SOAP Analysis for Tuberculosis
SUBJECTIVE • Persistent cough for over 3 weeks.
• Cough started gradually about 4 weeks ago.
• Cough has been constant for the past few weeks.
• Coughing up blood-tinged sputum, fever, night sweats, unexplained weight loss (about 5 kg in the past month), and fatigue.
• Cough worsens at night and with exertion.
• Rest does not alleviate symptoms.
• No known history of TB
OBJECTIVE Vital Signs
• Elevated body temperature (38.5°C)
• Rapid heart rate (95 bpm)
• Rapid breathing (22 breaths/min (mild tachypnea))
• Normal blood pressure (120/80 mmHg)
• Oxygen Saturation (96% on room air)
Physical Examination
Appears fatigued, moderately underweight
Crackles heard in the upper lobes of the lungs
Slightly decreased breath sounds over the right upper lobe
No cyanosis or clubbing. Profuse night sweats reported
Diagnostic Tests
Chest X-ray: Findings consistent with TB (e.g., upper lobe infiltrates, cavitations)
Sputum smear and culture: Positive for acid-fast bacilli (AFB)
Tuberculin Skin Test (TST): Positive (>15 mm induration)
Interferon-gamma release assay (IGRA): Positive for TB infection
Complete Blood Count (CBC): Mild anemia, slight leukocytosis
ASSESSMENT Primary Diagnosis: Pulmonary tuberculosis
Differential Diagnosis:
- Pneumonia
- Chronic bronchitis
- Lung abscess
- Lung cancer (less likely given the patient’s young age and history)
PLANNING • Treatment
SOAP Analysis for Tuberculosis
Initiate first-line anti-TB therapy (RIPE regimen) for active TB:
- Rifampin 600 mg daily
- Isoniazid 300 mg daily (with pyridoxine 25-50 mg to prevent neuropathy)
- Pyrazinamide 25 mg/kg daily
- Ethambutol 15-25 mg/kg daily
- Treatment duration: 6 months, with initial intensive phase of 2 months followed by a continuation phase of 4 months.
Follow-up
Repeat sputum AFB smear and culture after 2 months to assess treatment response.
Monthly follow-up visits to monitor adherence, response to treatment, and side effects of medications (e.g., liver function tests for
hepatotoxicity).
• Preventive Measures
The patient should be placed in a negative pressure room in the hospital and avoid contact with others until non-infectious (typically 2
weeks after starting treatment if smear-negative).
Notify public health authorities and contact tracing may be required to identify and treat those exposed.
Patient Education
Educate the patient on the importance of medication adherence to prevent drug-resistant TB.
Counsel on infection prevention (e.g., wearing a mask, good ventilation at home).
Discuss potential side effects of TB medications, including liver toxicity, visual changes (from ethambutol), and neuropathy (from
isoniazid).
Social and Psychological Support
Refer the patient to a social worker to assess for any needs, such as housing support, given the high potential for transmission in a
shared living space.
Nutritional counseling to address weight loss and support immune function.
