A female aged 40 years, taking ATT since 1 year from various doctors. She has mild cough , fever since 30 days. How to proceed for this case.

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Left fibrocavitory ipsilateral mediastinal shift.. compensatory hyperinflation of the right lung.. If the patient has a complete course of ATT, and sputum AFB culture/gene xpert is negative we can safely manage her without ATT.. however if the course is incomplete, then it warrants completion of treatment irrespective of sputum AFB status as patient can be sputum negative in partially treated cases also..

I agree with this approach. In my opinion 1st step is to revisit how the diagnosis of TB was made. If it is sputum microscopy: then see if sputum conversion has achieved. Next step is to assess current sputum status with smear, CBNAAT and rapid culture : all of them. If not possible or inconclusive: BAL fluid to be used. It will rule out NTM as well as MDR TB. Then CT thorax to assess the anatomical condition. Lastly to address the co morbidities and also HIV status.
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There is extensive fibrosis middle and lower zone on left side Cause is old tuberculosis Rule out actibe TB by sputum and esr tests Rule out sec infection by tlc and dlc

As per CXR findings and S/S pt seems to be a case of Old Pulmonary Koch with relapse.CXR shows fibrocavitatory lesions Lt hemithorax with mediastinal Lt mediastinal shift. Do first sputum for AFB if nonconclusive go for CBNAAT.and decide about ATT.

Fibrocavitory kochs with Hyperinflation... Left costophrenic angle obliterated... Do USG to know the volume of pleural effusion... if so tap it and send for histopath... Do CBNAAT sputum sample to rule out MDR XDR... HRCT is must to rule out any other Pathology.. Also there is cavitory lesion in left apex....

left cavity with fibrosis with hyperinflated right lung,this can be MDR proceed with sputum AND and then gene xpert

left cavity with fibrosis with hyperinflated right lung,this can be MDR proceed with sputum AND and then gene xpert

Sp for AFB /cbnaat will be decisive if ATT taken was adequate and regular.present symptoms could be due to sec inf that needs to be investigated and treated

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Left fibrocavity with bronchiectasis with volume loss on left side and compensatory hyperinflation..post tb sequelae

Fever not relieved despite the course of ATT (first line drugs..if taken regularly for adequate duration),there is a strong chance of drug resistance tb..should always go for Sputum examination followed by CBNAAT/LPA.. Sputum AFB if negative>go for CBNAAT..if positive>go for LPA...if both the test results are are negative for MTb....think about other bacterial sec infection (non resolving/necrotizing pneumonia)or rule out fungal disease by Sputum culture ..rule out endo bronchial mucous impaction causing collapse...lastly any possibility of Diabetes or HIV must be ruled out.

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