SOAP Note for Pulmonary Tuberculosis

Patient Name: AB

Date: 5/23/2024

Time: 15:30

Ethnicity/Race: African American

Age: 45

Sex: Male

Subjective:

Chief Complaint: “I have difficulty in breathing and a persistent cough with significant weight loss for the past 3 months."

HPI: The patient is a 45-year-old African American male with a 3-month history of productive cough with yellow-green sputum, fever, night sweats, and unintentional weight loss of about 15 pounds. The patient has improved his complaint of fatigue and mild shortness of breath on exertion. He says he has no previous history of chest pain, spitting of blood, or any episode of a similar nature in the past. The patient traveled to India last month and spent a month there.

Medications:

Lisinopril 10 mg daily (for hypertension)

Previous Medical History:

High Blood Pressure (diagnosed 5 years ago)

No prior history of tuberculosis or other respiratory illnesses

Developmental History:

Not applicable (Adult patient)

Allergies:

NKDA

Medication Intolerances:

None reported

Chronic Illnesses/Major Traumas:

Hypertension

Immunizations:

Up-to-date with childhood immunizations

Received annual influenza vaccine

Hospitalizations/Surgeries:

None

• Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: Smokes 1 pack/day for 20 years, occasional alcohol use, no illicit drug use
• Safety Measures: Uses seat belts, adheres to safety protocols at work
• Screening Exams: Last physical exam 1 year ago; no routine screenings done recently

Family History:

• Mother: Alive, 75, has diabetes
• Father: Deceased, lung cancer at 70

Social History:

Worked as a construction worker and recently traveled to India for a month.

He lives with his wife and two children.

Smokes 1 pack/day, occasional alcohol use.

Review of Systems

• General: The client admits to weight loss, fatigue, and night sweats. Reports weight loss, night sweats, and fatigue. He denies headaches and malaise.
• Cardiovascular: The patient denies chest pain
• Skin: He denies lesions and skin rash.
• Respiratory: The clients admit breathlessness. The patient admits coughing with the production of yellow-green sputum.
• Eyes: He denies pain and visual changes
• Gastrointestinal: He denies diarrhea, vomiting, and nausea.
• Ears: He denies loss of hearing and ear discharge.
• Genitourinary/Gynecological: The client denies hematuria frequency and dysuria.
• Nose/Mouth/Throat: The client denies nasal discharge and sore throat.
• Musculoskeletal: The client denies muscle weakness or joint pain.
• Neurological: The client denies dizziness or focal neurological deficits.
• Heme/Lymph/Endo: He denies enlargement of the lymph nodes and symptoms of endocrines disorder.
• Psychiatric: The client admits feeling anxious but denies a depression history.

Objective Data

Weight: 145 lbs (previously 160 lbs)

Height: 5’9”

BMI: 21.4

Blood Pressure: 128/82 mmHg

T: 100.2°F

P: 92 bpm

Respiratory rate: 18 breaths/min

SpO₂: 95% on room air

General Appearance:

• The client appears fatigued, thin, and slightly pale. Cachectic with notable weight loss. No acute distress. Mild anxiety was noted during the examination.
• Skin: No lesions, unusual pigmentation, or lesions on inspection. The skin appears dry

HEENT:

• Head: Normocephalic, atraumatic.
• Eyes: Conjunctivae pink, sclerae white; no icterus or discharge. PERRLA.
• Ears: External auditory canals are clear
• Nose: Nares patent, no nasal discharge or septal deviation.
• Mouth/Throat: Oropharynx clear, mucous membranes moist. No tonsillar hypertrophy or exudates. No lesions or erythema were noted.
• Neck: No cervical lymphadenopathy or jugular venous distention. Trachea midline.
• Cardiovascular: No gallops, murmurs, or rubs. Normal S1 and S2 on auscultation. Regular heart rate.
• Respiratory: Symmetrical chest movement. Inspection shows no use of accessory muscles for breathing. Upon inspection, crackles over the right upper lobe and decreased sound breaths were present.
• Gastrointestinal: The abdomen is flat and non-tender on palpation, with hyperactive bowel sound in all four quadrants on auscultation.
• Genitourinary: No masses or tenderness on palpation
• Musculoskeletal: No erythema, swelling, or joint deformities were observed during the inspection. No muscle wasting or crepitus in the joints during palpation. No pain and Full ROM in all the extremities.

Neurological:

• Cranial Nerves: All cranial nerves II-XII intact.
• Motor Function: Muscle strength is 5/5 in all extremities, with no atrophy or fasciculations.
• Sensory Function: Sensation is intact for light touch, pain, and temperature.
• Reflexes: Deep tendon reflexes 2+ and equal bilaterally.

Psychiatric:

• Inspection: Anxious demeanor was noted, and it had an appropriate effect.
• Behavior: Cooperative during examination.
• Thought Process: Clear, coherent, and logical.
• Mood: Reports anxiety related to health, but no signs of depression

Assessment

Presumptive Diagnosis

Pulmonary Tuberculosis (TB) (ICD-10 Code: A15.0)

Primarily, the symptoms like cough with productive sputum for more than three weeks, fever, weight loss, positive sputum smear AFB, and the chest X-ray showing a cavitary lesion in the right upper lobe indicate TB as the primary diagnosis (Alsayed & Gunosewoyo, 2023). The other factor that supports this diagnosis is the fact that the patient had traveled to an area that is known to have a high prevalence of TB. The positive sputum smear for AFB is a definitive diagnostic clue that brings the possibility of TB closer to the truth than a diagnosis of COPD or lung cancer.

Differential Diagnosis

Chronic Obstructive Pulmonary Disease (COPD) with Chronic Bronchitis (ICD-10 Code: J44.9)

Such a chronic productive cough and smoking history of 20 years could raise suspicion of COPD, especially the chronic bronchitis subtype (Dotan et al., 2019). However, it is not as probable as TB due to the absence of severe dyspnea, the lack of chronic symptoms, and the systemic signs (fever, night sweats, weight loss).

Lung Cancer (ICD-10 Code: C34.90)

Smoking history and weight loss observed in the patient make lung cancer to be a differential diagnosis. Symptoms of lung cancer include cough with or without sputum production, hemoptysis, and general unwellness (Vicidomini, 2023). However, there is no hemoptysis, and the presence of a positive sputum smear for AFB, along with the typical cavitary lesion, favors the diagnosis of TB over lung cancer in such cases.

Plan

Diagnostic Studies:

• CBC: WBC 11.2 x 10^3/µL, Hemoglobin 12.5 g/dL
• ESR: Elevated at 40 mm/hr
• HIV Test: Negative
• Sputum Smear: Positive for acid-fast bacilli (AFB)
• Chest X-ray: Cavitary lesion in the right upper lobe, suggestive of TB

Pharmacological Treatment for Active TB

Initial Phase (2 months)

Isoniazid (INH): 300 mg daily PO

• Rationale: Inhibits mycolic acid synthesis (Alsayed & Gunosewoyo, 2023).
• Side Effects: Hepatotoxicity, peripheral neuropathy (prevented with Vitamin B6).

Rifampin (RIF): 600 mg daily PO

• Rationale: Inhibits RNA synthesis.
• Side Effects: Hepatotoxicity, red-orange fluids, drug interactions.

Pyrazinamide (PZA): 25 mg/kg daily PO

• Rationale: Effective in acidic environments.
• Side Effects: Hepatotoxicity, hyperuricemia, arthralgia.

Ethambutol (EMB): 15 mg/kg daily PO

• Rationale: Inhibits cell wall synthesis.
• Side Effects: Optic neuritis (requires regular eye exams).

Continuation Phase (4 months)

Isoniazid (INH): 300 mg daily

Rifampin (RIF): 600 mg daily

Duration: Typically, 4 months, adjustable based on clinical response and susceptibility results.

Supplement

• Vitamin B6 (Pyridoxine): 50 mg daily
• Rationale: Prevents INH-induced neuropathy.

Non-Pharmacological Treatment

Monitoring

• Tests: Baseline and periodic LFTs, CBC, uric acid, renal function (Alsayed & Gunosewoyo, 2023).
• Sputum Cultures: Monthly until two consecutive negatives.

Nutrition and Hydration

• Diet: High-calorie, high-protein to combat weight loss and boost immunity.
• Hydration: Ensure adequate fluid intake for overall health and medication efficacy.

Rest and Activity

• Rest: Adequate rest to aid recovery.
• Activity: Gradual return to normal activities; avoid strenuous efforts until improvement.

Infection Control

• Isolation: Use masks and isolate from household members until negative sputum cultures.
• Hygiene: Practice proper respiratory hygiene and dispose of tissues properly.

Smoking Cessation

• Support: Provide resources and counseling for quitting smoking to improve lung health (Alsayed & Gunosewoyo, 2023).

Mental Health Support

Counseling: Address anxiety related to TB and treatment; refer to mental health services if needed.

Patient Education

• Educate the client on the importance of medication adherence
• Educate on the adverse effects of the prescribed medication
• Emphasize the significance of follow-up care
• Educate the client on the significance of isolation and using masks in public to avoid spreading the disease.
• Educate the patient on the importance of household screening to determine if the infection has spread to close family members for early management of the condition.

Referral

The client can be referred to an infectious disease specialist for further assessment and treatment guidance.

Follow-up Care

The client should return to the clinic two weeks after the initial treatment. After monthly follow-up, care should be scheduled to assess disease symptoms and the effectiveness of the prescribed medication.