Division of Substance Abuse Services
Tuberculosis Training Lesson 2

INSTRUCTIONS FOR COMPLETING THE TB Symptom Screening
Tool for Service Recipients/Employees/Volunteers

The Symptom Screening Tool's purpose:

Who should be assessed with the TB Symptom Screening Tool?

NOTE: Refer to Division of Alcohol and Drug Abuse Tuberculosis Control Guidelines
for Alcohol and Drug Treatment Programs; for timelines concerning screening of service recipients, volunteers and employees.

The TB Symptom Screening Tool should be completed by persons TRAINED to Counsel and Screen the patient concerning TB/LTBI and related issues. The patient should NOT be asked or allowed to complete this form themselves.

The TB Symptom Screening Tool is organized into three sections. It is very important that you ask the patient all the questions On the TOOL and then fill out the disposition section for documentation. Do not leave any blanks.

DEMOGRAPHICS:

  1. NAME/ALIAS: Emphasize to each patient the importance of using the same name for all health visits. Assure confidentiality and remind the patient that their names are recorded for medical records only. Inquire about other aliases that the patient may currently be using or may have used at other medical facilities such as the health department or at their place of employment;
  2. DATE OF BIRTH: Encourage patient to give an accurate date. Be sure to capture the month, day and year the patient was born;
  3. COUNTRY OF ORIGIN: The country where the patient was born;
  4. FACILITY: The official name of the site; and
  5. PROGRAM TYPE: Mark whether the program is residential, non-residential, or not applicable (if patient is an employee of the administering agency).

SECTION 1: Signs and Symptoms of TB Disease:

This Section is included to identify persons with active TB who should be immediately isolated and referred for further evaluation. By inquiring about classic TB symptoms (i.e. cough, night sweats, fever/chills, weight loss, etc), it is also possible that a person with active TB who has not yet been to a medical provider may be identified. In addition, the Purified Protein Derivative (PPD) can be falsely negative in persons with immunosuppression or acute or overwhelming disease and these cases may be first identified by symptoms alone. If a person other than a nurse is performing the symptom screening, they must be educated to notify the nurse or doctor if any of these symptoms are present. It is then up to that medical provider to determine if the symptom is truly suggestive of TB or represents a minor complaint as with a cold.

Section 1 should be asked using open-ended questions in a conversation type discussion. You want to obtain detailed and descriptive information to these questions. Circle yes or no to each symptom according to the patient’s answer.

Cough/Coughing Up Blood: Prolonged, productive cough that lasts 3 weeks or longer. It may be accompanied by thick, cloudy and sometimes bloody phlegm (thick mucous) also called hemoptysis (coughing up blood). This cough is usually worse in the morning.

Examples of open-ended discussion' questions to ask if patient's response to this question is "yes.":

  1. Tell me about the last time you remember having a cough?
  2. How long have you had this cough?
  3. When do you have this cough (morning, night, all day long, etc)?
  4. What type of cough is it...dry, hacking, .nagging, croupy, productive?
  5. What color is the phlegm that you produce?
  6. Have you noticed blood or pink tinged sputum/phlegm; and
  7. Have you seen a doctor about this cough?

Chest Pain: Pain with breathing or coughing, which may be sharp pain; as in pleurisy;
or dull ache.

Examples of open-ended discussion questions to ask if patient's response to this question is "yes.”

  1. Describe this pain. Is it sharp pain or dull aching type pain;
  2. How long have you been having this pain;
  3. How long does the pain last;
  4. Does it mainly occur with breathing or coughing;
  5. What makes the pain stop; and
  6. Have you seen a doctor about this pain?

Difficulty Breathing: Being short of breath; unable to do activities of daily living, due to breathlessness. Symptoms of breathlessness are usually mild, to begin with, before gradually getting worse.

Examples of open-ended discussion questions to ask if patient's response to this question is "yes."

  1. When did this shortness of breath start;
  2. How often are you short of breath;
  3. Does anything trigger this shortness of breath;
  4. Are you able to do your activities of daily living with this shortness of breath; and
  5. Have you seen a doctor about this shortness of breath?

Persistent Fever and/or Chills: Fever: temperature of 100.4 degrees F or above, chills: shaking body type chills

Examples of open-ended discussion questions to ask if patient's response to this question is “yes.”

  1. What degree has your temperature been registering;
  2. How long have you been running fevers;
  3. Are your fevers also causing chills;
  4. How many times per day are you having chills/fevers; and
  5. Have you seen a doctor about these fevers/chills?

Persistent Loss of Appetite: A decreased appetite, a reduced desire to eat, unable to
tolerate the thought of food

Examples of open-ended discussion questions to ask if patient's response to this question is “yes.":

  1. How long have you had a loss of appetite? Is this something unusual for you;
  2. Have you lost any weight? Are your clothes still fitting; and
  3. Have you seen a doctor about this?

Weight Loss (without dieting): Loss of body weight without dieting or exercising, not
intending to lose weight (Usually a gradual weight loss
over several weeks or months)

Examples of open-ended discussion questions to ask if patient's response to this question is "yes":

  1. How much weight have you lost;
  2. Over what period of time have you lost this weight;
  3. Are you eating routine meals and the usual amounts; and
  4. Have you seen a doctor about this weight loss?

Night Sweats (drenching): Severe hot flashes which occur at night and result in a drenching sweat, that soak your nightclothes or bedding, even when your bedroom is not excessively hot.

Examples of open-ended discussion questions to ask if patient's response to this question is "yes":

  1. How long have you been having these night sweats;
  2. Do you have these night sweats every night;
  3. Do you have to change your nightclothes or sheets;
  4. Is anyone else in the home having night sweats;
  5. Do you have air conditioning;
  6. What temperature is your home at night; and
  7. Have you seen a doctor about these night sweats?

Hoarseness and/or Trouble Swallowing: Term referring to abnormal voice changes. Hoarseness may be manifested as a voice that sounds breathy, strained, raspy, or a voice that has higher or lower pitch. Difficulty swallowing may range from mild discomfort during swallowing, to inability to swallow due to complaints of pain or sore throat.

Examples of open-ended discussion questions to ask if patient's response to this question is 'yes":

  1. How long have you had hoarseness and when did it start;
  2. Do you also have pain or a sore throat or difficulty swallowing;
  3. Describe your difficulty swallowing. When did you first notice this;
  4. How long have you had difficulty swallowing;
  5. How long have you had a sore/painful throat? When did it start; and
  6. Have you seen a doctor about these symptoms?

Persistent Fatigue: Characterized by a lessened capacity for work and reduced efficiency of accomplishment, weary or tired, difficulty performing activities of daily living

Examples of open-ended discussion questions to ask if patient's response to this question is 'yes":

  1. How long have you noticed being tired/weak;
  2. When did this tiredness/weakness start;
  3. Describe your day in relation to work and activities of daily living; and
  4. Have you seen a doctor about this tiredness/weakness?

Section II: Evaluation for Latent TB Infection (LTBI)

This Section is to determine if patient has documentation of a previous positive TB skin test or has been evaluated for LTBI within the past 12 months with documentation of a negative TB, skin test.

Note: The patient/employee must provide written documentation of a past positive TB skin test with measurements recorded, in millimeters; or a negative TB skin test, with measurements recorded in millimeters, within the past 12 months.

  1. Circle “yes” if the patient/employee has brought documentation of a previous
    positive TB skin test, recorded in millimeters. Fill out the date; result in
    millimeters from the documentation and the name and address of the facility
    that performed the TB skin test. If patient was treated for LTBI, note this on
    the line provided.
  2. Circle “no” if the patient/employee does not have a history of a previous positive TB skin test or if he did not bring documentation in millimeters.
  3. Circle “yes” if the patient/employee has brought documentation of a previous negative TB skin test, recorded in millimeters, within the last 12 months. Fill out the date; result, in millimeters, from the documentation; and the name and address of the facility that performed the TB skin test.
  4. Circle "no" if the patient/employee did not bring documentation, in millimeters, of a TB skin test within the past 12 months.

Section III: Disposition

This Section is to be used to determine the disposition of the patient/employee, to instruct the provider performing the symptom screening in the action steps needed, and to document where the patient/employee is being referred (if needed).

The box is divided into 4 sections. In order to determine which action to take, the interviewer must first read the options listed horizontally across the box.

Start at the left side of the box under Action Taken:

TB Screening Tool (PDF)

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