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Taking Medical History in Pulmonary Tuberculosis

Dr. Sunitha Mathew Dr. Sunitha Mathew Jun 30, 2020 / 7 mins read

Tuberculosis was one of the most dreaded ailments in the world widely known by an array of names like the consumption, phthisis, and white death. And it still is one contagious epidemic that needs prompt attention. The WHO lists TB as one among the top ten causes of death worldwide. According to an article by Sally Murray in 2006, approximately one-third of the population worldwide is infected with TB every year.

The WHO Director-General, Dr Tedros Adhanom G. said: “COVID-19 is highlighting just how vulnerable people with lung diseases and weakened immune systems can be. The world committed to end TB by 2030; improving prevention is key to making this happen. Millions of people need to be able to take TB preventive treatment to stop the onset of disease, avert suffering and save lives.”

Treatment and management of Tuberculosis can get challenging owing to two fundamental reasons

Firstly, TB can be misdiagnosed as just terrible flu or bronchitis. Plenty of times physicians have delayed diagnosis by prescribing medications for another respiratory condition when undoubtedly it could have been TB. This kind of misdiagnosis or delayed diagnosis tends to make the situation worse; where the patient becomes severely ill.

The mode of spread of this bacterium being airborne makes it easier for this organism to find newer hosts in less time. This means the longer a patient is left untreated, the higher the chance of their infection spreading to the people around them.

Secondly, the lack of compliance to treatment by patients. A typical TB treatment regimen can last from nine months to over two years. This lengthy treatment period is associated with plenty of side effects. Waking up each day to consume pills that they know is causing them harm makes it harder to comply with the treatment. However, this negligence towards treatment has led to the development of multi-drug resistant tuberculosis/ MDR-TB. Such TB becomes a lot more arduous to treat.

There are also other challenges faced by developing countries which aid the spread of the TB pathogen much easily. Namely, poor infection-control practices (eg. spitting in public and overcrowding) and a high prevalence of immunosuppressed patients (eg. HIV, cancer, diabetes)

The above reasons prove how important “diagnosing TB on time” can be, to curb its spread.

The pattern of patient history collection in patients with Pulmonary TB

INTRODUCTION

Any consultation yields the best results when patients are greeted cordially by the doctor and they have been comfortably seated.

This is followed by gathering details like age and gender. These help make an estimation of the likelihood of the patient having a particular illness; as the distribution of various ailments varies among different age populations and gender.

PRESENTING COMPLAINTS:

For any respiratory disease, the symptoms usually encountered are - breathlessness, cough, wheezing, chest pain, haemoptysis (coughing blood), and systemic symptoms like fever, night sweats, and weight loss.

Among these, *the hallmark symptoms of TB* include - a cough that lasts for more than three weeks, haemoptysis, and chest pain. Systemic symptoms like fatigue, weakness, weight loss, paleness, decrease in appetite, chills, fever, and night sweats may also accompany.

TB patients need not necessarily come to the clinic presenting all of the above symptoms. This is one reason why this infection is often misdiagnosed.

“The symptomology of Tuberculosis is of the utmost importance and it can be ascertained by any practising physician, and its bearing on the presence or absence of active phthisis especially in doubtful cases is of more significance than indefinitive physical signs”

Irving Fischer

HISTORY OF PRESENTING ILLNESS

For each of the symptoms listed above, gathering details like onset, duration, course, severity, precipitating factors, relieving factors, associated factors, and previous episodes is essential.

Onset - when did it start? Was it sudden or gradual? Duration - how long has it been there? Severity - has it been worsening or improving? Precipitating Factors - what aggravates the symptom? Relieving Factors - what relieves the symptom? Associated Features - are there any other symptoms that appear associated with this symptom? Previous episodes - has there been a previous encounter of this symptom?

In case of complaints of any kind of pain, the SOCRATES analysis is used to collect further details

S - Site (where is the pain?) O - Onset (How was the start - sudden/gradual?) C - Character (sharp/dull/stinging) R - Radiation (does it move to any other site?) A - Association (are there any associated symptoms with the pain?) T - Time course (has it been worsening or improving?) E - Exacerbating Factors (what aggravates the pain?) S - Severity (how would they rate their pain on a scale of 1-10?)

In the case of cough, further details to be collected are whether it’s dry or productive. If productive then the volume, colour, and consistency of the sputum have to be gathered. While taking a detailed history of cough, it is essential to keep an open mind as the cough symptom can be attributed to a wide and varied range of causes. Cough that is accompanied by haemoptysis or unintended weight loss is a trademark that can be used to distinguish TB from other respiratory illnesses.

For complaints of haemoptysis: enquire about the amount of blood expectorated and classify accordingly - Mild haemoptysis (less than 20ml in one day, blood streaks in phlegm); Moderate haemoptysis (20-250 ml in one day); and Severe haemoptysis (more than 250ml in one day).

Also, making sure that the haemoptysis is not caused by bleeding in the gastrointestinal tract or upper airway tract is called for.

PAST MEDICAL HISTORY

Has the patient been previously diagnosed with any respiratory illness like asthma, pneumonia, COPD, pulmonary embolism, malignancy, or TB? - This helps to rule out possible diagnoses.

Do they have any comorbidities or metabolic diseases like HIV AIDS, cancer or diabetes which renders them immunosuppressed?

Any previous surgical history or hospital admissions also come under this category.

MEDICATION HISTORY

When treating TB patients, it’s imperative to know if they have been previously treated for this condition. If so, the treatment regimen will have to be changed accordingly.

Further information on regular medications and recent-past antibiotic treatments is essential to flag drug-drug interactions.

Are they currently on any medications which cause immunosuppression?

Has the patient developed an allergy to any medications prescribed in the past?

FAMILY HISTORY

Has anyone in their family suffered from any respiratory illnesses?

Have they recently been to any highly infected area? Have they been in close contact with anyone who was infected?

SOCIAL HISTORY

Do they smoke, consume alcohol or abuse drugs? - Cigarette smoking, alcohol consumption and recreational drug abuse history help provide the right kind of counselling to patients.

Where do they live? Who lives with them?

Where do they work? - Occupation History which gathers details on where they work and their working conditions help understand whether the symptom could be associated with their occupation.

REVIEW OF SYMPTOMS

Before closing the history-taking process, a final review of their overall body symptoms can help detect any complaints the patient may have overlooked.

Central Nervous System - headache/ loss of consciousness/ confusion/ vision Cardiovascular - chest pain/ breathlessness/ palpitations/ syncope Respiratory - wheezing/ cough/ sputum/ breathlessness/ haemoptysis/ chest pain Gastrointestinal - nausea/ vomiting/ loss of appetite/ indigestion/ weight loss/ dysphagia/ abdominal pain Urinary - dysuria/ frequency/ urgency/ incontinence Musculoskeletal - joint pain/ muscle pain Dermatology - rashes/ ulcers/ lesion

In summary, the following groups of people should be compulsorily tested for TB:

  • people who have lived in close contact with someone infected
  • those who work in high-risk settings like hospitals and long-term health care facilities.
  • an individual who has recently travelled to or resided in a highly TB infection-prone area.

Apart from this, people with HIV AIDS or any illnesses that weaken the immune system and patients who were not treated properly for TB in the past are also likely to develop TB disease and must be tested.