Extrapulmonary Site 2 :_____________________ Name (surname, first name) Age (in years) Sex F...
2
Extrapulmonary Site 2 :_____________________ Name (surname, first name) Age (in years) Sex F Alternative address Physical Address (in full) M INTERIM TUBERCULOSIS TREATMENT CARD BOTSWANA NATIONAL TUBERCULOSIS PROGRAMME Date Date Date Date Registered IN To OUT Registered IN To OUT Transfer/ Moved 1 D C B D C B A D C B A Unit TB No. Pre-treatment history and clinical findings Revised September 2005 (MH 1050) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Weight in Kg Month Date 1. Transfer/Moved Transfer In– patient transfers in from facility in another reporting unit Transfer Out- patient who has been transferred to another reporting unit for whom treatment outcome is not known. Moved In- patient who moves in from another facility in 2. Site of Extrapulmona ry Lymph nodes Pleura Meninges Bones/Joints Miliary Other sites 3. Patient Category New: a patient who has never had treatment for TB or who has taken antiTB treatment for less than 1 month. A patient previously treated and cured (3 or more years ago) who is diagnosed with TB again should be registered as a New patient as well. Retreatment Categories - All retreatment cases should undergo sputum culture and sensitivities Failure: a patient who is started on a re-treatment regimen after having failed previous treatment. Default: a patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. Relapse: a patient previously treated for TB (3 years or less ago) who has been declared cured or 4. Sputum Examination for AFB Results P= Positive N= Negative Indicate the grading: +; ++; +++; 5. HIV Status Test 2 HIV test 2 not needed if patient has previously been diagnosed as HIV positive 6. HIV Status and Interventions Date For HIV tests indicate date when test was done For ART and IPT indicate the date when treatment was started HIV Status and Interventions Date 6 (dd/mm/yy) Test 1 Positive Negative Test 2 5 Positive Negative ART Yes No IPT before TB diagnosis Yes No 8 6 2 0 0 (pretreatment) 0 Result 4 Date of Collection At month Sputum Examination for AFB Other Tests Test Date Result Biopsy PPD Other (Specify) Instructions for recording drug administration: On days of supervised drug administration enter healthcare worker’s initials; On self- supervised days enter (▬); On missed treatment days enter (0) Relapse Default Failure Patient Category 3 Pulmonary Tubercul osis Classifi cation New A Omang/Passport Number (if available) I. INITIAL PHASE Prescribed regimens and dosages E H R Z S Fir st Lin e Dose in G/Mg Which corresponds to No.Tabl./Capsu les Reser ve Dose in G/Mg S= Streptomycin H=Isoniazid R=Rifampicin Z=Pryazinamide E= Ethambutol Pre-treatment weight kg Dosages of Drugs in relation to pre-treatment weight Pretreatm ent weight (in kg) E mg H mg R mg Z mg over 50 1200 300 600 2000 30-50 1000 300 450 1500 Under 30 800 100 - 200 150 - 300 500- 1000 Drug Reaction Specify……………………… ………………………………
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Transcript of Extrapulmonary Site 2 :_____________________ Name (surname, first name) Age (in years) Sex F...
ExtrapulmonarySite2:_____________________
Name (surname, first name)
Age(in years)
SexF
Alternative address
Physical Address (in full)
M
INTERIM TUBERCULOSIS TREATMENT CARDBOTSWANA NATIONAL TUBERCULOSIS PROGRAMME
Date
Date
Date
Date
RegisteredIN
ToOUT
RegisteredIN
ToOUT
Tran
sfer
/Mov
ed1
DCB
DCBA
DCBA
Uni
t TB
No.
Pre-treatment history and clinical findings
Revised September 2005 (MH 1050)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Weight in KgMonth
Date
1. Transfer/Moved
Transfer In– patient transfers in from facility in another reporting unit Transfer Out- patient who has been transferred to another reporting unit for whom treatment outcome is not known.Moved In- patient who moves in from another facility in the same reporting unitMoved Out- patient who moves out to another facility in the same reporting unit
2. Site of Extrapulmonary
Lymph nodesPleuraMeningesBones/JointsMiliaryOther sites
3. Patient Category
New: a patient who has never had treatment for TB or who has taken antiTB treatment for less than 1 month. A patient previously treated and cured (3 or more years ago) who is diagnosed with TB again should be registered as a New patient as well.
Retreatment Categories - All retreatment cases should undergo sputum culture and sensitivities
Failure: a patient who is started on a re-treatment regimen after having failed previous treatment.Default: a patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. Relapse: a patient previously treated for TB (3 years or less ago) who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive TB.
4. Sputum Examination for AFB Results
P= PositiveN= NegativeIndicate the grading: +; ++; +++; or scanty
5. HIV Status Test 2
HIV test 2 not needed if patient has previously been diagnosed as HIV positive6. HIV Status and Interventions Date
For HIV tests indicate date when test was doneFor ART and IPT indicate the date when treatment was startedAdd referral information in the Remarks field.
HIV Status and Interventions Date6 (dd/mm/yy)
Test 1 Positive Negative
Test 25 Positive Negative
ART Yes No
IPT before TB diagnosis
Yes No
8
6
2
0
0
(pretreatment)0
Result4Date of CollectionAt monthSputum Examination for AFB
Other Tests
Test Date Result
Biopsy
PPD
Other (Specify)
Instructions for recording drug administration: On days of supervised drug administration enter healthcare worker’s initials; On self-supervised days enter (▬); On missed treatment days enter (0)
Relapse
Default
Failure
Patient Category3
PulmonaryTuberculosisClassification
New
A
Omang/Passport Number (if available)
I. INITIAL PHASE
Prescribed regimens and dosages
E H R Z S
First Line
Dose in G/Mg
Which corresponds to No.Tabl./Capsules
Reserve Dose in G/Mg
S= Streptomycin H=Isoniazid R=Rifampicin Z=Pryazinamide E= Ethambutol
Pre-treatment weight kg
Dosages of Drugs in relation to pre-treatment weight
Pretreatment weight (in kg)
Emg
H mg
Rmg
Z mg
over 50 1200 300 600 2000
30-50 1000 300 450 1500
Under 30 800 100- 200
150-300
500-1000
Drug Reaction
Specify………………………………………………………
Weight in Kg3130292827252416 2623222120191817151413121110987654321Month
Date
No. ScreenedNo. Expected
No. No.
Date_________ Date_________
CHEST X-RAY
CULTURE & SENSITIVITY REPORTS
Date Remarks (include other treatment, referral, or follow-up information)
Date Drug Sensitive Resistant
H
R
Z
E
S
CONTACT SCREENINGII. CONTINUATION PHASE
Cured Died
Treatment Completed Defaulted
Treatment Failure Transferred Out
TREATMENT OUTCOMES7
Instructions for recording drug administration: On days of supervised drug administration enter healthcare worker’s initials; On self-supervised days enter (▬); On missed treatment days enter (0)
7. TREATMENT OUTCOMES: Cured: Initially smear-positive patient who is smear-negative in the last month of treatment and on at least one previous occasion Treatment Completed: Patient who has completed treatment but does not meet the criteria to be classified as cure or a failureTreatment Failure: Patient who is sputum smear-positive at 5 months or later during treatment
Died: Patient who dies for any reason during treatmentDefaulted: Patient whose treatment was interrupted for two consecutive months or moreTransferred Out: Patient who has been transferred to another reporting district for whom treatment outcome is not known
Prescribed regimens and dosages H R E S
First Line
Dose in G/Mg
Which corresponds to No. Tabl./Capsules
Reserve
Weight at start of continuation phase kg.
Dosages of drugs in relation to weight at time of start continuation phase
Weight (in kg) H R
mg mg
Over 50 300 600
30-50 300 450
Under 301 100-200 150-300
1. Patients under 20 kg receive the lower dosage
