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  #1  
Old 03-17-2013
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Question Homeless with TB

Archers question - RS

A 36 year old homeless man is evaluated in the Emergency Room for intermittent fever, cough, night sweats and weight-loss. He also reports having chronic cough with progressively increasing bloody expectoration for the past 1 month. He has lost about 10lbs weight over the past 3 months. He smokes 1 pack per day and has a history of intravenous drug abuse. On examination, he is cachectic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%. Reminder of the physical examination is unremarkable. Which of the following is the most appropriate initial step in managing this patient?
A) Sputum samples for Acid Fast Bacilli
B) Start Multi-drug therapy for Tuberculosis
C) Obtain a Chest X-ray
D) Tuberculin Skin test
E) Air-Borne Isolation
F) Test for HIV
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Old 03-17-2013
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Question A

A, I guess.
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Old 03-17-2013
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Wouldn't it make more sense to isolate the patient first, and reduce the risk of transmission?
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Old 03-18-2013
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Quote:
Originally Posted by docwedsengr27 View Post
Wouldn't it make more sense to isolate the patient first, and reduce the risk of transmission?
Yea seems like. What is your answer mbbs2010?
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Old 03-18-2013
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I picked E too - cos its the first thing to do before you do anything else.
plus its NO cost and NO intervention. (likely answer on the usmle

though the popular answer seems to be CXR or sputum for AFb

will post the answer once they put it up.
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Old 03-19-2013
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Correct Answer Correct Answer

yup we were correct

Answer . E . Airborne isolation first. Hemoptysis carries a high risk of infectivity if this patient has TB. If we were to choose CXR option, if he has cavitary TB or sputum +ve TB ; we would be putting radiology personnel and other ER staff at risk for TB exposure until CXR is obtained! Hence, these simple concepts can be still be difficult unless we know the accurate step by step approach and the rationale for such approach.
If three sputum samples are negative, isolation can be discontinued even if he has positive chest x-ray findings. Sputum AFB smears determine infectivity. If they are negative , infectivity is very low. Remember negative AFB smear does not rule out TB ( most often they are negative even in active pulmonary TB therefore, we start empiric TB therapy and wait cultures which takes about 6 weeks) . The only thing that negative sputum smears exclude is infectivity so, giving you a green signal to discontinue airborne isolation.
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