7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 1/51
Clinical Presentationand Diagnosis of
TuberculosisMakiyatul M
BBKPM Surakarta
International Standards 1-5
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 2/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
Objectives: At the end of this presentation,participants will be able to
Describe the signs!sy"pto"s and risk factors thatshould raise suspicion for the diagnosis of TB
#nderstand the i"portance of sputu" s"ear"icroscopy, as well as the need to obtainspeci"ens for "icrobiologic e$a"ination fro"e$trapul"onary sites
%ecogni&e that C'% alone is not sufficient for thediagnosis of TB
(ist criteria used for the diagnosis of s"ear)negati*e TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 3/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
International Standards 1 2 ! " and 5
Overvie#: +eneral considerations
Signs and sy"pto"s
%ole of AB s"ear %adiographic
presentation
AB s"ear)negati*ediagnosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 4/51
ISTC TB Training Modules 2009
Standards for Diagnosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 5/51
ISTC TB Training Modules 2009
%apid, accuratediagnosis is essential
for indi*idual and
public health
Despite technical
ad*ances, clinical
acu"en with a high
inde$ of suspicion
re"ains *ital to the
diagnosis of TB T$in% TB
unda"ental Principles
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 6/51
ISTC TB Training Modules 2009
-Classic. TB Clinical Presentation
/nsidious onset and chronic course Chest sy"pto"s
• Cough 0usually producti*e1
•
2e"optysis• Chest pain 0usually pleuritic1
3onspecific constitutional sy"pto"s
0"ore co""on in children and 2/41
5$trapul"onary sy"pto"s 0if in*ol*ed1
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 7/51 ISTC TB Training Modules 2009
3onspecific Syste"ic Sy"pto"s
e*er in 67)89: of cases Chills!night sweats
atigue!"alaise Anore$ia!weight loss
However , ;9)<9: of TB cases ha*e no
sy"pto"s at the ti"e of diagnosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 8/51 ISTC TB Training Modules 2009
Diagnosis of TB in 2/4
Cannot rel& on 't&(ical) indicators o* TB
e*er and weight loss are i"portant
sy"pto"s
Cough is less co""on
Chest radiographic pattern "ore *ariable
More e$trapul"onary and disse"inated TB Differential diagnosis is broader
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 9/51 ISTC TB Training Modules 2009
Standard ; Prolonged Cough
All persons withotherwise
une$plained
producti*e coughlasting two)three
weeks or "ore
should bee*aluated for
tuberculosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 10/51 ISTC TB Training Modules 2009
Prolonged Cough
T$in% TB: Prolonged Cough 0<)= weeks1 Cough "ay not be specific for TB,
howe*er, long duration raises likelihood ofTB diagnosis
Criterion for suspecting TB in "ostnational and international guidelines
Percentage of AB s"ear)positi*e sputu"increases with increasing duration ofcough
>ill not identify all TB cases? use bestclinical @udg"ent
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 11/51 ISTC TB Training Modules 2009
Clinical Presentation %isk actors
+is% *or +ecent In*ection Contact with acti*e TB case
ccupational risk eg healthcare worker
Crowded conditions eg @ails, institutionalresidences
%ecent stay in a healthcare facility
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 12/51 ISTC TB Training Modules 2009
Clinical Presentation %isk actors
+is% o* ,rogression to ctive TB 2/4 infection
Abnor"al C'% suggesti*e of prior TB 0withinadeuate treat"ent1
Children 0less than 7 years of age1
#nderlying "edical conditions
• /""unosuppressi*e therapy
• Malnutrition
• Diabetes, renal failure, and other conditions
• Tobacco use, in@ection drug use 0E1
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 13/51 ISTC TB Training Modules 2009
Clinical Presentation Physical 5$a"ination
May be nor"al in "ild"oderate disease Chest rales, rhonchi? absent breath sounds
and dullness to percussion if pleural fluid ispresent
5$trapul"onary 0site specific1 adenopathy,skin lesions, bone tenderness, neck stiffness,etc
The physical e$a"ination is nonspecific, butit is helpful to identify e$trapul"onary sites of
in*ol*e"ent
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 14/51 ISTC TB Training Modules 2009
Standard < Sputu" Microscopy
All patients 0adults,adolescents, and
children who are
capable of producing
sputu"1 suspectedof ha*ing pul"onary
TB should ha*e at
least two sputu"
speci"ens obtained
for "icroscopic
e$a"ination in a uality)assured laboratory
>hen possible, at least one early "ornings eci"en should be obtained
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 15/51 ISTC TB Training Modules 2009
Sputu" Microscopy
To pro*e a diagnosis of TB, e*ery effort "ustbe "ade to identify the causati*e agent
The .B s/ear in high)pre*alence areas is
• 2ighly specific for TB• Most rapid "ethod for deter"ining TB diagnosis
• /dentifies those at greatest risk of dying fro" TB
• /dentifies those "ost likely to trans"it disease
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 16/51 ISTC TB Training Modules 2009
Mase S%, Int J tuberc Lung Dis <99F?;;071 G87)H7
A*erage yield of single early "orning speci"en 86G:
A*erage yield of single spot speci"en F=H:
S(eci/enu/ber
Incre/ental ield o*s/ear s(eci/ens
0of all s"ear positi*e1
Incre/ental Sensitivit&o* s/ear s(eci/ens
0co"pared with culture1
; 878: 7=8:
< ;;H: ;;;:
= <G: =;:
Total 100 340
Perfor"ance of Sputu" Microscopy
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 17/51 ISTC TB Training Modules 2009
5"-&ear-old /an #it$
t$ree /ont$s o* *ocal
lo#-bac% (ain
Can this be TBE
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 18/51 ISTC TB Training Modules 2009
5"-&ear-old /an #it$
t$ree /ont$s o* *ocal
lo#-bac% (ain
Can this be TBE 5$trapul"onary
'PottIs disease.
Signs and sy"pto"s of e$trapul"onary TB are sitespecific
Sa"pling of e$trapul"onary sites for s"ear, culture, andhistopathology "ay confir" diagnosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 19/51 ISTC TB Training Modules 2009
Standard = 5$trapul"onary Speci"ens
or all patients0adults, adolescents,
and children1
suspected of ha*inge$trapul"onary TB,
appropriate
speci"ens fro" the suspected sites ofin*ol*e"ent should be obtained for
"icroscopy, culture, and
histopathological e$a"ination
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 20/51 ISTC TB Training Modules 2009
Pul"onary, F;:
5$trapul"onary, <9:
Both, H:
Pleural, ;8:
(y"phatic, G<:
Bone!@oint, ;;: +enitourinary, 7:
Meningeal, 7:
ther, ;=:
TB Cases b& .or/ o* 6isease
7nited States C6C 2004 Peritoneal, 6:
5$a"ple of 5$trapul"onary Sites
Incidence8site /a& var& TB can involve an& organ
More co//on in I8TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 21/51 ISTC TB Training Modules 2009
5$trapul"onary Tuberculosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 22/51 ISTC TB Training Modules 2009
%adiographicPresentation
of TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 23/51 ISTC TB Training Modules 2009
Standard G 5*aluation of Abnor"al C'%
All persons withchest radiographic
findings suggesti*e
of tuberculosisshould ha*e sputu"
speci"ens
sub"itted for"icrobiological
e$a"ination
ISTC Training Modules 2004
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 24/51 ISTC TB Training Modules 2009
Can this be TBE
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 25/51
ISTC TB Training Modules 2009
6istribution Apical ! posterior
seg"ents of upper lobes
Superior seg"ents oflower lobes
/solated anterior seg"entin*ol*e"ent is unusual
Can this be TBE
T&(ical ,attern:+eactivation,ost-(ri/ar& TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 26/51
ISTC TB Training Modules 2009
%eacti*ation!Post)pri"ary TB
,atterns o* disease Air)space consolidation
Ca*itation, ca*itary
nodule Miliary
ibro)nodular densities
3odule 0Tuberculo"a1 Pleural effusions
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 27/51
ISTC TB Training Modules 2009
Can this be TBE
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 28/51
ISTC TB Training Modules 2009
Can this be TBE
Distribution Any lobe in*ol*ed 0slight lowerlobe predo"inance1
Air)space consolidation
Ca*itation is unco""on0J ;9:1
Adenopathy is co""on0esp in children and 2/41
Miliary pattern
t&(ical (attern:,ri/ar& TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 29/51
ISTC TB Training Modules 2009
Can this be TBE
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 30/51
ISTC TB Training Modules 2009
Can this be TBE Miliary TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 31/51
ISTC TB Training Modules 2009
Can this be TBE
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 32/51
ISTC TB Training Modules 2009
Can this be TBE
.indings suggestive o*
(rior TB
Ca granulo"a +hon
lesionCa granulo"a and hilar
node calcification %ankeco"ple$
Apical pleuralthickening
ibrosis and*olu"e loss
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 33/51
ISTC TB Training Modules 2009
C'% /ssues
%eliance on chest radiograph aloneresults in both o*er)diagnosis and "isseddiagnosis of TB and other diseases
%adiography needs to be held to highstandards of technical uality andinterpretation
%esults of poor i"aging uality "ay be
har"ful to patient care
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 34/51
ISTC TB Training Modules 2009
5*aluation of Abnor"al C'%
Stud& *ro/ India:2229 out(atients evaluated b& C;+8culture
f <<F cases dee"ed TB by C'% alone•
=6: had negati*e sputu" cultures for TB f ;FF culture)positi*e cases of TB
• ;8: would ha*e been "issed based on C'%alone
C'% alone is not enough
3agpaul D%, Proceedings of the Hth 5astern %egion Tuberculosis Conference
and <Hth 3ational Conference on Tuberculosis and Chest Diseases ;HFG Delhi,
as cited in Toman’s tuberculosis. Case detection, treatment and monitoring,
2 nd Edition >orld 2ealth rgani&ation, <99G
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 35/51
ISTC TB Training Modules 2009
The diagnosis of s(utu/ s/ear-negative pul"onarytuberculosis should be based on the following criteria
At least two negati*e sputu" s"ears 0including at
least one early "orning speci"en1
Chest radiography findings consistent with
tuberculosis
(ack of response to a trial of broad)spectru"
anti"icrobial agents03ote Because the fluorouinolones are acti*e against M.
tuberculosis co"ple$, and thus "ay cause transient i"pro*e"ent in
persons with tuberculosis, they should be a*oided1
Standard 7 S"ear)negati*e Diagnosis
0; of <1
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 36/51
ISTC TB Training Modules 2009
0Continued1 or such patients, sputu" cultures should
be obtained
/n persons who are seriously ill or ha*eknown or suspected 2/4 infection, thediagnostic e*aluation should be e$peditedand if clinical e*idence strongly suggests
tuberculosis, a course of antituberculosistreat"ent should be initiated
Standard 7 S"ear)negati*e Diagnosis
ISTC Training Modules 2004
0< of <1
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 37/51
ISTC TB Training Modules 2009
Clinical assess/ent I test;
s(utu/ s/ear /icrosco(&
t least 2 s(utu/ s(eci/ens .B negative
I < and8or severe illness2
I- /ild8/oderate illness2
; %eco""ended in countries or areas with adult 2/4 pre*alence L;: orpre*alence a"ong TB cases L7:
< Se*ere illness respiratory rate L=9 breaths!"in, te"perature L=HNC, pulseL;<9 beats!"in, unable to walk unaided, sy"pto"s!signs progressing rapidly
TB Diagnostic Algorith"S,7T7M SM=+-=>TI= TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 38/51
ISTC TB Training Modules 2009
I < and8or severe illness
S,7T7M SM=+-=>TI= TB
Clinical!radiographic findingsOT suggestive of TB
3egati*e culture
Consider ot$er diagnoses
ot TB
• Clinical!radiographic findingssuggestive of TB
• Positi*e or negati*e culture
Treat 0e"piric TB treat"ent before confir"eddiagnosis if se*ere illness1
• I staging ? =valutate *or +s ? C,T (ro($&la@is
%epeat clinical assess"ent Chest radiograph Sputu" culture 0or other test1
Parenteral broad)spectru"anti"icrobials 0e$cludingfluorouinolones1
TB Diagnostic Algorith"
TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 39/51
ISTC TB Training Modules 2009
IA /ild8/oderate illness
S,7T7M SM=+-=>TI= TB
Broad-s(ectru/ anti/icrobials0e$cluding anti)TB drugs and fluorouinolones1
Consider ot$er diagnosis
%epeat clinical assess"ent Chest radiograph Sputu" culture 0or other test1
Treat
TB Diagnostic Algorith"
O IM,+O=M=T
ot TB ot TBTB
Clinical!radiographic findings OT suggestive of TB
3egati*e culture
Clinical!radiographicfindings suggestive of TB
Positi*e culture
IM,+O=M=T
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 40/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
dditional (oints: Sy"pto"s!se*erity none to o*erwhel"ing
Te"po of illness ranges fro" indolent to fast
TB can in*ol*e any organ or tissue
Signs!sy"pto"s "ay be both local andsyste"ic
Consider 2/4 testing in the diagnostice*aluation
TB is capable of presenting in "any ways
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 41/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
Su//ar&:
T$in% TB A prolonged duration of cough should raise TB
suspicion and trigger a diagnostic e*aluation
TB risk factors and e$posure increase le*el ofsuspicion
AB s"ear in high)pre*alence areas is highlyspecific and "ost rapid tool for diagnosing TB
%adiographic patterns "ay help in TB diagnosisif suspicion high and AB s"ear is negati*e, buta radiograph alone is not enough to "akediagnosis
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 42/51
ISTC TB Training Modules 2009O Abbre*iated *ersions
Su""ary /STC Standards Co*eredO
Standard 1: #ne$plained producti*e cough lasting<)= weeks or "ore should be e*aluated for
tuberculosis
Standard 2: All TB suspects should ha*e at least
< sputu" speci"ens obtained for "icroscopic
e$a"ination 0at least one early "orning
speci"en if possible1 in a uality)assured
laboratoryStandard !: Speci"ens fro" suspected
e$trapul"onary TB sites should be obtained for
"icroscopy, culture and histopathological e$a"
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 43/51
ISTC TB Training Modules 2009
Su""ary /STC Standards Co*eredO
O Abbre*iated *ersions
Standard ": All persons with chest radiographicfindings suggesti*e of TB should ha*e sputu"
speci"ens sub"itted for "icrobiological
e$a"ination
Standard 5: The diagnosis of s"ear)negati*e
pul"onary TB should be based on the following
at least two negati*e sputu" s"ears 0including at
least one early "orning speci"en1? C'% findingconsistent with TB? lack of response to broad)
spectru" antibiotics 0a*oid fluorouinolones1, and
culture data 5"piric treat"ent if se*ere illness
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 44/51
ISTC TB Training Modules 2009
lternate Slides
Purpose of /STC
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 45/51
ISTC TB Training Modules 2009
Purpose of /STC
/STC K P i t
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 46/51
ISTC TB Training Modules 2009
/STC Key Points
<; Standards 0re*ised!renu"bered in <99H1 Differ fro" e$isting guidelines standards
present what should be done, whereas,
guidelines describe how the action is to be
acco"plished
5*idence)based, li*ing docu"ent
De*eloped in tande" with atients’ C!arter
"or Tuberculosis Care
Handboo# "or using t!e International
$tandards "or Tuberculosis Care
/STC K P i t
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 47/51
ISTC TB Training Modules 2009
udience: all health care practitioners,public and pri*ate
Sco(e: diagnosis, treat"ent, and public
health responsibilities? intended toco"ple"ent local and national guidelines
+ationale: sound tuberculosis control
reuires the effecti*e engage"ent of all
pro*iders in pro*iding high uality care and
in collaborating with TB control progra"s
/STC Key Points
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 48/51
ISTC TB Training Modules 2009
uestions
Cli i l P t ti d Di i f TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 49/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
1 A =< year)old "an co"plains of cough and"alaise for the past three weeks 2is wife is
currently being treated for acti*e tuberculosis f
the following choices, your *irst ste( would be
A Begin an e"piric trial of treat"ent with afluorouinolone antibiotic for a possible co""unity)
acuired pneu"onia
B btain a chest fil" to confir" your suspicion for TB
which will "ake sputu" testing unnecessaryC btain two sputu" speci"ens for AB "icroscopy
0including at least one early "orning speci"en1
D Both answers A and C
Cli i l P t ti d Di i f TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 50/51
ISTC TB Training Modules 2009
Clinical Presentation and Diagnosis of TB
2 /n high pre*alence areas, the AB sputu""icroscopy s"ear
A /s highly specific for TB
B /dentifies those at greatest risk of dying fro" TB
C /dentifies those "ost likely to trans"it disease
D All of the abo*e
Cli i l P t ti d Di i f TB
7/18/2019 Clinical Diagnosis Nov2009 [Autosaved]
http://slidepdf.com/reader/full/clinical-diagnosis-nov2009-autosaved 51/51
Clinical Presentation and Diagnosis of TB
! A 7G year)old wo"an co"plains of cough, fe*er,and une$pected weight loss o*er the past
"onth She ad"its s"oking ;9 cigarettes per
day for o*er <9 years Two sputu" s"ears were
negati*e for AB ou would consider each ofthe following e@ce(t
A An e"piric trial of antibiotics 0non)fluorouinolone1
B btaining a chest fil" for further e*aluation
C A trial of bronchodilator "edication alone and
follow)up in = "onths
D Sending sputu" speci"ens for AB culture