Pulmonary tuberculosis

Diagnosis: The suspected reactivation pulmonary tuberculosis — the chronic cough (the 6 weeks), the haemoptysis, the night sweats, the weight loss, the migrant from the endemic region, and the right upper-lobe cavity on the radiograph.

Management:

1. The suspect, the isolate, the sputum, the notify.
2. The respiratory isolation at the suspicion — the airborne precautions, the negative-pressure room, the N95 mask for the staff (BEFORE the confirmation).
3. The three sputum samples (the morning and the spot) for the AFB smear, the culture, and the NAAT (the GeneXpert) — the GeneXpert detects the rifampicin resistance.
4. The bloods — the full blood count, the liver function (the baseline for the RIPE), the renal function, and the HIV test.
5. The public-health notification — the TB is the notifiable disease; the contact tracing.
6. The RIPE therapy — the rifampicin, the isoniazid, the pyrazinamide, the ethambutol for the 2 months, then the rifampicin and the isoniazid for the 4 months. The pyridoxine with the isoniazid. The baseline visual acuity for the ethambutol. The liver-function monitoring.
7. The disposition — the admission for the unwell, the cavitation, the social instability, or the MDR-suspected; the discharge with the isolation instruction and the public-health and the follow-up for the well.^[2]

Common errors

The failure to isolate at the suspicion; the omission of the three sputum samples; the missing of the HIV test; and the discharge of the unwell without the admission — each restates the cited model-answer teaching above.^[2]

Examiner notes

Credit for: the reactivation picture (the cavity, the endemic region); the airborne precautions; the three sputum samples with the GeneXpert; the RIPE therapy; and the public-health notification.^{[2] [2]}The cardinal principle: The isolation and the airborne precautions at the SUSPICION, before the confirmation.