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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Tuberculosis, Respiratory


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
010.90 - Primary Tuberculous Infection, Unspecified Type, Confirmation Unspecified
010.91 - Primary Tuberculous Infection, Unspecified; Bacterial or Histological Examination Not Done
010.92 - Primary Tuberculous Infection, Unspecified; Bacterial or Histological Examination Unknown
010.93 - Primary Tuberculous Infection, Unspecified; Tubercle Bacilli Found (in Sputum) by Microscopy
010.94 - Primary Tuberculous Infection, Unspecified; Tubercle Bacilli Found by Bacterial Culture
010.95 - Primary Tuberculous Infection, Unspecified; Tuberculosis Confirmed Histologically
010.96 - Primary Tuberculous Infection, Unspecified; Tubercle Bacilli Confirmed by Other Methods, Inoculation of Animals
012.00 - Tuberculous Pleurisy; Tuberculosis of Pleura; Tuberculous Empyema; Tuberculous Hydrothorax; Unspecified
012.80 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Unspecified
012.81 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Bacterial or Histological Examination Not Done
012.82 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Bacterial or Histological Examination Unknown
012.83 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Tubercle Bacilli Found (in Sputum) by Microscopy
012.84 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Tubercle Bacilli Found by Bacterial Culture
012.85 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Found by Tuberculosis Confirmed Histologically
012.86 - Respiratory Tuberculosis, Other Specified; Tuberculosis of Mediastinum, Nasopharynx, Nose (Septum), Sinus, Any Nasal; Tuberculosis Confirmed by Other Methods [Inoculation of Animals]
137.0 - Late Effects of Respiratory or Unspecified Tuberculosis

Related Terms

  • Consumption
  • TB
  • White Death
  • White Plague

Overview

Tuberculosis (TB) is a chronic infection of the lungs caused by the bacterium Mycobacterium tuberculosis. It is contagious and can be very difficult to treat. The disease is spread through airborne droplets expelled from an infected individual's mouth through coughing, sneezing, or spitting.

If the bacterium is inhaled, the lungs respond by walling off the infected area; this primary lesion is known as a Ghon focus. The spreading of the infection into adjacent lymphatics and hilar lymph nodes is known as the Ghon's complex or primary complex. A Ghon's complex that has undergone fibrosis and calcification, and hence is detectable by x-rays, is called a Ranke complex. This stage of TB is termed primary infection, and for most individuals, the immune system stops the disease here. However, 5-10% of these individuals progress to an active TB infection. An active infection occurs when the bacteria spread from the original site into the blood or lymph systems, and then move to other areas, most commonly to other areas of the lungs, or in 20% of all TB cases to any other part of the body such as skin, kidneys, bones, and reproductive and urinary systems (extrapulmonary tuberculosis), where they cause infection with formation of inflammatory nodules with caseous necrosis (tubercles).

The body's immune system tries to control the infection rather than eliminate it, and the bacteria may become inactive (dormant). At a later time (perhaps years), if the individual's immune system becomes impaired (due to leukemia, lymphoma, cancer, steroid therapy, radiation treatment, or infection with certain viruses [including HIV], bacteria, or fungi), the dormant bacteria may become active.

Incidence and Prevalence: In 2012, 9,945 TB cases (3.2 cases per 100,000 population) were reported in the US, a 5.4% and 6.1% decline compared with 2011 ("Reported"). Approximately 10% of all infected patients are likely to develop reactivation of TB with the highest risk of doing so occurring within the first 2 years of primary infection. Worldwide about 9 million people have TB (CDC), 1.5% of whom have the miliary form (caused by the spreading of tubercle bacilli through the bloodstream, and characterized by small tubercles in various organs) (Lessnau).

Source: Medical Disability Advisor



Causation and Known Risk Factors

TB is more common in men and blacks. Miliary TB mostly affects patients aged 65 years and older (Lessnau). Native Americans are more likely to develop TB.

At one time, TB was the leading cause of death in the US, but improvements in hygiene, nutrition, and medical care during the early part of the twentieth century dramatically reduced the incidence of TB. Since 1985, however, the number of TB cases has increased. Reasons for this increase include the HIV/AIDS epidemic, increased numbers of immigrants from countries where TB is prevalent, increased poverty, illicit drug use, poor compliance with treatment programs, and more individuals residing in nursing homes.

Source: Medical Disability Advisor



Diagnosis

History: Individuals with early symptoms may report fatigue, weight loss, fever, chills, night sweats, and loss of appetite (anorexia). As the disease progresses, there may be chest pain with a productive persistent cough. Sputum also increases and may eventually be streaked with blood (hemoptysis). Shortness of breath (dyspnea) may indicate damage in the lungs.

Physical exam: Individuals with TB are often chronically ill, but may present with only minimal signs and symptoms. Chest sounds may be abnormal, especially over the upper lobes of the lungs. Weight loss and muscle wasting ("consumption") may be present. Rales or bronchial breath signs may be heard (auscultated), and are sign of lung consolidation.

Tests: A tuberculin skin test (Mantoux test) is used to identify individuals infected with the TB bacteria 6 to 8 weeks after exposure. A positive test, however, does not indicate that the individual has active TB, only that there has been an infection by the bacteria sometime in the past. Because this test can report false negative with a recent infection (less than 2 to 3 months previously) or in immunocompromised individuals (e.g., HIV infected), it should be repeated if a person has recent exposure to TB. Once the individual has had a positive skin test, further skin testing is not recommended due to skin damage at the reaction site. Those with a positive skin test should be tested by chest x-ray.

An x-ray identifies the characteristic lesions in the lungs and may also reveal fluid in the pleural space (pleural effusion) or an enlarged heart (pericarditis). An x-ray of the kidneys using injected dye outlines the kidneys, revealing abnormal masses or cavities that may be caused by TB. A chest computed tomography (CT) is a better test than a chest x-ray and has increased sensitivity and specificity. Ultrasound can be helpful in imaging the liver. Head CT and magnetic resonance imaging (MRI) can reveal lesions in the brain that are infected with TB.

To confirm the diagnosis, a culture is used to identify the TB bacteria. Material for culture may include a sample of material expelled from the lungs (sputum), infected fluid drawn from the chest, abdomen, joint, or around the heart, or a small piece of infected tissue (biopsy). Because TB bacteria grow very slowly, this culture can take up to 4 weeks. Cultures are also used in sensitivity tests to determine what drugs will best combat the bacteria. A polymerase chain reaction (PCR) may be performed on a sample of spinal cord fluid to identify tuberculous meningitis. Tuberculosis of the female reproductive organs may be identified through examination of the pelvis using a laparoscope or from scrapings inside the uterus.

Newer and more rapid DNA tests are beginning to be used for diagnosis. These tests use techniques that amplify the tuberculosis bacterial DNA and can speed the time for diagnosis to 2 days.

People who have come into close contact with the patient, such as spouse and family members, need tuberculin skin testing. If their close contacts have a positive skin test, a chest x-ray is indicated to rule out the spread of disease to the lungs.

Individuals with TB should also be tested for HIV infection since TB often occurs early in the course of HIV infection.

Source: Medical Disability Advisor



Treatment

Because the emergence of drug-resistant strains of TB bacteria has made treatment difficult, the disease is typically treated with a combination of antibiotics, such as, isoniazid and rifampin for 6 to 12 months and pyrazinamide and ethambutol for 2 months. Drugs used to treat TB may have many side effects and should be constantly monitored. Although individuals with pulmonary TB are usually not contagious after 10 to 14 days of drug therapy, treatment should be continued for 3 months after sputum cultures are negative for the TB bacteria.

More resistant strains of TB are treated for 18 to 24 months with more powerful antibiotics that may have more serious side effects. Successful treatment requires cooperation between the individual and health care providers. Individual compliance is a problem with TB treatment due to the side effects of the drugs. For example, isoniazid and rifampin can cause hepatitis, and ethambutol can cause vision problems. If an individual does not complete treatment, the cure rate decreases, and there is an increased risk of reactivation of disease and development of drug-resistant TB.

In order to prevent the development of active TB, treatment can be given to individuals in close contact with infected individuals and to those with a positive skin test. Individuals with active TB need to take precautions to prevent the spread of the disease by properly covering their mouths and noses when they cough and sneeze and by washing their hands.

Although a vaccine for TB is available, it is not widely used in the US, except in carefully selected high-risk individuals.

Source: Medical Disability Advisor



Prognosis

With appropriate antibiotic therapy, only 10% of patients with miliary TB will die (Lessnau). Relapse of TB often occurs because of noncompliance with treatment. With complete and proper treatment, relapse rates are less than 5% (Lessnau).

Individuals infected with resistant strains of TB have a lower cure rate. Strains of TB bacteria resistant to two or more drugs (multidrug-resistant) can have a higher reported mortality rate.

Source: Medical Disability Advisor



Differential Diagnosis

  • Acute respiratory distress syndrome (ARDS)
  • Addison's disease
  • Albuminuria
  • Alcoholism
  • Ascites
  • Blastomycosis
  • Bone marrow failure
  • Cardiac tamponade
  • Disseminated intravascular coagulopathy (DIC)
  • Eosinophilic pneumonia
  • Epididymal tuberculosis
  • Histoplasmosis
  • HIV-related pulmonary opportunistic infections
  • Hyponatremia
  • Influenza
  • Lactic acidosis
  • Lung, nontuberculous mycobacterial infections
  • Lymphangitic spread of cancer
  • Measles
  • Pancreatic abscess
  • Pneumocystis jiroveci pneumonia
  • Pneumonia, bacterial
  • Pneumonia, community-acquired
  • Pneumonia, fungal
  • Pneumonia, viral
  • Pulmonary alveolar microlithiasis
  • Sarcoidosis, thoracic
  • Silicosis and coal worker pneumoconiosis

Source: Medical Disability Advisor



Specialists

  • Infectious Disease Internist
  • Internal Medicine Physician
  • Preventive Medicine Specialist
  • Pulmonologist

Source: Medical Disability Advisor



Rehabilitation

Physical and respiratory therapy applied in conjunction with medications can be important in the overall treatment of the individual with TB. Physical therapy improves ventilation through breathing exercises followed by a gradual strengthening program. When tolerated, an exercise that promotes both relaxation and a postural alteration for the muscles that aid in breathing begins with the individual assuming a relaxed sitting position while leaning forward and resting the forearms on the thighs or a pillow in the lap. This position is held for up to 15 to 20 minutes.

If the individual is hospitalized, the physical therapist and/or respiratory therapist help him or her cough in order to mobilize secretions and clear the airway by having the individual lie in a position that allows for the most effective drainage of secretions. The individual may lie on his or her side with the affected side upward and the head slightly lower than the chest. In addition to proper positioning, the physical therapist uses percussion and vibration techniques to the affected areas to help "shake loose" mucous and secretions. The therapist performs chest percussion with the hands in a cupped position, mildly striking repeatedly over the area of the lung affected by TB.

Once medications are effective, the symptoms of TB subside, and breathing becomes easier, focus is then placed on strength and endurance by incorporating aerobic-type activity into the rehabilitation program. By building endurance, the individual increases the ability to work and the resistance to fatigue. A physical therapist experienced in cardiac and pulmonary rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. As endurance increases without symptoms of shortness of breath, the individual begins active upper and lower extremity exercises using very light resistance in addition to light aerobic activities such as brisk walking and low-resistance biking.

The individual with TB is told that the exercise program can be a lengthy process in order to obtain the maximum benefit of increased pulmonary stamina. Because most individuals with TB are managed with medication, it is important that they let the rehabilitation personnel know what medications they are taking as many of these drugs alter the acute and chronic response to exercise. During the course of rehabilitation, the individual is reminded that a full course of therapy is necessary to kill all the bacteria. Failure to properly complete treatment can create drug-resistant strains of the disease that may render the treatment ineffective.

Source: Medical Disability Advisor



Comorbid Conditions

  • Bacterial infection
  • Cancer
  • Fungal infection
  • HIV/AIDS
  • Leukemia
  • Lymphoma
  • Radiation induced disorders
  • Steroid induced disorders

Source: Medical Disability Advisor



Complications

Complications of TB may include collapsed lung (pneumothorax) and abscess in the lymph nodes. TB that has spread outside the lungs (extrapulmonary tuberculosis) commonly affects the kidney (renal tuberculosis), bones (skeletal tuberculosis), and joints (tuberculous arthritis). The infection may spread to the prostate, seminal vesicles, and epididymis in men, and to the peritoneum (tuberculous peritonitis) in women. Scarring of the ovaries and fallopian tubes can cause sterility. TB can spread to the heart (tuberculous pericarditis) or the base of the brain (tuberculous meningitis). Delayed treatment can result in irreparable brain damage. Tuberculous meningitis can also result in a brain tumor (tuberculoma).

Source: Medical Disability Advisor



Factors Influencing Duration

Length of disability may be influenced by the severity and extent of infection, response to treatment, and whether the infection has spread to other body systems. Individuals with a drug-resistant strain of bacteria or those with a weakened immune system may have a longer period of disability. Individuals experiencing drug side effects may also experience extended disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Decreased lung capacity may make strenuous activity difficult. Significant loss of vital organ function due to secondary or opportunistic infections may lengthen disability or require permanent accommodations.

Risk: Individuals with pulmonary TB are usually not contagious after 10 to 14 days of drug treatment. However, a follow-up sputum analysis should be performed to make sure there is no longer any danger of transmission. In an immune compromised individual, working with heavy public contact, indigent or incarcerated populations, or in health care settings, may place the individual at increased risk of further or recurrent infection. A person with symptom onset within the last 24-48 hours be at a more infectious state and should avoid working in settings with immune compromised individuals. Some risk can be mitigated by frequent hand washing, gloves or masks.

Capacity: Capacity may be influenced by whether the TB infection is uncomplicated or if it is caused by a resistant bacterial strain that requires treatment with antibiotics associated with significant side effects. Some individuals may have a temporarily reduced capacity for work-related activities due to muscle wasting and dyspnea; in such cases, temporary job reassignment to more sedentary duties may be necessary. Objective testing with PFT and Stress ECHO can be helpful.

Tolerance: No impact on tolerance would be expected, once healed.

Accommodations: Employers willing to accommodate activities as needed can have employees return to work earlier.

Source: Medical Disability Advisor



Maximum Medical Improvement

180 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Were symptoms such as fatigue, weight loss, fever, chills, night sweats, anorexia, chest pain, or a productive persistent cough present?
  • Does individual have a history of past infection or recent exposure to TB?
  • Does individual have underlying immune suppression (i.e., HIV, leukemia, lymphoma, cancer, steroid or radiation treatment)?
  • Did individual have a positive Mantoux test? Was the diagnosis confirmed with a sputum culture? Chest x-ray?
  • Were additional diagnostic tests done to rule out other organ involvement?
  • If the diagnosis is uncertain, were other conditions with similar symptoms (i.e., other lung infections, sarcoidosis, or lung cancer) ruled out?

Regarding treatment:

  • Did individual receive prompt diagnosis and appropriate combination antibiotic therapy?
  • Has individual been compliant with antibiotic treatment regimen?
  • Has individual undergone follow-up cultures to verify effectiveness of treatment?
  • Has individual experienced any side effects from the medication?
  • Has individual stopped taking medication because of side effects? If so, what alternatives are available?
  • Does individual fully understand the importance of completing the whole course of medication?

Regarding prognosis:

  • Based on the severity of symptoms, the type of treatment required, and the general health of individual, what was the expected outcome?
  • Has adequate time elapsed for recovery?
  • Has individual completed the full course of medications?
  • Have repeat cultures been done to determine if there is drug resistance? Have appropriate changes been made in the medications?
  • Does individual have an underlying condition (HIV or other immune suppressing condition) that may impact ability to recover?

Source: Medical Disability Advisor



References

Cited

"Reported Tuberculosis in the United States, 2012." CDC. Oct. 2013. Centers for Disease Control and Prevention. 22 Jul. 2015 <http://www.cdc.gov/tb/statistics/reports/2012/pdf/report2012.pdf>.

Lessnau, Klaus-Dieter, and Cynthia de Luise. "Miliary Tuberculosis." eMedicine. 13 Sep. 2013. Medscape. 22 Jul. 2015 <http://emedicine.medscape.com/article/221777-overview#showall>.

Source: Medical Disability Advisor