Latent Tuberculosis Evaluation and Treatment Note

Date/Time: [Date and time]

Encounter Type: [in-person / telehealth / phone]

Reason for Visit: [Reason for visit]

Chief Concern

[One-sentence statement of the reason for evaluation] (May include a brief clarifying patient quote if relevant.)

History of Present Illness

[Narrative summary of why TB testing was performed or why the patient is presenting now] (Describe the precipitating event, timeline, and context, then transition to structured risk documentation below.)

TB Exposure History:

• [Known TB contact(s): relationship, setting, index case infectiousness if known, dates/timeframe]
• [Congregate setting exposure: correctional facility / shelter / long-term care / other; timeframe]
• [Occupational exposure: healthcare / laboratory / correctional / other; role and duration]
• [Country of birth and years living outside the U.S.; high-incidence regions if relevant]
• [Travel or residence in high-incidence regions: location(s) and timeframe]

Progression Risk Factors: (Document each as present, absent, or unknown with details when available.)

• HIV status: [positive / negative / unknown]; [test date if known]
• Immunosuppression: [present / absent / unknown]; [specify: transplant / TNF-alpha inhibitor / prolonged steroids / chemotherapy / other]
• Diabetes: [present / absent / unknown]
• Chronic kidney disease/dialysis: [present / absent / unknown]
• Silicosis: [present / absent / unknown]
• Underweight/malnutrition: [present / absent / unknown]
• Recent TB test conversion: [present / absent / unknown]
• Pregnancy or postpartum: [present / absent / not applicable]

Prior TB History:

• [Prior active TB: site, treatment dates, completion status, drug susceptibility if known]
• [Prior LTBI treatment: regimen, dates, completion, adverse reactions]
• [Prior TB testing: IGRA/TST type, dates, results; include TST induration in mm if applicable]
• [BCG vaccination history: yes / no / unknown]

Active TB Symptom Screen (Required): [positive / negative / pending]

• Pulmonary: [cough, hemoptysis, chest pain, dyspnea; duration and severity if present]
• Constitutional: [fever, night sweats, unintentional weight loss, fatigue, anorexia; duration and severity if present]
• [If symptoms present: alternative diagnoses considered and rationale]

(Do not infer a negative symptom screen; must be explicitly elicited and documented. If not yet assessed, mark as pending.)

Additional Context: (Include when relevant.)

• [Pregnancy intentions; breastfeeding status]
• [Contraception method]
• [Alcohol use pattern]
• [Barriers to adherence: housing, transportation, work schedule, language, health literacy]

Medications and Drug Interaction Review

Current Medications: [List all medications including OTCs and supplements] (If HIV-positive, list complete antiretroviral regimen. Include hormonal contraception method if applicable.)

Allergies: [Drug allergies with reaction type and severity] (Note rifamycins and isoniazid specifically; document prior hepatotoxicity if any.)

DDI Screening Summary: (Required if rifamycin regimen considered.)

• [Interaction review performed on date]
• [Interacting medications identified: anticoagulants, methadone, anticonvulsants, hormonal contraception, azoles, antiretrovirals, immunosuppressants]
• [Mitigation plan: dose adjustments / alternative medications / backup contraception / specialty consultation]
• (If no significant interactions identified, state explicitly.)

Objective Data

TB Infection Testing:

• IGRA: [Test name], [collection date], [positive / negative / indeterminate], [quantitative values if available]; [verified records / patient-reported]
• TST: [Placement date], [read date], [induration in mm], [interpretation threshold used based on risk category]; [verified records / patient-reported]

Chest Imaging: (Required before LTBI treatment.)

• [CXR / CT], [date], [facility]
• Radiology impression: [Findings]
• Clinical interpretation: [Evidence of active pulmonary TB: present / absent]

(If not yet obtained, document as pending and note that LTBI therapy is deferred until imaging reviewed.)

Additional Studies: (Include if applicable.)

• [Sputum AFB smear/culture/NAAT: dates and results]
• [Baseline labs (AST, ALT, bilirubin) if indicated: values and dates]
• [Pregnancy test result and date if relevant]
• [HIV test date and result if relevant]

Physical Examination: (Include if performed.)

• Vitals: [Temperature, weight]
• General: [Appearance]
• Respiratory: [Lung exam findings]
• Lymph nodes: [Findings if examined]
• Abdominal: [Findings if hepatotoxicity concern]

(For remote visits, note exam limitations.)

Assessment

TB Status Classification: [Latent TB infection confirmed / TB infection test positive, active TB not yet excluded / Suspected active TB requiring further evaluation]

Basis for Classification: [Test interpretation, symptom screen result, imaging review] (State explicitly whether active TB has been excluded.)

Progression Risk Level: [low / moderate / high] based on [key risk factors summarized]

Safety Considerations: [Hepatic risk, pregnancy/lactation, DDIs, prior adverse reactions, adherence barriers] (Include only those that affect regimen choice.)

Plan

Active TB Evaluation

(Include only if active TB has not yet been excluded.)

• [Chest imaging plan if not obtained]
• [Sputum testing plan if indicated: number of specimens, timing, NAAT order]
• [Infection control precautions if applicable]
• LTBI monotherapy will not be initiated until active TB is excluded.

LTBI Treatment

Regimen: [Drug name(s)], [dose in mg], [frequency], [route], [planned start date], [target duration], [total dose goal]

• Pyridoxine (B6): [Dose and indication if prescribed]
• Regimen rationale: [Efficacy, DDI profile, tolerability, pregnancy considerations, source case susceptibility]

(If deferring treatment, document reason and conditions for initiation.)

DDI Mitigation:

• [Specific actions taken for identified interactions]
• [For hormonal contraception with rifamycins: backup or alternative method counseling]
• [Rifamycin body fluid discoloration counseling provided]

Monitoring Plan:

• Monthly clinical monitoring for adherence, TB symptoms, and adverse effects
• [Lab monitoring plan: routine periodic labs if abnormal baseline or hepatic risk factors; otherwise symptom-prompted only]

Adverse Effect Counseling: Patient instructed to stop medication and seek care immediately for:

• Jaundice, dark urine, light-colored stools
• Persistent nausea/vomiting or abdominal pain
• Severe rash
• Numbness/tingling in extremities

[Alcohol moderation/avoidance counseling: provided / not indicated]

Adherence Support:

• [Barriers addressed]
• [Tools provided: pill organizer / reminders / calendar / education materials]
• [DOT or video DOT: yes / no]

Follow-up

• [Next visit timing and modality]
• [Coordination with TB program / referring provider / specialists if applicable]

Interval Follow-up

(Use for monthly monitoring visits. May replace detailed HPI if prior history unchanged.)

• Adherence: [Doses taken since last visit], [missed doses and reasons], [current dose count] of [total planned]
• Adverse Effect Screen: [Hepatotoxicity symptoms / rash / neuropathy / other concerns: present / absent]
• Interval TB Symptom Screen: [Cough / fever / night sweats / weight loss: present / absent]
• Medication Changes: [New medications requiring DDI reassessment]
• Labs: [Interval lab results if obtained]
• Plan Update: [Continue / hold / modify regimen]; [updated dose count]; [projected completion date]; [next follow-up]

Treatment Completion

(Use for final treatment visit.)

• Regimen Completed: [Drug(s)], [dose/frequency], [start date], [end date], [total doses completed] of [goal], [completed within acceptable timeframe: yes / no]
• Completion Status: [Completed / Partially completed (doses and reason) / Discontinued due to adverse event (specify) / Lost to follow-up / Switched regimens]
• Final Symptom Screen: [Asymptomatic for active TB: yes / no] (If symptomatic, describe and evaluate.)
• Completion Counseling: TB tests may remain positive after successful treatment; patient advised to retain documentation and seek evaluation if TB symptoms develop in future
• Documentation: [Completion letter provided: yes / no], [problem list updated], [notification sent to referring provider / public health: yes / no / not applicable]

(Meta-instructions: Use placeholders such as "Not yet obtained," "Pending," or "Unknown" for decision-critical items including symptom screen, chest imaging, pregnancy status, and baseline labs. Do not infer that symptoms are absent, exposures did not occur, or drug interactions were reviewed unless explicitly documented. Omit sections that do not apply to the visit type.)