Tuberculosis is a respiratory disease that is spread through the air from person to person when an infected individual speaks, coughs or sings (Kuan, 2018). A person can have what is called a latent case of TB which means that the individual’s immune system will keep the TB infection from spreading in their body and they are not considered contagious. Individuals with an active TB case can spread the disease to other people. Individuals with this respiratory illness will have many symptoms such as chest pain, coughing up blood, night sweats, chills, fever and difficulty breathing. These patients will have to be put on a long treatment plan in order to get treated. TB is known to affect poor and vulnerable populations such as immigrants that are coming from third world countries. These individuals live in overcrowded living conditions and are from low social-economical status.
Clinical Case Study
A 29-year old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.
Clinical SOAP Note Format
History of present illness (HPI) – A 29-year old female came into the clinic with complaints of having shortness of breath, having weakness and a cough a sweats at night for the last month
When did you first notice there might be a problem?
It is important to establish a timeline for when the patient first started to notice a change in her health.
Where is the discomfort coming from?
The patient needs to be asked if she is having any chest discomfort or pain as well as asking if she has noticed any other changes such as an aching throat or headache.
When did you first notice these symptoms? Have you ever noticed these symptoms before?
What can be possible contributing factors? This patient states to be a recent immigrant, which is a high risk population for the TB disease process (Kuan, 2018).
What makes her symptoms feel worse? Does she feel her symptoms getting worse?
What helps to relieve these symptoms?
Did you provide any Tylenol or any home remedies, if so which ones?
Inquire about any past treatments such as over the counter medications or any home remedies.
Past History: The patient will be asked if she has any other medical issues.
Preventive Health: The patient needs to be asked if she is up to date with her vaccinations and if she received the Bacille Calmette-Guérin (BCG) vaccine in the country she is from.
Focused Review of System (ROS)
General: Is the patient dressed for the weather, are they acting “bizarre”?
HEENT: Eyes: can you count the fingers on my hand?; Ears: Do you have earaches, infections, discharge?; Nose: Any nasal obstruction, nosebleeds, allergies? Mouth and throat: Do you have any mouth pain, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, tonsillectomy
Respiratory System: Any history of lung disease? Any chest pain with breathing, wheezing or noisy breathing, shortness of breath, cough, sputum, any toxin, or pollution exposure. Does she smoke?
Cardiovascular system: Any history of a heart murmur, anemia?
Abdominal: The patient will be asked about their appetite, any food intolerance, dysphagia, pain, nausea, and vomiting, flatulence, frequency of bowel movement, any recent change in the stool characteristics
Urinary System: Is the patient having any pain or discomfort when urinating?
Musculoskeletal System: Any deformity, limitation of motion, gait problems, or problems with coordinated activities?
General: Patient is coughing, has visible diaphoresis, generalized weakness
Cardiovascular/pulmonary system: S1, S2 heard, no murmurs, no bruits, breathing is labored, Both upper lobes rales auscultated, middle and lower right lobe rhonchi, left lower lobe clear
HEENT: Conjunctiva clear, sclera white, left and right tympanic membranes intact, pearly white with visible landmarks
Integumentary system: Skin is warm, diaphoretic, no lesions, skin intact
Musculoskeletal system: gross symmetry during standing, sitting, and activities; the gross range of motion; gross strength; height and weight
Neuromuscular system: unbalanced gait
A and P:
Working diagnosis: Tuberculosis
Differential diagnosis : Pneumonia
Labs: Mantoux tuberculin skin test, Sputum culture, CBC, Chest x-ray, pulmonary function test
The patient with a confirmed TB diagnosis will have to be educated on the long term medication regimen they will be on and the importance and seriousness it will be for them to be compliant. The Patient will be prescribed INH 15mg/kg for a standard dose of 9 months and rifapentine 900mg to be administered once weekly utilizing the DOT (Woo et al., 2020). The patient will be instructed to self isolate at home and to isolate from family members which includes no sharing utensils or plates and cups. After the medication regimen is done, pt will be instructed to redo a sputum culture and she will be instructed to attend a follow up visit.
Kuan, M.-M. (2018, October 3). Nationwide surveillance algorithms for Tuberculosis.https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6029-x.
Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse prescribers (page 1315).