Examine this patient's chest.



· Fever and night sweats.

· Malaise, fatigue, anorexia.

· Weight loss.

· Cough with sputum.


These'patients tend to have signs of common chest diseases which are not cut and dried. There are several masons for this, such

as pleural thickening, thoracotomy and pneumonectomy, associated COAD, associated chest infection, plombage or phrenic nerve


The following provide some examples:

Patient 1

The candidate was asked to examine the chest from the front, as a result of which the old thoracotomy scar was not seen. The

patient was wheezy. The trachea was deviated to the right. Percussion note was stony dull from the right second inter-costal space

downwards. Wheeze was present on the left side. This patient had a right pneumonectomy with COAD in the left lung. The

candidate's diagnosis of right-sided pleural effusion with underlying collapse and left-sided COAD was accepted.

Patient 2

The trachea was central. A phrenic nerve crush scar was seen. Percussion note was dull in the left infra-axillary region and there

were associated crackles. The diag-nosis of pleural thickening with associated chest infection was accepted; that of pleural effusion

was not.


How would you manage a patient with old tuberculosis?

Old tuberculosis requires no antituberculosis treatment. However, the patient may require symptomatic treatment for wheeze and

shortness of breath.

In which groups of people is the risk of tuberculosis high?

· Asian and Irish immigrants.

· The elderly.

· Immunocompromised individuals, particularly AIDS patients.

· Alcoholics.

* Occupations at risk: doctors, nurses, chest physiotherapists.


Would you isolate a patient with newly diagnosed, sputum-positive, pulmonary TB?

Yes. Segregation in a single room for 2 weeks is recommended for patients with smear-positive tuberculosis. Barrier nursing,

however, is unnecessary. Adults with smear-negative or non-pulmonary disease may be in a general ward. A child with TB should

be segregated until the source case is identified as this person may be visiting the child.

How are contacts investigated?

Contacts are investigated by inquiry into bacille Calmette-Gudrin (BCG) vac-cination site, Heaf testing and CXR examination.

To whom would you offer BCG vaccination?

BCG vaccination is offered to previously unvaccinated, persistently Heat' test-negative or grade 1 contacts aged under 35 years

unless there is a special occu-pational, travel or ethnic risk. Patients with known or suspected HIV infection should not be offered the


What are the indications for chemoprophylaxis?

· Chemoprophylaxis may be given to those with strongly positive Heat' test reactions but no clinical or radiological evidence of

TB (Thorax 1994; 49:1193-200).

· Chemoprophylaxis should be given to children under 5 years who are close contacts of a smear-positive adult irrespective of

their tuberculin test result.

· If chemoprophylaxis is not undertaken, follow-up with periodic CXR examin-ations for 2 years is recommended in all these


Which rapid test allows early diagnosis of tuberculosis?

Polymerase chain reaction (PCR).

Robert Koch (1843-1910), Institute for Infectious Diseases, Berlin, was awarded the 1905 Nobel Prize for Medicine for his

investigations and discoveries in relation to tuberculosis.

Kary Mullis of the USA was awarded the Nobel Prize for developing the technique of polymerase chain reaction.