Date:
Patient:
Reason for Visit:
Follow-up for PTB
Assessment of treatment response and adherence
Monitoring for adverse effects of medication
Evaluation of symptoms and chest x-ray findings
History:
Presenting Illness:
Date of PTB diagnosis and confirmation method (e.g., sputum smear microscopy, culture)
Initial symptoms at presentation (e.g., cough, hemoptysis, weight loss, night sweats)
Current symptoms and any changes since diagnosis
Past Medical History (PMH):
Underlying medical conditions that may increase susceptibility to PTB (e.g., HIV, diabetes)
Prior history of PTB treatment
Social History:
Living situation (risk of transmission to household contacts)
Substance use (alcohol, tobacco)
Immigration history (countries with high PTB burden)
Treatment:
Current PTB treatment regimen:
Medications (type, dosage, duration)
Directly Observed Therapy (DOT) status (if applicable)
Adherence to treatment:
Patient self-reported adherence
Discussion of any challenges with medication adherence
Assessment:
Symptoms:
Improvement in cough, fever, night sweats, and fatigue
Presence of any new or worsening symptoms
Chest X-ray:
Comparison to previous X-ray to assess for improvement in infiltrates or cavities
Laboratory Tests:
Results of sputum smears and cultures (if repeated) to monitor for conversion to negative (indicating successful treatment)
Adverse effects of medication:
Evaluate for potential side effects of anti-tuberculosis medications (e.g., hepatotoxicity, ototoxicity, neuropathy)
Plan:
Continue current treatment regimen: If patient is tolerating medications well and showing improvement.
Adjust treatment regimen: Consider modifications based on drug resistance testing results, adverse effects, or lack of response.
Extend treatment duration: May be necessary for complex cases or drug-resistant PTB.
Referral to a pulmonologist or infectious disease specialist: For complex cases, drug-resistant PTB, or management challenges.
Public health department involvement: Ensure proper reporting, contact tracing, and completion of treatment to prevent transmission.
Education:
Reinforce the importance of completing the entire course of treatment to prevent drug resistance.
Educate on proper cough hygiene and infection control measures to prevent transmission to others.
Discuss the importance of follow-up appointments and chest x-rays.
Provide resources for social support services (if needed).
Follow-up:
Schedule for next clinic visit based on treatment phase (intensive vs. continuation phase).
Discuss the importance of contacting the healthcare provider if any new symptoms develop or if medication side effects become intolerable.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pulmonary tuberculosis.