DR-TB PATIENT IDENTITY CARD

Transcription

1 Ministry of Health Community Development Gender Elderly and Children National Tuberculosis and Leprosy Programme DR-TB 02 DR-TB Treatment Unit: DR-TB PATIENT IDENTITY CARD DR-TB Reg. Number: Date of registration: Patient name: Age M F Address: Telephone number: Place of work: Close relative/treatment supporter contacts Name and Number: Village/Street chairperson : (name and Phone number) Previous TB treatment history: Number of previous treatments with first-line TB drugs ( 4 weeks ): Other Contact Name and Number: Number of previous treatments with second-line TB drugs ( 4 weeks): Period TB drugs were taken (start - stop date each episode) Rifampicin (R) Isoniazid (H) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) Fluoroquinolone (Gtx, Lfx, Mfx) Amikacin (Am)/Kanamycin(Km) Capreomycin (Cm) Cycloserine (Cs) Ethionamide (Eto)/Prothionamide(Pto) Linezolid(Lzd) p-aminosalicylic Acid (PAS) Bedaquilin (BDQ) Delaminid(DLM) Other Registration Group (tick) New patient, never treated for TB, or treated for less than 4 weeks Previously treated with first-line drugs more than 4 weeks; H, R, Z, E only (New) Previously treated with first-line drugs more than 4 weeks (Retreatment regimen) Previously treated with secondline drugs more than 4 weeks Transfer in (from another MDR-TB treatment site) Other (previously treated without known outcome)

2 Pulmonary TB Extra-Pulmonary TB Extra-Pulmonary TB Site: Body weight (kgs) Initial sputum-smear results (neg, positive and grading, not done, no data) Date Lab # Result Date Lab # Result Initial Culture results (Negative/positive M.tb/contaminated/not done/pending) Drug Sensitivity Test Results (S = sensitive; R = resistant; P = pending; ND = Not done) Date Specimen sent for DST H R E S Cs Am Cm Km Ofx Lfx Eto PAS LZD BDQ DLM CFZ Pto Type of test Xpert, LPA, DST Contacts Tracing information: S/No Name of contacts Relation to index Screened Presumptive Confirmed

3 Medical History: (Adverse reactions and allergies to non-tb medications; last menstrual period; method of contraception; pregnancy history) Other complicating conditions: (Diabetes, renal insufficiency, hepatitis, drug or alcohol abuse, psychiatric disorders, depression etc.) Other drugs that the patient is currently taking: Physical examination: (General physical condition, blood pressure, length, BMI, full physical examination, urine analysis, liver /kidney function) X-ray findings: ECG Findings:

4 TREATMENT Treatment Start Date: Second-line Regimen Initial phase Dose Continuation phase Dose Pyrazinamide (Z) Fluoroquinolone ( Lfx, Mfx, Gtx)) Amikacin (Am)/ Capreomycin(Cm) Ethionamide(Eto) /Prothionamide(Pto) Cycloserine(Cs) Pyrazinamide(Z) Fluoroquinolone( Lfx, Mfx, Gtx) Ethionamide(Eto)/Prothio namide(pto) Cycloserine(Cs) Ethambutol (E) Linezolid (Lzd) Para aminosalicylic Acid (PAS) Ethambutol(E) Linezolid(Lzd) Para aminosalicylic Acid (PAS) Bedaquillin (BDQ) Delaminid (DLM) Isoniazid(INH hd) Additional treatment Cotrimoxazole Cotrimoxazole Pyridoxine( Vit B6) Pyridoxine( Vit B6) Anti-Retroviral Treatment: Other medicines: SPUTUM and WEIGHT MONITORING Month of DR-TB Treatment Initial Sputumsmear Weight Month of Sputumsmear Culture BMI DR-TB (in Kg) Treatment End of treatment Culture Weight (in Kg) BMI

5 INTENSIVE PHASE OF TU BERCULOSIS CHEMOTHERAPY Month/ day (X) for date of facility-based DOT Month/ day CONTINUATION PHASE OF TUBERCULOSIS CHEMOTHERAPY For patients on health-facility DOT, put X on days of directly observed treatment. For patients on home -based DOT, draw a horizontal line to indicate the number of days supply given to supporter Treatment Outcome : Cured Completed Died Failed Lost to follow up Not evaluated Date :