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Instructions to Panel Physicians for Completing Chest X-Ray and Classification Worksheet (DS-3024)
Please note: this page provides instructions for completing specific Department of State forms. The forms are not available on this website. Additional information about the forms is provided by the U.S. Department of State.
The information concerning chest radiographs (X-ray) for applicants younger than 15 years of age was updated 4/02. See Technical Instructions and Updates for a summary of the changes.
Each immigrant and refugee applicant 15 years of age or older must have a chest radiograph (X-ray); any applicant younger than 15 years must have a chest X-ray if he or she has symptoms of tuberculosis (see below), has a history of tuberculosis, or has possible exposure to tuberculosis (such as contact with a family or household member with possible tuberculosis). The chest X-ray findings determine if the following is needed:
- Further evaluation overseas with sputum collection to assess the presence of acid-fast bacilli (AFB).
- Follow-up evaluation after resettlement in the United States for tuberculosis (TB).
- Follow-up evaluation after resettlement in the United States for non-TB conditions.
The process by which immigrant and refugee applicants are evaluated and classified for TB has three components: (1) the clinical presentation (medical history, and current signs and symptoms), (2) chest X-ray findings, and (3) sputum smear examination for AFB.
Because determining the final classification can be complex, a worksheet has been developed to assist in the process.
The following are the steps needed to complete this worksheet:
Attach a current signed photograph of the applicant, that has been verified by the panel physician or a member of the physician's professional staff by comparing it with the applicant and his or her photograph in an official document such as a passport or letter from the International Organization for Migration, to this worksheet or other official document used for requesting the chest X-ray.
Complete the top section with the applicant's
- Name (last name, first name, and middle name).
- Age in years.
- Birth date giving month, day, and year.
- Passport number.
- Alien number, or case number if a refugee, whichever if available.
After completing the top section, SECTION 1 (see below), and attaching the signed photograph, provide this chest X-ray worksheet to the radiologist for him or her to complete SECTION 2. Chest X-ray Findings. If desired, the panel physician can ask for a signature from the radiology facility or radiologist. This can be placed in SECTION (2)—Chest X-ray Findings, under the Remarks row. The explanation to the radiologist of how this worksheet is used is the responsibility of the panel physician. The panel physician should complete SECTION 3. Sputum Smears after determining if sputum smears are needed or not, and if smears are needed, results of the sputum smear examination must be included on the form.
Complete Sections 1 Through 5 on the DS-3024 Worksheet.
SECTION 1—Chest X-Ray Needed
The panel physician must determine whether chest X-ray evaluation is required. Currently, all immigrants and refugees 15 years of age or older require evaluation. Those younger than 15 years of age must be evaluated if they have:
- A history of TB disease.
- Close contact with someone with TB disease.
- Signs or symptoms suggestive of TB.
If none of these conditions apply, no further TB evaluation is required for children.
(In the future revision of the Technical Instructions for Medical Examination of Aliens, June 1991 [Technical Instructions], all immigrants and refugees 11 years of age or older will have routine chest X-ray evaluation. Those younger than 11 years of age will be evaluated if they have a history of TB disease; have close, prolonged contact [household, or workplace or school] with someone with TB; or have signs or symptoms suggestive of TB.)
For those people requiring evaluation, an assessment for TB-like signs or symptoms should be performed. For general appearance, the applicant with TB can appear ill, pale, or cachectic, or have wasting of muscles. In pulmonary TB, examination of the chest could reveal:
- Signs of consolidation, such as dullness on percussion, or rales or bronchial breath sounds on auscultation. Evidence of pleural effusion such as dullness and decreased air entry on percussion, and decreased tactile vocal fremitus.
Pulmonary TB symptoms include chronic cough (lasting more than 2 to 3 weeks), hemoptysis (coughing up blood), unexplained fever, night sweats, unexplained weight loss, anorexia, or fatigue.
Other body systems should also be examined to identify other evidence of TB, such as lymphadenopathy and spinal deformity. These signs and symptoms depend on the site of the TB disease. For example, the finding for TB of the kidney can be blood in the urine and TB of the lymph nodes can be lymphadenopathy (enlargement of the lymph nodes).
If the applicant reports one or more of these signs or symptoms, the appropriate boxes on the form should be marked.
For an adult without any of the above (history of TB, contact with TB, or signs or symptoms of TB), check the box to the left of Adult.
SECTION 2—Chest X-Ray Findings
The panel physician should give the chest X-ray worksheet (after completing the top section and SECTION 1. Chest X-ray Needed) to the radiologist for him or her to complete SECTION 2. Chest X-ray Findings. The worksheet and the chest X-ray should then be sent to the panel physician in a secure manner to reduce any risk of substitution of the worksheet or the film.
All people requiring evaluation for TB should have a standard, postero-anterior (PA) X-ray of the chest that meets the technical standards described in the Technical Instructions to be published in 2002. The X-ray should be read with special attention to abnormalities that might suggest active TB disease. The date that the chest X-ray was taken must be included on the worksheet.
The chest X-ray and classification worksheet is designed to group findings into categories based on their likelihood of being related to TB or non-TB conditions needing medical follow-up (either at the time of the chest X-ray or after resettlement).
Normal findings
These are films that are completely normal, with no identifiable cardiothoracic or musculoskeletal abnormality; therefore, check the box to the left of Normal findings. In addition, if the applicant has no signs or symptoms of TB, simply check under SECTION 4, the box to the left of No Class.
Abnormal findings
Chest X-Ray Findings that Can Suggest ACTIVE TB: This category comprises all findings typically associated with active pulmonary TB. An applicant with any of the following findings must submit sputum specimens for examination.
- Infiltrate or consolidation—Opacification of airspaces within the lung parenchyma. Consolidation or infiltrate can be dense or patchy and might have irregular, ill-defined, or hazy borders.
- Any cavitary lesion—Lucency (darkened area) within the lung parenchyma, with or without irregular margins that might be surrounded by an area of airspace consolidation or infiltrates, or by nodular or fibrotic (reticular) densities, or both. The walls surrounding the lucent area can be thick or thin. Calcification can exist around a cavity.
- Nodule with poorly defined margins—Round density within the lung parenchyma, also called a tuberculoma. Nodules included in this category are those with margins that are indistinct or poorly defined. The surrounding haziness can be either subtle or readily apparent and suggests coexisting airspace consolidation.
- Pleural effusion—Presence of a significant amount of fluid within the pleural space. This finding must be distinguished from blunting of the costophrenic angle, which may or may not represent a small amount of fluid within the pleural space (except in children when even minor blunting must be considered a finding that can suggest active TB).
- Hilar or mediastinal lymphadenopathy—Enlargement of lymph nodes in one or both hila or within the mediastinum, with or without associated atelectasis or consolidation.
- Linear, interstitial disease (in children only)—Prominence of linear, interstitial (septal) markings.
- Other—Any other finding suggestive of active TB, such as miliary TB. Miliary findings are nodules of millet size (1 to 2 millimeters) distributed throughout the parenchyma.
Chest X-Ray Findings that Can Suggest INACTIVE TB: This category includes findings that are suggestive of prior TB, that is inactive. It must be remembered that assessments of the activity of TB cannot be made accurately on the basis of a single radiograph alone. If there is any question of active TB, sputum smears must be obtained. Furthermore, if the applicant has any signs or symptoms of TB, sputum smears must be obtained. Obtaining sputum smears is necessary if there is any question of active TB. Therefore, any applicant might have findings grouped in this category, but still have active TB as suggested by:
- The presence of signs or symptoms of TB (Class B1).
- Sputum smears positive for AFB (Class A).
- Discrete fibrotic scar or linear opacity—Discrete linear or reticular densities within the lung. The edges of these densities should be distinct and there should be no suggestion of airspace opacification or haziness between or surrounding these densities. Calcification can be present within the lesion and then the lesion is called a "fibrocalcific" scar.
- Discrete nodule(s) without calcification—One or more nodular densities with distinct borders and without any surrounding airspace opacification. Nodules are generally round or have rounded edges. These features allow them to be distinguished from infiltrates or airspace opacities. To be included here, these nodules must be noncalcified. Nodules that are calcified are included in the category "OTHER X-ray findings, No follow-up needed".
- Discrete fibrotic scar with volume loss or retraction—Discrete linear densities with reduction in the space occupied by the upper lobe. Associated signs include upward deviation of the fissure or hilum on the corresponding side with asymmetry of the volumes of the two thoracic cavities.
- Discrete nodule(s) with volume loss or retraction—One or more nodular densities with distinct borders and no surrounding airspace opacification with reduction in the space occupied by the upper lobe. Nodules are generally round or have rounded edges.
- Other—Any other finding suggestive of prior TB, such as upper lobe bronchiectasis. Bronchiectasis is bronchial dilation with bronchial wall thickening.
OTHER Chest X-Ray Findings
Follow-up needed: This category includes findings that suggest the need for a follow-up evaluation for non-TB conditions either at the time of the chest X-ray or after resettlement of the applicant in the United States.
- Musculoskeletal abnormalities—New bony fractures or radiographically apparent bony abnormalities that need follow-up.
- Cardiac abnormalities—Cardiac enlargement or anomalies, vascular abnormalities, or any other radiographically apparent cardiovascular abnormality of significant nature to require follow-up.
- Pulmonary abnormalities—Pulmonary finding of a non-TB nature, such as a mass, that needs follow-up.
- Other—Any other finding that the panel physician believes needs follow-up, but is not one of the above.
No follow-up needed: This category includes findings that are minor and not suggestive of TB disease. These findings require no follow-up evaluation after resettlement of the applicant.
- Pleural thickening—Irregularity or abnormal prominence of the pleural margin, including apical capping (thickening of the pleura in the apical region). Pleural thickening can be calcified.
- Diaphragmatic tenting—A localized accentuation of the normal convexity of the hemidiaphragm as if "pulled upwards by a string."
- Blunting of costophrenic angle (in adults)—Loss of sharpness of one or both costophrenic angles. Blunting can be related to a small amount of fluid in the pleural space or to pleural thickening and, by itself, is a non-specific finding (except in children, when even minor blunting may suggest active TB). In contrast a large pleural effusion, or the presence of a significant amount of fluid in the pleural space, may be a sign of active TB at any age.
- Solitary calcified nodules or granuloma—Discrete calcified nodule or granuloma, or calcified lymph node. The calcified nodule can be within the lung, hila, or mediastinum. The borders must be sharp, distinct, and well defined. This was considered a Class B3 TB in the past; however, Class B3 has been omitted from the classification scheme because it has not been found to be associated with active TB.
- Minor musculoskeletal findings—Minor findings needing no follow-up.
- Minor cardiac findings—Minor findings needing no follow-up.
Boxes corresponding to all of the findings should be checked even if they fall into different categories. Although the category "Chest X-ray findings can suggest INACTIVE TB" is marked if the applicant has signs or symptoms of TB, the applicant must have sputum smears and the classification will be Class A or B1 (depending on the results of the sputum smears). In addition, an applicant can have a TB condition as well as other conditions listed in this section.
SECTION 3—Sputum Smears
The panel physician must determine whether sputum examination will be required or whether a classification can be assigned based on information gathered to this point. The appropriate box should be checked on the worksheet. All applicants with TB-like signs or symptoms should submit sputum for AFB microscopy. In addition, all applicants with chest X-ray finding(s) suggestive of active TB must submit sputum for examination.
Applicants for whom sputum examination is not required can be classified first in SECTION 3 as indicated by the worksheet:
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X-ray suggests INACTIVE TB, this is Class B2/TB |
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OTHER X-ray findings suggest follow-up needed after arrival, this is B Other |
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OTHER X-ray findings suggest no follow-up needed, this is No Class |
|
X-ray Normal, this is No Class |
If sputum examinations are required, the results must be used to classify the applicant. For applicants requiring sputum examinations, the dates the smears were obtained must be indicated and then the three results (one per specimen). If all smears are negative for AFB, the classification can be assigned based on the results of the chest X-ray and signs or symptoms.
- If an applicant had a normal chest X-ray but had TB signs or symptoms, smears must be obtained. If the smears are all negative, and the signs or symptoms resolved,
- check the box on the left of "X-ray Normal with" and
- check the box on the left of "Signs or symptoms resolved, this is No Class."
- If an applicant had a normal chest X-ray but had unresolved signs or symptoms needing follow-up, smears must be obtained. If the smears are all negative,
- check the box on the left of "X-ray Normal with" and
- check the box on the left of "Signs or symptoms suggest follow-up needed after arrival, this is B Other Class."
- If an applicant had a chest X-ray suggestive of ACTIVE TB, smears must be obtained. If an applicant had a chest X-ray suggestive of INACTIVE TB but had signs or symptoms needing follow-up, smears must be obtained. If the smears in either case (chest X-ray suggestive of ACTIVE OR INACTIVE TB) are all negative, check the box to the left of "X-ray suggests ACTIVE OR INACTIVE TB, this is Class B1/TB."
- If an applicant had chest X-ray suggestive of OTHER (non-TB) findings but had signs or symptoms needing follow-up, smears must be obtained. If the smears are all negative, check the box to the left of "OTHER X-ray findings suggest follow-up needed after arrival, this is Class B Other."
- If any smear is positive, for any chest X-ray finding check the box on the left of "Any chest X-ray finding, this is Class A/TB."
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SECTION 4—Final Classification
The final classification as determined in SECTION 3 is recorded here. Check the box to the left of the appropriate classification:
No Class Class A/TB Class B1/TB Class B2/TB Class B Other, follow-up neededSECTION 5—Follow-up Needed After Arrival
Indicate if follow-up is needed and whether it is for a TB or a non-TB condition. If follow-up is needed, regardless if for a TB or non-TB condition, the condition must be described (for example, cardiac enlargement with symptoms of shortness of breathe [dyspnea] with exertion), including any additional tests performed, any treatment used (names and doses) with start and stop dates (mm/dd/yyyy), and any changes in treatment. If tuberculin skin testing (TST) was performed, give results in this section.
Note: The class and condition must also be written on the MEDICAL EXAMINATION FORM FOR U.S. ADMISSION (DS-2053). For TB conditions, check the appropriate boxes for
- "Class A Conditions" and for "TB, active, infectious," or
- "Class B Conditions" and for "TB active, noninfectious (Class B1)," or
- "Class B Conditions" and "TB inactive (Class B2)."
If the class is Class B Other, check the box to the left of "Class B Conditions," and the box to the left of "Other." Give details of the condition in the space provided.
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