Studying complaints and anamnesis
When familiarizing yourself with an anamnesis, it is necessary to establish when and how the tuberculosis was diagnosed: when you see a doctor about any complaints or when you are examined (preventive or for another disease). The patient is asked about the time of the onset of symptoms and their dynamics, previously transferred diseases, injuries, operations. Pay attention to such possible symptoms of tuberculosis as pleurisy and lymphadenitis, identify concomitant diseases: diabetes, silicosis, peptic ulcer and duodenal ulcer, alcoholism, drug addiction, HIV infection, chronic obstructive pulmonary disease (COPD), bronchial asthma. Specify whether he received drugs that inhibit cellular immunity (glucocorticosteroids, cytostatics, antibodies to the tumor necrosis factor).
Important information about the stay in regions with a high incidence of tuberculosis, in the institutions of the penitentiary system, about participation in hostilities, the place and conditions of the patient's residence, the presence of children in the family. The profession and nature of work, material and living conditions, way of life, the presence of bad habits (smoking, drinking alcohol, drugs) are important. Assess the level of culture of the patient. Parents of ill children and adolescents are asked about the anti-tuberculosis vaccinations and the results of tuberculin tests. It is also necessary to obtain information about the health of family members, possible contact with tuberculosis patients and its duration, and the presence of patients with tuberculosis of animals.
When contact with a patient with tuberculosis is detected, it is important to clarify (ask another medical institution) the form of the disease, the bacterial release, the presence of resistance of mycobacteria to anti-tuberculosis drugs, the treatment and its success.
Typical symptoms of tuberculosis of the respiratory system: weakness, fatigue, deterioration of appetite, weight loss, fever, sweating. Cough, shortness of breath, chest pain, hemoptysis. The severity of symptoms of tuberculosis varies, they occur in various combinations.
Early manifestations of tuberculosis intoxication may include symptoms of tuberculosis, such as weakness, fatigue, impaired appetite, weight loss, irritability, decreased efficiency. Patients often do not associate these symptoms of tuberculosis with the disease, believing that their appearance is due to excessive physical or mental stress. Symptoms of tuberculosis and intoxication require increased attention, especially in persons belonging to the risk groups for tuberculosis. With an in-depth examination of such patients, initial forms of tuberculosis can be identified.
An increase in body temperature (fever) is a typical clinical symptom of infectious and many non-infectious diseases.
With tuberculosis, body temperature can be normal, subfebrile and febrile. It often differs considerable lability and can increase after physical or mental stress. Rise of body temperature patients are usually easily tolerated and often almost do not feel it.
When tuberculous intoxication in children, body temperature rises in the afternoon for a short time to 37.3-37.5 ° C. Such uplifts are observed periodically, sometimes not more than twice a week, and alternate with long intervals of normal temperature. Less frequently, the body temperature is maintained at 37.0 ° C with a difference between morning and evening temperatures of about one degree.
Stable subfebrile condition with insignificant fluctuations of temperature during the day is not characteristic for tuberculosis and is more common in chronic nonspecific inflammation in the nasopharynx, paranasal sinuses, biliary tracts or genital organs. Elevated body temperature to subfebrile may also be due to endocrine disorders, rheumatism, sarcoidosis, lymphogranulomatosis, kidney cancer.
Hectic fever is characteristic of acute progressive and severe tubercular lesions (miliary tuberculosis, caseous pneumonia, pleural empyema). Intermittent hectic fever is one of the diagnostic features that makes it possible to distinguish the typhoid form of miliary tuberculosis from typhoid fever. Unlike tuberculosis, with typhoid fever the body temperature has a steady tendency to increase, and then remains stably high for a long time.
In rare cases, patients with pulmonary tuberculosis note a perverse type of fever, when the morning temperature exceeds the evening temperature. Such a fever indicates severe intoxication.
Increased sweating is a common symptom of tuberculosis. Patients with tuberculosis in the early stages of the disease often note increased sweating on the head and chest at night or in the morning. The marked sweating (a symptom of a "wet pillow") in the form of profuse sweat occurs with caseous pneumonia, miliary tuberculosis, other severe and complicated forms of tuberculosis, as well as with nonspecific acute infectious diseases and exacerbations of chronic inflammatory processes.
Cough very often accompanies inflammatory, tumorous and other diseases of the lungs, respiratory tract, pleura, mediastinum.
In the early stages of tuberculosis, cough may be absent, and sometimes the patients notice a recurrent cough. With the progression of tuberculosis, the cough intensifies. It can be dry (unproductive) and with sputum (productive). A dry paroxysmal cough appears when the bronchus is compressed by enlarged lymph nodes or displaced mediastinal organs, for example, in a patient with exudative pleurisy. Especially often dry paroxysmal cough occurs with bronchial tuberculosis. A productive cough appears in patients with pulmonary tuberculosis in the destruction of pulmonary tissue, the formation of the lymphoblocchial fistula, the breakthrough into the bronchial tree of fluid from the pleural cavity. Cough with tuberculosis can also be caused by chronic non-specific bronchitis or bronchiectasias accompanying tuberculosis.
Sputum in patients with early stages of tuberculosis is often absent or its isolation is associated with concomitant chronic bronchitis. After the disintegration of the lung tissue, the amount of sputum increases. In uncomplicated pulmonary tuberculosis, mild phlegm is usually colorless, homogeneous and odorless. Attachment of nonspecific inflammation leads to increased cough and a significant increase in sputum, which can become purulent.
Shortness of breath is a clinical symptom of respiratory or cardiovascular failure. In diseases of the lungs, it is caused by a decrease in the respiratory surface, violation of bronchial patency, restriction of chest excursion, violation of gas exchange in the alveoli. Certain significance is the impact on the respiratory center of toxic products of vital activity of pathogenic microorganisms and substances formed during the decay of tissues.
Pronounced dyspnea - with acute pulmonary tuberculosis, as well as with chronic disseminated, fibrous-cavernous, cirrhotic pulmonary tuberculosis.
Progression of tuberculosis can lead to the development of chronic pulmonary heart (CHLS) and pulmonary-cardiac failure. In these cases, dyspnea is markedly increased.
A large share of smokers among tuberculosis patients determines the prevalence of concomitant COPD, which can affect the frequency and severity of expiratory dyspnea, and requires differential diagnosis.
Dyspnea is often the first and the main symptom of such complications of pulmonary tuberculosis, as spontaneous pneumothorax, atelectasis of the lobe or the entire lung, pulmonary embolism of the pulmonary artery. With the rapid accumulation of a significant amount of exudate in the pleural cavity, sudden inspiratory dyspnea may suddenly appear.
Chest pain is a symptom of diseases of various organs: trachea, lungs, pleura, heart, aorta, pericardium, chest wall, spine, esophagus, sometimes abdominal organs.
With pulmonary tuberculosis, chest pain usually occurs due to the spread of inflammation to the parietal pleura and the appearance of perifocal adhesive pleurisy. Pain arises and intensifies with breathing, coughing, and abrupt movements. The localization of pain usually corresponds to the projection of the affected part of the lung to the chest wall. However, with inflammation of the diaphragmatic and mediastinal pleura, the pain irradiates into the epigastric region, the neck. Shoulder, heart area. The weakening and disappearance of pain in tuberculosis is possible even without regression of the underlying disease.
With dry tuberculous pleurisy, the pain appears gradually and persists for a long time. It increases with coughing and deep breathing, pressing on the chest wall and, depending on the localization of inflammation, can be irradiated to the epigastric or lumbar region. This makes diagnosis difficult. In patients with exudative tubercular pleurisy, chest pain arises sharply, but decreases with accumulation of exudate and remains blunt until it resorbs.
In cases of acute pericarditis, which sometimes occurs in tuberculosis, the pain is more often blunt, unstable. It decreases in a sitting position when tilted forward. After the appearance of effusion in the pericardium, the pain subsides, but when it disappears, it may reappear.
A sudden sharp pain in the chest occurs when the tuberculosis is complicated by spontaneous pneumothorax. Unlike pain in angina pectoris and myocardial infarction, pain with pneumothorax increases during a conversation and cough, does not radiate to the left arm.
With intercostal neuralgia, pain is limited by the zone of the intercostal nerve and is strengthened by pressure on the intercostal space. In contrast to pain in tuberculous pleurisy, it increases when the body tilts to the affected side.
With neoplasm of the lung, the pain in the chest is constant and can gradually increase.
Hemoptysis (pulmonary hemorrhage) is more often observed with infiltrative, fibrous-cavernous and cirrhotic pulmonary tuberculosis. Usually it gradually stops, and after the allocation of fresh blood, the patient continues to cough up the dark clots for a few more days. In cases of blood aspiration and the development of aspiration pneumonia after hemoptysis, an increase in body temperature is possible.
Hemoptysis is also observed in chronic bronchitis, nonspecific inflammatory, neoplastic and other diseases of the thoracic organs. Unlike tuberculosis, in patients with pneumonia, usually a chill occurs and the body temperature rises, and then hemoptysis and stitching in the chest appear. When a lung infarct is more often, first there is pain in the chest, followed by a rise in temperature and hemoptysis. Long hemoptysis is typical for patients with lung cancer.
Massive pulmonary hemorrhages occur more often in patients with fibrous-cavernous. Cirrhotic tuberculosis and gangrene of the lungs.
In general, it should be borne in mind that respiratory tuberculosis often begins as a common infectious disease with symptoms of intoxication and often occurs under the masks of influenza or pneumonia, and in the context of broad-spectrum antibiotics (especially fluoroquinolones, aminoglycosides, rifampicins), the patient's condition may improve. The further course of tuberculosis in these patients is usually wavy: periods of exacerbation of the disease are replaced by periods of relative well-being. In extrapulmonary forms of tuberculosis, along with symptoms caused by tuberculous intoxication, local manifestations of the disease are noted in patients. For example, tuberculosis meningitis is characterized by a headache, with throat tuberculosis, sore throat and hoarseness, with osteoarticular tuberculosis - pain in the back or joint, change and stiffness of gait, with tuberculosis of female genital organs - pain in the lower abdomen, menstrual disturbance functions, with tuberculosis of the kidneys, ureters and bladder - pain in the lumbar region, dysuric disorders, with tuberculosis of mesenteric lymph nodes and intestines - pain in the abdomen and violations of the function of the gastrointestinal tract, intestinal tract. However, patients with extrapulmonary forms of tuberculosis, especially in the early stages, do not make any complaints, and the disease is detected only by special research methods.
Physical methods of examination of patients with tuberculosis
Not only in medical but also in fiction literature is described the external appearance of patients with progressive pulmonary tuberculosis, which is known as habitus phtisicus. Patients are characterized by a deficiency in body weight, a blush on the pale face, eye shine and wide pupils, dystrophic skin changes, a long and narrow chest, enlarged intercostal spaces, an acute epigastric angle, and lagging pterygoids. Such external signs are usually observed in patients with late stages of the tuberculosis process. When examining patients with initial manifestations of tuberculosis, any pathological changes are sometimes not detected at all. However, inspection is always necessary. It often allows you to identify various important symptoms of tuberculosis and should be carried out in full.
Pay attention to the physical development of the patient, skin color and mucous membranes. Compare the severity of supraclavicular and subclavian pits, the symmetry of the right and left halves of the chest, evaluate their mobility with deep breathing, participate in the act of breathing auxiliary muscles. Note the narrowing or widening of intercostal spaces, post-operative scars, fistulas or scars after their healing. On the fingers and toes pay attention to the deformation of the end phalanges in the form of tympanic sticks and changes in the shape of the nails (in the form of watch glass). Children, adolescents and young people are examined on the shoulder scars after vaccination with BCG.
Palpation allows you to determine the degree of skin moisture, its turgor, the severity of the subcutaneous fat layer. Carefully palpate the cervical, axillary and inguinal lymph nodes. In inflammatory processes in the lungs with the involvement of the pleura often mark the lag of the affected half of the chest during breathing, the soreness of the pectoral muscles. In patients with chronic tuberculosis, atrophy of the muscles of the shoulder and chest can be detected. A significant displacement of the mediastinal organs can be determined by palpation according to the position of the trachea.
Voice tremor in patients with pulmonary tuberculosis can be normal, strengthened or weakened. It is better performed over the sites of the compressed lung with infiltrative and cirrhotic tuberculosis, over a large cavern with a wide draining bronchus. Attenuation of vocal tremor right up to its disappearance is observed when there is air or fluid in the pleural cavity, atelectasis, massive pneumonia with obstruction of the bronchus.
Percussion makes it possible to detect relatively gross changes in the lungs and thorax with infiltrative or cirrhotic lesions of the lobar character, pleural fibrosis. An important role is played by percussion in the diagnosis of such urgent conditions as spontaneous pneumothorax, acute exudative pleurisy, atelectasis of the lung. The presence of boxed or shortened pulmonary sound allows you to quickly assess the clinical situation and carry out the necessary studies.
Tuberculosis may not be accompanied by a change in the nature of breathing and the appearance of additional noises in the lungs. One of the reasons for this is the obstruction of the bronchi, draining the affected area with dense caseous-necrotic masses.
Weakening of breathing is a characteristic sign of pleurisy, pleural effusion, pneumothorax. Hard or bronchial breathing can be heard above the infiltrated pulmonary tissue, amphoric breathing - over a giant cavern with a wide draining bronchus.
Cramps in the lungs and the noise of friction of the pleura often allow us to diagnose such a pathology, which is not always evident in radiographic and endoscopic studies. Small-bubbly wet wheezing in a limited area is a sign of predominance of the exudative component in the inflammation zone, and medium- and large-bubbling rales are a sign of a cavity or cavity. To listen to wet rales, you should suggest that the patient cough after a deep breath, an exhalation, a short pause, and then again a deep breath. At the same time at the height of a deep breath there are wheezing or increasing their number. Dry wheezing occurs with bronchitis, whistling - with bronchitis with bronchospasm. With dry pleurisy, the noise of friction of the pleura is heard, with pericarditis - the pericardial friction noise.
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