Date:
Patient:
MRN:
Attending Physician:
Reason for Visit:
New diagnosis of EPTB involving [specify anatomic site, e.g., lymph nodes, pleura, bone]
Follow-up for EPTB
Evaluation of treatment response
Management of complications
History of Present Illness:
Briefly describe the patient’s presentation:
Onset and duration of symptoms (specific to the involved site, e.g., lymphadenopathy, pleural effusion, back pain)
Severity of symptoms
Prior evaluations or procedures (imaging studies, biopsies)
Past Medical History:
Include any relevant past medical conditions, such as:
Previous pulmonary tuberculosis (PTB)
Underlying conditions that increase risk for EPTB (immunosuppression, HIV)
Past surgeries (relevant to the site of EPTB)
Social History:
Risk factors for TB exposure (travel to high-burden regions, contact with individuals with TB)
Tobacco use (current and past)
Alcohol use
Family History:
History of TB in first-degree relatives
Physical Exam:
General: Appearance of illness, signs of systemic infection (fever, weight loss), findings specific to the involved site (e.g., lymphadenopathy, chest exam abnormalities)
Vital Signs: Temperature, pulse, blood pressure
Labs:
List recent laboratory tests:
Complete blood count (CBC) – may show anemia or elevated white blood cells
Inflammatory markers (CRP, ESR) – may be elevated
Sputum smear and culture (if applicable, depending on the site)
Consider mentioning other tests as relevant, such as HIV testing.
Imaging:
Mention recent imaging studies:
Chest X-ray (may show pleural effusion in some cases)
CT scan (may reveal detailed findings of the involved site)
MRI scan (may be used in specific cases)
Mention any biopsies performed to confirm diagnosis (e.g., lymph node biopsy).
Microbiology:
Document results of TB culture and drug susceptibility testing (specimen source and organism identified).
Assessment:
Confirm the diagnosis of EPTB based on clinical presentation, imaging studies, and microbiological testing.
Specify the anatomic site involved.
Assess the severity of disease and presence of complications.
Plan:
Outline the treatment plan, which typically follows a 4-phase regimen similar to pulmonary TB:
Initial intensive phase: Combination antibiotic therapy for several weeks (drugs used are isoniazid, rifampin, pyrazinamide, and ethambutol).
Continuation phase: After the initial phase, treatment continues with fewer antibiotics for a longer duration (typically isoniazid and rifampin).
The total treatment duration can vary depending on factors like drug susceptibility and immune status.
Consider mentioning the importance of directly observed therapy (DOT) to ensure medication adherence.
Address any surgical needs (e.g., drainage of pleural effusion).
Prognosis:
Briefly discuss the patient’s prognosis, which depends on factors such as the involved site, timely diagnosis, and adherence to treatment. Extrapulmonary TB can be effectively treated with appropriate antibiotic regimens.
Education:
Document any education provided to the patient regarding:
The nature of EPTB and its treatment
Importance of completing the entire antibiotic regimen
Precautions to prevent transmission to others (if applicable)
Follow-up schedule
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and emotional well-being.
Consider mentioning the need for public health measures to identify close contacts and prevent further transmission (if applicable).
Disclaimer: This is a template and should be adapted to the specific needs of each patient.