1. Extrapulmonary Site 2 :_____________________ TUBERCULOSIS TREATMENT CARD BOTSWANA NATIONAL TUBERCULOSIS PROGRAMME Date RegisteredIN ToOUT RegisteredIN ToOUT Transfer/Moved 1 DCB DCBA D 200 5 CBA Unit TB No. Pre-treatment history and clinical findings Revised September 2005 (MH 1050) 750mg H – Isoniazid R – Rifampicin Z – Pyrazinamide E – Ethambutol S – 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 20-24 Note : If severe drug side-effect, use single dose regimen and indicate in the remarks field Weight in Kg. Children - HRZ ( H 30mg+ R 60mg+ Z 150mg) Adults - HRZE ( H 75 mg +R 150 mg +Z 400 mg +E 275 m g ) Pre-treatment Weight_____ 42 _______Kg I. INITIAL PHASE – (FDC- Fixed Dose Combinations) 12345678910111213141516171819202122232425262728293031 Weight in Kg 06/2005NB 43 kg 07/2005NB O 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 the same reporting unit Moved Out- patient who moves out to another facility in the same reporting unit 2. Site of Extrapulmonary 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 treatment completed, and is diagnosed with bacteriologically positive TB. 4. Sputum Examination for AFB Results P = Positive N = Negative Indicate 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 done For ART and IPT indicate the date when treatment was started Add referral information in the Remarks field. HIV Status and InterventionsDate 6 (dd/mm/yy) Test 1 Positive Negative 01/06/05 Test 2 5 Positive Negative ART Yes No 02/07/05 IPT before TB diagnosis Yes No 8 6 N05/12/05 2 N 02/08/05 0 31/05/05 0 P+++ 31/05/05 (pretreatment) 0 Result 4 Date of Collection At month Sputum Examination for AFB Other Tests TestDateResult 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 Tuberculosis Classification New A Age (in years) Alternative address Name (surname, first name) Beti, Magdalene Sex F Physical Address (in full) M Omang/Resident certificate/Passport Number (if available) 28 30/05/05 P+++

2. Month Date Weight at start of Continuation Phase ________Kg. II. Continuation Phase (FDC) Adults – HR ( H 75mg+ R 150 mg) Children – HR ( H 30mg + R 60mg) Weight in Kg. Daily Dose in Tablets Weight in Kg.Daily Dose in Tablets 30-392≤71 40-5438-142 ≥55415-193 20-244 25-295 No. ScreenedNo. Expected No. Date_________ CHEST X-RAY CULTURE & SENSITIVITY REPORTS DateRemarks (include other treatment, referral, or follow-up information ) DateDrugSensitiveResistant 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 failure Treatment Failure: Patient who is sputum smear-positive at 5 months or later during treatment Died : Patient who dies for any reason during treatment Defaulted : Patient whose treatment was interrupted for two consecutive months or more Transferred Out : Patient who has been transferred to another reporting district for whom treatment outcome is not known