Ministry of Health Community Development Gender Elderly and Children National Tuberculosis and Leprosy Programme

DR-TB 02

DR-TB PATIENT IDENTITY CARD DR-TB Treatment Unit:

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:

Other Contact 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 ):

Number of previous treatments with second-line TB drugs ( 4 weeks):

Period TB drugs were taken (start - stop date each episode) Registration Group (tick)

Rifampicin (R) New patient, never treated for TB, or treated for less than 4 weeks

Isoniazid (H) Pyrazinamide (Z) Previously treated with first-line

drugs more than 4 weeks; H, R, Z, E only (New)

Ethambutol (E)

Streptomycin (S) Previously treated with first-line drugs more than 4 weeks (Retreatment regimen)

Fluoroquinolone (Gtx, Lfx, Mfx)

Amikacin (Am)/Kanamycin(Km)

Previously treated with second-line drugs more than 4 weeks

Capreomycin (Cm)

Cycloserine (Cs) Transfer in (from another MDR-TB treatment site)

Clofazmine(Cfz)

Ethionamide (Eto)/Prothionamide(Pto)

Linezolid(Lzd) Other (previously treated without known outcome)

p-aminosalicylic Acid (PAS)

Bedaquilin (BDQ)

Delaminid(DLM)

Other

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)

S/No

Name of contacts

Relation to index

Screened (Tick appropriately)

Presumptive (Tick appropriately)

Confirmed

(Tick appropriately)

Date Specimen sent for DST

H R E S Cs Am Cm Km Ofx Lfx Eto PAS LZD CFZ Pto BDQ DLM Type of test

Xpert, LPA, DST

Contacts Tracing information:

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

ECG Findings:

-ray findings:

TREATMENT

Treatment Start Date: Second-line Regimen Initial phase Dose Continuation phase Dose

Pyrazinamide (Z) Pyrazinamide(Z) Fluoroquinolone ( Lfx,

Mfx, Gtx)) Fluoroquinolone( Lfx, Mfx,

Gtx)

Amikacin (Am)/ Capreomycin(Cm)

Ethionamide(Eto) /Prothionamide(Pto)

Ethionamide(Eto)/Prothionamide(Pto)

Cycloserine(Cs) Cycloserine(Cs)

Ethambutol (E) Ethambutol(E)

Linezolid (Lzd) Linezolid(Lzd)

Para aminosalicylic Acid (PAS)

Para aminosalicylic Acid (PAS)

Clofazmine(Cfz) Clofazmine(Cfz)

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

Sputum-smear Culture

Month of DR-TB Treatment

Sputum-smear

1 2 1 2

Initial

End of

treatment

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192021222324252627282930313233343536

Weight (in Kg)

BMI Culture Weight (in Kg)

BMI

INTENSIVE PHASE OF TU BERCULOSIS CHEMOTHERAPY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Treatment Outcome : Cured Completed Died Failed Lost to follow up Not evaluated

Date : ____________________

Month/day

(X) for date of facility-based DOT. 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

CONTINUATION PHASE OF TUBERCULOSIS CHEMOTHERAPY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Month/day

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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.