Extrapulmonary

Site2:_____________________

TUBERCULOSIS TREATMENT CARDBOTSWANA NATIONAL TUBERCULOSIS PROGRAMME

Date

Date

Date

Date

RegisteredIN

ToOUT

RegisteredIN

ToOUT

Tran

sfer

/Mov

ed1

DCB

DCBA

D

2005CBA

Uni

t TB

No.

Pre-treatment history and clinical findings

Revised September 2005 (MH 1050)

750mg

H – Isoniazid

R – Rifampicin

Z – Pyrazinamide

E – EthambutolS – Streptomycin

15mg/kg

Maximum Daily Dose

Daily Dose

Streptomycin - 1gm vial

Reserve Drug

525-29

4

3

2

1

4

3

2

15-19≥55

8-1440-54

≤730-39

Daily Dose in Tablets

Daily Dose in Tablets

20-24Note: If severe drug side-effect, use single dose regimen and indicate in the remarks field

Weight in Kg.

Weight in Kg.

Children - HRZ (H30mg+R60mg+Z150mg)

Adults - HRZE(H75mg+R150mg+Z400mg+E275mg)

Pre-treatment Weight_____42_______Kg

I. INITIAL PHASE – (FDC- Fixed Dose Combinations)

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

06/2005 NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB 43 kg

07/2005 NB NB O NB NB NB NB NB NB NB NB NB NB NB NB

MonthDate

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 positive

6. 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 01/06/05

Test 25 Positive Negative

ART Yes No 02/07/05

IPT before TB diagnosis

Yes No

8

6 N05/12/05

2 N02/08/050 31/05/05

0 P+++31/05/05

(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

Pulmonary

TuberculosisClassification

New

A

Age(in years)

Alternative address

Name (surname, first name) Beti, Magdalene SexF

Physical Address (in full)

M

Omang/Resident certificate/Passport Number (if available)

28

30/05/05

P+++

P+++

Weight in Kg3130292827252416 2623222120191817151413121110987654321Month

Date

Weight at start of Continuation Phase ________Kg.

II. Continuation Phase (FDC)

Adults – HR(H75mg+R150 mg)

Children – HR(H30mg + R60mg)

Weight in Kg.

Daily Dose in Tablets

Weight in Kg. Daily Dose in Tablets

30-39 2 ≤7 1

40-54 3 8-14 2

≥55 4 15-19 3

20-24 4

25-29 5

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 SCREENINGCONTINUATION PHASE

Cured

Treatment Completed

Treatment Failure

Died

Defaulted

Transferred Out

TREATMENT OUTCOMES

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