochka 2005

Diagnostic methods for tuberculosis patients

According to the Concept of the National Tuberculosis Control Program in Ukraine, the Diagnosis of this disease is carried out in two stages: detection of the disease and ESTABLISHMENT OF THE diagnosis. Tuberculosis detection is performed in general healthcare facilities based on patient Complaints, medical history, physical examination, sputum smear Cell/15.html">Microscopy for MBT, and chest X-ray Examination.

There are three main tactical approaches for general healthcare facilities regarding tuberculosis detection:

a) if acid-fast bacilli (AFB) are detected in at least one sputum sample and there are radiological changes suspicious for tuberculosis, the patient must be referred to a tuberculosis facility for further evaluation to confirm or rule out the diagnosis;

b) if MBT are not detected in any of the three examined sputum smears, but infiltrative or focal Changes in the Lungs are determined radiologically, broad-spectrum antibiotic test-therapy lasting up to 2 weeks is administered. Drugs with antituberculosis activity (streptomycin, kanamycin, amikacin, capreomycin, rifampicin, mycobutin, fluoroquinolones) must not be used. If there is no response to the antimicrobial broad-spectrum therapy, the patient must be referred to a tuberculosis facility for additional examination;

c) if acid-fast Bacteria are not detected in any of the three examined sputum smears, but dissemination, a round formation, a cavity, enlargement of intrathoracic Lymph Nodes, or Pleurisy is radiologically determined in the lungs, the patient must be referred to a tuberculosis facility for further examination, including instrumental Diagnostics, for morphological, cytological, and microbiological verification of the diagnosis.

Establishment of a tuberculosis diagnosis is carried out in specialized tuberculosis medical facilities through a more comprehensive examination, which includes sputum microscopy for MBT, sputum culture (including drug susceptibility testing for antituberculosis drugs), and an adequate chest X-ray examination. In case of negative results of diagnostic material microscopy for MBT in the presence of clinical and radiological symptoms that give grounds to suspect tuberculosis, material obtained from the affected area via biopsy is examined, and cytological and morphological studies are performed.

In general, Methods for examining patients with respiratory diseases, including tuberculosis, are conventionally divided into three groups.

The first group consists of mandatory methods, which include Clinical examination of the patient (complaints, medical history, inspection, Palpation, Percussion, Auscultation), thermometry, radiological examination (Overview and lateral chest radiography, tomography of affected lung areas), three-time sputum examination for AFB by Ziehl-Neelsen microscopy, three-time sputum analysis for MBT by culture on Löwenstein-Jensen medium, the Mantoux tuberculin Skin test (2 TU), complete Blood and urine counts, and drug susceptibility testing for antituberculosis drugs.

The second group includes additional methods: tomography (computed tomography) of the lungs and Mediastinum, fibrobronchoscopy, immunological tests, instrumental examinations (bronchoscopy, biopsy, bronchography, pleuroscopy), and trial therapy.

The third group consists of optional methods: investigation of external Respiration, Circulation, Liver function, and other Organs and systems.

According to the Order of the Ministry of Health of Ukraine No. 499 dated October 28, 2003, a specific scope of examination is outlined for cohorts of children, adolescents, and adults under dispensary observation, depending on the specific category and observation group, as shown in Tables 12 and 13.

Tuberculosis is an infectious disease caused by MBT, characterized by The Development of specific inflammation in the affected organs and a polymorphism of clinical signs—namely, intoxication and local syndromes.

Among A number of probable manifestations of general tuberculous intoxication, general weakness, malaise, decreased performance, sweating, loss of appetite, weight loss, Sleep disturbances, and fever are most frequently observed. Body Temperature in tuberculosis patients can vary: normal, subfebrile, febrile, or even hectic. However, subfebrile temperature is most common, characterized by pronounced lability and lack of monotony. Patients often tolerate elevated body temperature relatively well.

At the onset of the disease, sweating is insignificant. In pronounced exudative and caseous specific processes, profuse sweats are typical, predominantly at night.

Local manifestations of Pulmonary Tuberculosis include prolonged cough, sputum production, hemoptysis, chest pain, and shortness of breath.

Cough is the most frequent symptom in patients with pulmonary tuberculosis. In initial forms of the process, the cough is quiet, infrequent, in the form of a mild, prolonged clearing of the throat. Uncontrollable, paroxysmal, loud coughing is characteristic of patients with tuberculous bronchoadenitis and tuberculous endobronchitis.

At the disease onset, sputum may be absent or very scanty. As the tuberculous process progresses, particularly when destructive, a patient may produce up to 200 ml of sputum, which is mucous or mucopurulent in character and almost odorless.

Chest pain often occurs early in the disease, caused by an extensive process in the lungs. Acute, sudden pain occurs in Spontaneous pneumothorax.

Shortness of breath is not typical for initial forms of tuberculosis, with the exception of Miliary tuberculosis and exudative pleurisy. In chronic disseminated processes complicated by respiratory or cardiopulmonary failure, shortness of breath can be markedly pronounced.

Hemoptysis and hemorrhages can occur in any form and phase of the process, but more frequently in destructive forms of tuberculosis, and less commonly in post-tuberculosis pneumosclerosis with Bronchiectasis. Hemoptysis is characterized by the presence of streaks or admixtures of blood in the sputum, or individual spits of blood. In Pulmonary Hemorrhage, a significantly larger amount of pure blood is coughed up at once (over 10 ml), either continuously or intermittently. The blood is usually bright red, foamy, with small air bubbles, and tends not to clot. After the cessation of bleeding or hemoptysis, blood clots are coughed up for several days, and body temperature rises due to blood aspiration.

In extrapulmonary forms of tuberculosis, In addition to general symptoms caused by intoxication, local manifestations of the disease also occur.

The onset of tuberculosis can be asymptomatic, subacute, and rarely acute. When interviewing the patient, it is very important to find out whether there was contact with tuberculosis patients. By the way, individuals living in the focus of a tuberculosis infection (a tuberculosis patient shedding mycobacteria, the dwelling where the bacteria excretor lives, and persons living with them) fall ill with tuberculosis 5–10 times more often. Information about a past history of "flu," Pneumonia, or exudative pleurisy—under the guise of which tuberculosis can occur—as well as concomitant diseases, working conditions, bad habits, etc., is of great importance.

During an external physical examination in initial forms of tuberculosis, patients show no visible deviations from the norm. However, in most patients at later Stages of the disease, manifestations of tuberculous intoxication can be detected: eye brilliance, hectic flush against the Background of a pale facial skin; paraspecific manifestations in tuberculosis (erythema nodosum, keratoconjunctivitis, phlyctenules), enlarged peripheral lymph nodes, fistulas or scars following them, and chest deformity. Palpation often reveals decreased skin turgor and Muscle tone, micropolyadenitis, and a positive Rubinstein "phrenic" symptom (placing two fingers above the Sternum on the sides of the Trachea can reveal its displacement toward the affected side), which is observed in unilateral lung cirrhosis and Atelectasis. Enhanced vocal fremitus is noted over areas of infiltration or cirrhosis, while diminished fremitus is observed in exudative pleurisy and pneumothorax.

Percussion reveals a shortened and dull percussion sound over airless lung tissue or in areas of reduced aeration due to infiltrates, fibro-focal changes, and exudative pleurisy. A tympanitic sound occurs over tension spontaneous pneumothorax and giant cavities. However, shortening of the percussion sound is more frequently observed over a cavity. The height of the lung apex standing and the width of Krönig's fields are reduced due to focal, infiltrative, or fibrotic changes in the upper lung segments.

Auscultation should be performed sequentially over symmetrical areas of the lungs while the patient breathes quietly and deeply with a half-open Mouth. To provoke rales, the patient should be asked to cough lightly at the end of exhalation. During this Procedure, the physician should stand to the side of the patient to avoid infection.

It is necessary to determine the type of breath sounds (vesicular, bronchial, mixed) and adventitious sounds (moist and dry rales, crepitation, pleural friction rub). Diminished vesicular breathing is detected in pulmonary emphysema, exudative pleurisy, pneumothorax, and obesity; enhanced vesicular breathing is observed in weight loss, cirrhosis, and infiltrative pulmonary processes. Harsh or bronchial breathing may be auscultated over condensed lung tissue (infiltrate, cirrhosis, fibrosis), while amphoric breathing is heard over a large cavity with fibrotic walls and a wide draining bronchus. Local moist rales heard after coughing in "alarm zones"—anteriorly above and below the clavicle, posteriorly over the lung apices, near the scapular spine, and between the scapulae—are of crucial diagnostic importance. Local fine moist rales indicate the onset of pulmonary tissue destruction, whereas medium and coarse moist rales indicate a cavity. Furthermore, medium or coarse moist rales over the upper lung fields are a significant sign of a breakdown cavity. Dry rales occur in Bronchitis, and wheezing rales occur in bronchitis with bronchospasm. A pleural friction rub is auscultated in dry (fibrinous) pleurisy.

CONTROL QUESTIONS

1. Local and general complaints of a patient with tuberculosis.

2. Specific features of the medical history and lifestyle of a patient with tuberculosis.

3. The Significance of contact with a tuberculosis patient in the Development of the disease.

4. Features of the physical examination of a patient with pulmonary tuberculosis (facial expression, potential skin changes, chest shape).

5. Palpation of peripheral lymph nodes, assessment of vocal fremitus, and Rubinstein's "Thymus" sign.

6. Comparative and topographic percussion, lung borders, apex standing height, and Krönig's isthmuses.

7. Auscultation (Types of breathing, dry and moist rales, pleural friction rub).

8. Name the "alarm zones" where auscultatory changes are most frequently present in pulmonary tuberculosis.

TESTS

1. Patient P. has infiltrative Tuberculosis of the upper lobe of the right lung, destruction phase, MBT (+). What respiratory sounds would you expect to hear over the affected areas?

A. Dry wheezing rales

B. Crepitation

C. Pleural friction rub

D. Bronchial breathing

E. Moist rales of various calibers

2. A tuberculosis patient has a percussion sound with a tympanic tint over the upper region of the right lung, and amphoric breathing upon auscultation. What pulmonary changes should be suspected?

A. Infiltration of lung tissue

B. Pulmonary cirrhosis

C. Atelectasis

D. Giant cavity

E. Spontaneous pneumothorax

3. A six-year-old boy with a Primary tuberculous complex presents with a pleural friction rub auscultated over the lower right chest. What pathological changes should be suspected?

A. Spontaneous pneumothorax

B. Dry pleurisy

C. Exudative pleurisy

D. Pleuropneumonia

E. Pleural Empyema

4. Patient S. presents with the "fork" sign. What pathological changes should be suspected?

A. Primary tuberculous complex

B. Spontaneous pneumothorax

C. Pulmonary cirrhosis

D. Dry pleurisy

E. Tuberculosis of intrathoracic lymph nodes

5. A patient with pulmonary tuberculosis has medium-bubbling moist rales auscultated between the shoulder blades. What do these changes indicate?

A. Focal changes in the lung tissue

B. Bronchitis

C. Presence of destruction cavities

D. Spontaneous pneumothorax

E. Atelectasis

6. What type of breathing is characteristic in the PROJECTION OF THE lesion in Infiltrative pulmonary tuberculosis?

A. Vesicular

B. Amphoric

C. Mixed

D. Bronchial

E. Cogwheel

7. When interviewing a patient with suspected tuberculosis, the most important factor is:

A. Marital status of the patient

B. Occupation

C. Material and living conditions

D. Contact with a tuberculosis patient

E. Keeping cattle (cows) in the household

8. Which disease can be characterized by the "thymus" sign?

A. Disseminated pulmonary tuberculosis

B. Tuberculoma

C. Dry pleurisy

D. Cirrhotic pulmonary tuberculosis

E. Silicotuberculosis

9. Local manifestations of pulmonary tuberculosis include:

A. low-grade fever, cough, headache, shortness of breath, generalized weakness,

B. hemoptysis, shortness of breath, chest pain, persistent cough, expectoration,

C. pain in The Heart region, low-grade fever, cough, hemoptysis, shortness of breath,

D. pain in the liver region, shortness of breath, cough, hemoptysis, low-grade fever,

E. vomiting, hoarse voice, cough, shortness of breath, expectoration.

10. How many times more frequently do close contacts develop tuberculosis compared to non-contacts?

A. 2-4

B. 5-10

C. 15-20

D. 25-30

E. 31-35

11. During provocation, rales are auscultated twice as often. Method of rale provocation:

A. Deep breathing

B. Breathing through the mouth

C. Gentle coughing at the end of exhalation

D. Nasal breathing

E. Quiet breathing