IM27.{5-6,8} | Tuberculosis Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

TB clinical evaluation integrates three inseparable skills:

History (IM27.5): Structured symptom assessment (cough ≥2–3 weeks + fever + night sweats + weight loss = NTEP four-symptom screen; add haemoptysis, breathlessness, extrapulmonary symptoms) + systematic risk-factor assessment (contact, prior TB, HIV, DM, immunosuppression, occupation, crowding, smoking). Document chronologically; conclude with a summary probability statement.

Examination (IM27.6):
- General: Nutritional state, pallor, fever pattern, clubbing, lymphadenopathy (palpate all chains — cervical, supraclavicular, axillary), oral cavity, meningeal signs if indicated.
- Chest: Inspection (apical flattening, tracheal deviation, respiratory rate, symmetry) → palpation (expansion, TVF: increased over consolidation, absent over effusion) → percussion (dull over consolidation, stony dull over effusion, Kronig's isthmus) → auscultation (bronchial breathing over open consolidation, absent over effusion, post-tussive crepitations over cavity).
- Lymphatic: Matted cervical nodes + cold abscess = TB lymphadenitis until proven otherwise.
- CNS: GCS, meningeal signs, cranial nerves, fundoscopy (choroidal tubercles = miliary TB).

Differential diagnosis (IM27.8): Rank by probability: (1) Pulmonary TB (most likely in India — subacute onset, upper lobe signs); (2) Lung carcinoma (must exclude in >40 + smoker + haemoptysis); (3) CAP (acute onset, responds to antibiotics); (4) Lymphoma (mimics TB systemically — biopsy any lymph node); (5) HIV-related pulmonary disease. Document as ranked list with supporting evidence from history and examination for each entry.

REFLECT

Return to Sunita, the 28-year-old schoolteacher from the opening hook. You now have the structured history-taking framework, the examination skills, and the differential diagnosis reasoning. Mentally walk through her encounter: what four symptoms would you systematically screen for first? What three risk factors make this a high-probability TB case even before examination? On chest examination, what two sites would you examine most carefully and what specific signs would confirm your clinical suspicion? How would you explain to Sunita, in plain language, why you are ordering a sputum test and a chest X-ray, and what the possible results mean for her and her household contacts? The ability to do all of this — efficiently, kindly, and in a sequence that makes clinical sense — is what these competencies demand. A checklist memorised but never performed is not a skill; a skill is built only through practice, feedback, and repetition.