PPD vent

[rabsa]

So today I went to get my annual PPD read at my doctor's office. The nurse said I came back at 47 hours, and said I had to wait EXACTLY 48 hours before she could document it as negative. I asked if she would just document it negative at t=48 hours so I could get on my merry way---but, alas, they made me wait an extra hour.

Is it just me, or was this a little excessive? I mean, if I didn't have any induration at 47 hours, would I have really mounted a type IV hypersensitivity response within the next hour? I didn't realize the 48-72 hour timeframe was such an exact science.

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[HatWobble]

So today I went to get my annual PPD read at my doctor's office. The nurse said I came back at 47 hours, and said I had to wait EXACTLY 48 hours before she could document it as negative. I asked if she would just document it negative at t=48 hours so I could get on my merry way---but, alas, they made me wait an extra hour.

Is it just me, or was this a little excessive? I mean, if I didn't have any induration at 47 hours, would I have really mounted a type IV hypersensitivity response within the next hour? I didn't realize the 48-72 hour timeframe was such an exact science.

Yes, that is just silly.

 

[NYEMMED]

So today I went to get my annual PPD read at my doctor's office. The nurse said I came back at 47 hours, and said I had to wait EXACTLY 48 hours before she could document it as negative. I asked if she would just document it negative at t=48 hours so I could get on my merry way---but, alas, they made me wait an extra hour.

Is it just me, or was this a little excessive? I mean, if I didn't have any induration at 47 hours, would I have really mounted a type IV hypersensitivity response within the next hour? I didn't realize the 48-72 hour timeframe was such an exact science.

Very silly, but by the book.

 

[loltopsy]

I went to a school FP clinic to get my physical taken care of. I tell the doc that I already got the TB vaccine, so the PPD would be positive and that we should skip it. They flat out refused because the print out sheet from my school required it. I told them to look it up as it was in my file. Nope, not good enough. I had to either give them my arm, so it could swell up like a baseball or I could not get the physical. I even offered just to get the CXR prescription since that would be the next step after a positive PPD anyway. Nope, give us your arm. Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

 

[HatWobble]

I went to a school FP clinic to get my physical taken care of. I tell the doc that I already got the TB vaccine, so the PPD would be positive and that we should skip it. They flat out refused because the print out sheet from my school required it. I told them to look it up as it was in my file. Nope, not good enough. I had to either give them my arm, so it could swell up like a baseball or I could not get the physical. I even offered just to get the CXR prescription since that would be the next step after a positive PPD anyway. Nope, give us your arm. Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

Shoulda walked out and found a new MD.

 

[madchemist89]

I went to a school FP clinic to get my physical taken care of. I tell the doc that I already got the TB vaccine, so the PPD would be positive and that we should skip it. They flat out refused because the print out sheet from my school required it. I told them to look it up as it was in my file. Nope, not good enough. I had to either give them my arm, so it could swell up like a baseball or I could not get the physical. I even offered just to get the CXR prescription since that would be the next step after a positive PPD anyway. Nope, give us your arm. Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

What country are you from?

 

[loltopsy]

What country are you from?

US, east coast.

 

[J ROD]

So today I went to get my annual PPD read at my doctor's office. The nurse said I came back at 47 hours, and said I had to wait EXACTLY 48 hours before she could document it as negative. I asked if she would just document it negative at t=48 hours so I could get on my merry way---but, alas, they made me wait an extra hour.

Is it just me, or was this a little excessive? I mean, if I didn't have any induration at 47 hours, would I have really mounted a type IV hypersensitivity response within the next hour? I didn't realize the 48-72 hour timeframe was such an exact science.

This is a good example of not using your clinical judgment. If she would have though about it in a real world way, you know you are not going to see a reaction at that point. But, she is alas a RN. Many dont think. And, that is why I get calls all night as a pharmacist fielding stupid questions. That could have been answered if one would or could think critically and not just blindly follow the number.

Prime example of why we treat the patient and not the number.

Please remember to think and not just do what you learn.

 

[rabsa]

Thanks everyone--knew I wasn't crazy. Can't wait for this kind of shenanigans every day when I start M3 next week

 

[loveoforganic2]

I went to a school FP clinic to get my physical taken care of. I tell the doc that I already got the TB vaccine, so the PPD would be positive and that we should skip it. They flat out refused because the print out sheet from my school required it. I told them to look it up as it was in my file. Nope, not good enough. I had to either give them my arm, so it could swell up like a baseball or I could not get the physical. I even offered just to get the CXR prescription since that would be the next step after a positive PPD anyway. Nope, give us your arm. Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

What country are you from?

US, east coast.

So why'd you get the bcg? And since when do you start INH without a CXR or other compelling indication?

 

[tiedyeddog]

I went to a school FP clinic to get my physical taken care of. I tell the doc that I already got the TB vaccine, so the PPD would be positive and that we should skip it. They flat out refused because the print out sheet from my school required it. I told them to look it up as it was in my file. Nope, not good enough. I had to either give them my arm, so it could swell up like a baseball or I could not get the physical. I even offered just to get the CXR prescription since that would be the next step after a positive PPD anyway. Nope, give us your arm. Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

To be fair, the BCG vaccine has been documented to provide very little immunity. I am assuming you were raised in a country where TB is more prevalent, where the BCGs are given. Because the BCG sucks you could possibly have latent TB if you've never had the INH course....

also, I believe the guidelines set by the CDC say to ignore if someone says they have been given the BCG vaccine, so your physician wasn't doing anything abnormal.

 

[madchemist89]

Afterwards, I got to go on 6 months of isoniazid as a preventative from my god damn vaccine in case it decides to generate ****ing TB out of my ass.

Who gave you your daily isoniazid?

 

[loltopsy]

So why'd you get the bcg? And since when do you start INH without a CXR or other compelling indication?

Born in a 3rd world country. I had a CXR and was given INH as a preventative due to a positive PPD. CXR was clean, but they didn't care.

To be fair, the BCG vaccine has been documented to provide very little immunity. I am assuming you were raised in a country where TB is more prevalent, where the BCGs are given. Because the BCG sucks you could possibly have latent TB if you've never had the INH course....

also, I believe the guidelines set by the CDC say to ignore if someone says they have been given the BCG vaccine, so your physician wasn't doing anything abnormal.

Stop pooping on my parade! This is the PPD vent, not the 'use logic about PPD' thread. Now I can only recount this story with feigned anger in front of non-medical people. 👎

 

[madchemist89]

Born in a 3rd world country. I had a CXR and was given INH as a preventative due to a positive PPD. CXR was clean, but they didn't care.




Stop pooping on my parade! This is the PPD vent, not the 'use logic about PPD' thread. Now I can only recount this story with feigned anger in front of non-medical people. 👎

You trolling?

 

[tiedyeddog]

Born in a 3rd world country. I had a CXR and was given INH as a preventative due to a positive PPD. CXR was clean, but they didn't care.




Stop pooping on my parade! This is the PPD vent, not the 'use logic about PPD' thread. Now I can only recount this story with feigned anger in front of non-medical people. 👎

sorry, haha. 🙁

I have this talk with immigrants from mexico/south america pretty often. They always want to argue that they shouldn't get the PPD because of BCG vaccination twenty years ago. I can't remember the study but after ten years most people who received the BCG test negative on the PPD.

 

[Donald Juan]

So today I went to get my annual PPD read at my doctor's office. The nurse said I came back at 47 hours, and said I had to wait EXACTLY 48 hours before she could document it as negative. I asked if she would just document it negative at t=48 hours so I could get on my merry way---but, alas, they made me wait an extra hour.

Is it just me, or was this a little excessive? I mean, if I didn't have any induration at 47 hours, would I have really mounted a type IV hypersensitivity response within the next hour? I didn't realize the 48-72 hour timeframe was such an exact science.

The guidelines are pretty clear: 48-72 hours. It sounds like you are a non compliant and hostile patient. I guess maybe the nurse should have been well read up on the primary literature on PPDs and have used her judgement to go against the CDC guidelines on how PPDs are supposed to be read to suit you.

I hope you remember this when you have a patient who gets pissed off at you for not wanting to bend the rules on standards of care.

 

[Spinach Dip]

But, she is alas a RN.

=/

I had an RN willing to read my TB screen at 47.5 hours*... so realize there are all kinds.



*Of course, I had to promise that if it suddenly swelled up in the next 30 minutes, I'd come straight back and tell her.

 

[link2swim06]

Why we still do PPDs I have no clue.

It's a pretty crappy test compared to IGRAs. Plus it requires two visits which makes it about the same net cost.

I had a reaction once to a PPD but luckily my doc did a IGRA which ended up negative and I was able to avoid isoniazid.

Since then I just get to fill out a questionnaire.

 

[7starmantis]

sorry, haha. 🙁

I have this talk with immigrants from mexico/south america pretty often. They always want to argue that they shouldn't get the PPD because of BCG vaccination twenty years ago. I can't remember the study but after ten years most people who received the BCG test negative on the PPD.

Do you have any link or remember the name of this study? I would be interested in reading it.

 

[7starmantis]

Why we still do PPDs I have no clue.

It's a pretty crappy test compared to IGRAs. Plus it requires two visits which makes it about the same net cost.

I had a reaction once to a PPD but luckily my doc did a IGRA which ended up negative and I was able to avoid isoniazid.

Since then I just get to fill out a questionnaire.

IGRA = International Gay Rodeo Association?

 

[tiedyeddog]

Why we still do PPDs I have no clue.

It's a pretty crappy test compared to IGRAs. Plus it requires two visits which makes it about the same net cost.

I had a reaction once to a PPD but luckily my doc did a IGRA which ended up negative and I was able to avoid isoniazid.

Since then I just get to fill out a questionnaire.

Your point is better but I also don't get why IGRA doesn't follow any positive PPD? Because INH is so cheap, probably more so than an IGRA?

 

[tiedyeddog]

IGRA = International Gay Rodeo Association?

Interferon gold

 

[link2swim06]

Your point is better but I also don't get why IGRA doesn't follow any positive PPD? Because INH is so cheap, probably more so than an IGRA?

IGRAs (both the QuantiFERON and T-spot) are definitely under a $100. Plus it's only one visit (granted...the second visit with a PPD is only a 'nurse visit' but that still at least a few dollars, right?). 6 months of INH might actually be more expensive. Plus it has side effects.

 

[madchemist89]

IGRAs (both the QuantiFERON and T-spot) are definitely under a $100. Plus it's only one visit (granted...the second visit with a PPD is only a 'nurse visit' but that still at least a few dollars, right?). 6 months of INH might actually be more expensive. Plus it has side effects.

I believe that it is fairly new, and most clinics do not have the lab facilities to perform it. PPD is easy. No lab required.

 

[calvnandhobbs68]

IGRA = International Gay Rodeo Association?

Damn you beat me to it...

Interferon gold

This is the first link that comes up in google

http://www.igra.com/

 

[link2swim06]

Damn you beat me to it...



This is the first link that comes up in google

http://www.igra.com/

 

[rabsa]

The guidelines are pretty clear: 48-72 hours. It sounds like you are a non compliant and hostile patient. I guess maybe the nurse should have been well read up on the primary literature on PPDs and have used her judgement to go against the CDC guidelines on how PPDs are supposed to be read to suit you.

I hope you remember this when you have a patient who gets pissed off at you for not wanting to bend the rules on standards of care.

It's not like I was rude or yelled at her. Your definition of hostility must be excessively prudish.
Perhaps they should have communicated better and given me a time stamp of the exact instant when the needle met my forearm?

I guess maybe the nurse should have been well read up on the primary literature on PPDs and have used her judgement to go against the CDC guidelines on how PPDs are supposed to be read to suit you.

Right, since it's a guideline. Not Mosaic law.

I hope you remember this when you have a patient who gets pissed off at you for not wanting to bend the rules on standards of care.

I would rather evaluate patients individually and according to my understanding of basic and clinical science than be a drone and perfunctorily enforce 'standards' no matter the scenario or evidence supporting them. 😉

 

[rabsa]

IGRAs (both the QuantiFERON and T-spot) are definitely under a $100. Plus it's only one visit (granted...the second visit with a PPD is only a 'nurse visit' but that still at least a few dollars, right?). 6 months of INH might actually be more expensive. Plus it has side effects.

I say make it standard of care. Plus I'm sure they are more sensitive tests.

 

[Siggy]

IGRAs (both the QuantiFERON and T-spot) are definitely under a $100. Plus it's only one visit (granted...the second visit with a PPD is only a 'nurse visit' but that still at least a few dollars, right?). 6 months of INH might actually be more expensive. Plus it has side effects.

$15 at my school through the pharmacy. The pharmacist (student) places it and then reads it when you come back.

 

[KTD]

We got the quantiferon this year at my school, so at least some places are moving towards it.

 

[badasshairday]

Wow the ignorance in this thread is astounding. Shows the real reason why some medical professionals still insist on giving people the PPD even if they have had bcg. People can get a positive PPD for there whole life, not just 10 years. The right next step for the OP should have been the quantiferon gold test. Not ****ing isoniazid. Are you kidding me? Abx for six months for no reason is not benign.

 

[DrOwnage]

Now if life really wanted to screw you over, it would deal you a case of isoniazid induced hepatitis...

 

[MSTPlease]

This is a good example of not using your clinical judgment. If she would have though about it in a real world way, you know you are not going to see a reaction at that point. But, she is alas a RN. Many dont think. And, that is why I get calls all night as a pharmacist fielding stupid questions. That could have been answered if one would or could think critically and not just blindly follow the number.

Prime example of why we treat the patient and not the number.

Please remember to think and not just do what you learn.

I don't think it's a "lack of clinical judgment issue," it's probably a liability issue. If the literature says 48-72 hours and she reads it at 47 hours and then by some ridiculous chance you get indurated at 48 hours because you actually do have TB then I assume it becomes her/the school's fault because they didn't follow protocol that could have prevented TB exposure. If you wait 48 hours then it's not really anyone's fault if it's a false negative.

 

[Kahreek]

^this

 

[CaptainSSO]

IGRA = International Gay Rodeo Association?

Interferon gamma release assay

 

[RoboChicken]

Just to add to the vent: I get borderline PPD readings each yr that, depending on the person reading the result, either prompt quantiferon gold testing or are determined to be negative. It's adds a little juicy bit of stress to the yearly PPD test: will I be positive this yr or not? I just stare at that bleb for the entire 48-72 hrs...

 

[Cali2]

I don't think it's a "lack of clinical judgment issue," it's probably a liability issue. If the literature says 48-72 hours and she reads it at 47 hours and then by some ridiculous chance you get indurated at 48 hours because you actually do have TB then I assume it becomes her/the school's fault because they didn't follow protocol that could have prevented TB exposure. If you wait 48 hours then it's not really anyone's fault if it's a false negative.[/QUOTE

This. The nurse takes on legal liability if she forges the medical documentation to say that your PPD was negative at 48 hours when you have not reached that time point yet. She has no reason to take on that risk for you and did the right thing by making you wait.

Also, those of you who were complaining about isoniazid after a positive PPD with a negative CXR - that's latent TB which does indeed require treatment. If your BCG was 20 years ago, it's extremely unlikely to be why your PPD is positive now.

 

[Instatewaiter]

The guidelines are pretty clear: 48-72 hours. It sounds like you are a non compliant and hostile patient. I guess maybe the nurse should have been well read up on the primary literature on PPDs and have used her judgement to go against the CDC guidelines on how PPDs are supposed to be read to suit you.

I hope you remember this when you have a patient who gets pissed off at you for not wanting to bend the rules on standards of care.

I hope you remember to think when you become a doctor

Wow the ignorance in this thread is astounding. Shows the real reason why some medical professionals still insist on giving people the PPD even if they have had bcg. People can get a positive PPD for there whole life, not just 10 years. The right next step for the OP should have been the quantiferon gold test. Not ****ing isoniazid. Are you kidding me? Abx for six months for no reason is not benign.

Agreed. The ppd is worthless in someone who got the bcg vaccine bc you don't know if they have latent tb or the positive ppd is from the bcg

 

[Bacchus]

My residency program just did the Quantiferon test. It was nice to just get it over with and not have to go back. I'd say in the past 4 years of medical school I probably had 5-8 TB tests. I was ready to just ask for my own tuberculin and syringes.

 

[tiedyeddog]

Damn you beat me to it...



This is the first link that comes up in google

http://www.igra.com/

wtf, lol. I had no idea it was a real thing.

 

[loveoforganic2]

I don't think it's a "lack of clinical judgment issue," it's probably a liability issue. If the literature says 48-72 hours and she reads it at 47 hours and then by some ridiculous chance you get indurated at 48 hours because you actually do have TB then I assume it becomes her/the school's fault because they didn't follow protocol that could have prevented TB exposure. If you wait 48 hours then it's not really anyone's fault if it's a false negative.[/QUOTE

This. The nurse takes on legal liability if she forges the medical documentation to say that your PPD was negative at 48 hours when you have not reached that time point yet. She has no reason to take on that risk for you and did the right thing by making you wait.

Also, those of you who were complaining about isoniazid after a positive PPD with a negative CXR - that's latent TB which does indeed require treatment. If your BCG was 20 years ago, it's extremely unlikely to be why your PPD is positive now.

Wouldn't latent TB give you a coin lesion on CXR?

 

[tiedyeddog]

People can get a positive PPD for there whole life, not just 10 years. The right next step for the OP should have been the quantiferon gold test. Not ****ing isoniazid. Are you kidding me? Abx for six months for no reason is not benign.

From uptodate:

"Most individuals who have received BCG vaccine have a tuberculin reaction of 3 to 19 mm in size at two to three months following vaccination. The reaction wanes with time; at more than 10 years after vaccination it is generally <10 mm. However, with repeated tuberculin testing such reactions may be boosted to >10 mm as discussed below.

Childhood BCG vaccination is not a major cause of positive tuberculin skin test results in adulthood; in a study including 5952 individuals with history of BCG who underwent tuberculin skin testing 10 to 25 years later, only 8 percent had positive results [55].

Therefore, previous BCG vaccination should NOT influence decisions regarding tuberculin skin testing or interpretation of results in individuals vaccinated more than 10 years earlier. This is especially important since most individuals who receive BCG vaccine come from countries where the incidence of tuberculosis is high. Testing with an interferon-gamma release assay permits distinction between positive tuberculin reactions due to BCG versus tuberculosis."

http://www.ncbi.nlm.nih.gov/pubmed/1546843

Do you have a study showing something else?

I agree, the right next step should have been the IGRA.

 

[Kahreek]

from this thread i learned that physicians should be more open minded about organizing gay rodeos in order to screen tb more eficiently.

 

[ucbsmd]

I worked at a hospital doing research between M1 and M2 that screened with Interfon gold before starting there. This year when I went to my PCP to get my annual TB screen, he refused to do another interferon gold "because it is not first line screening" so I was stuck doing another 2 step ppd (and 4 visits to his office) 👎

 

[buccsmf1]

Had to get a ppd a couple months ago so I get the injection and go back to have it read 2 days later. Nurse looks at it, sees that there's no lump and then goes to fill out the form I gave her.

"Hmmm, well I dont just want to put zero on it, I'll put 1 centimeter."

She sees the look of utter confusion on my face.

"Wait, is a centimeter the same thing as a millimeter?"

I have to explain the difference between a centimeter and millimeter to her.

"Oh, ok, I'll put 10 mm down then"

Before she can get it down and screw up my paper I have to explain to her that for a healthcare worker, 10mm is a POSITIVE TEST RESULT.

She basically refused to put 0 mm because she said, "you can't do that," so I finally got her to put 2mm down.

And they say all these nursing student mills arent causing any problems......

 

[Banned]

Had to get a ppd a couple months ago so I get the injection and go back to have it read 2 days later. Nurse looks at it, sees that there's no lump and then goes to fill out the form I gave her.

"Hmmm, well I dont just want to put zero on it, I'll put 1 centimeter."

She sees the look of utter confusion on my face.

"Wait, is a centimeter the same thing as a millimeter?"

I have to explain the difference between a centimeter and millimeter to her.

"Oh, ok, I'll put 10 mm down then"

Before she can get it down and screw up my paper I have to explain to her that for a healthcare worker, 10mm is a POSITIVE TEST RESULT.

She basically refused to put 0 mm because she said, "you can't do that," so I finally got her to put 2mm down.

And they say all these nursing student mills arent causing any problems......

lol legit nursing education.

If anyone ever asks me if cm=mm,

 

[The Buff OP]

I had gotten the PPD done on a Thursday and my physician made me come on Monday. Weird......😕

 

[ClinPathDO]

I worked at a hospital doing research between M1 and M2 that screened with Interfon gold before starting there. This year when I went to my PCP to get my annual TB screen, he refused to do another interferon gold "because it is not first line screening" so I was stuck doing another 2 step ppd (and 4 visits to his office) 👎

Is the PPD cheaper than the quantiferon gold? When I got hired in my hospital I needed titers so they just added the quantiferon gold to my blood work but every year since its been PPD.

 

[ClinPathDO]

I had gotten the PPD done on a Thursday and my physician made me come on Monday. Weird......😕

yea it is weird its supposed to by 2-3 days.

 

[Banned]

I had gotten the PPD done on a Thursday and my physician made me come on Monday. Weird......😕

They goofed.

Is the PPD cheaper than the quantiferon gold? When I got hired in my hospital I needed titers so they just added the quantiferon gold to my blood work but every year since its been PPD.

Yes, it's cheaper. PPD doesn't require labs. Your insurance probably had to pay $ to Quest Diagnostics or somebody for the QFT-G. IGRA can be used for a baseline test, but it's more common to just get a 2-step PPD.