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Extrapulmonary Site 2 :_____________________

TUBERCULOSIS TREATMENT CARD. Name (surname, first name) Beti, Magdalene. Sex. OUT. To. Date. M. F. A. B. C. D 2005. Omang/Resident certificate/Passport Number (if available). Age (in years). IN. Registered. Date. Physical Address (in full). A. B. C. D. Unit TB No. OUT.

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Extrapulmonary Site 2 :_____________________

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  1. TUBERCULOSIS TREATMENT CARD Name (surname, first name) Beti, Magdalene Sex OUT To Date M F A B C D 2005 Omang/Resident certificate/Passport Number (if available) Age (in years) IN Registered Date Physical Address (in full) A B C D Unit TB No. OUT To Date B C D Date IN Registered Alternative address TuberculosisClassification Pulmonary Pre-treatment history and clinical findings Patient Category3 Pre-treatment Weight_____42_______Kg Failure I. INITIAL PHASE – (FDC- Fixed Dose Combinations) Reserve Drug Default Adults - HRZE(H75mg+R150mg+Z400mg+E275mg) Children - HRZ(H30mg+R60mg+Z150mg) Streptomycin - 1gm vial Daily Dose Maximum Daily Dose Relapse Weight in Kg. Daily Dose in Tablets Weight in Kg. Daily Dose in Tablets 750mg 15mg/kg 30-39 2 ≤7 1 H – Isoniazid R – Rifampicin Z – Pyrazinamide E – EthambutolS – Streptomycin 40-54 3 8-14 2 ≥55 4 15-19 3 Note: If severe drug side-effect, use single dose regimen and indicate in the remarks field 20-24 4 25-29 5 Revised September 2005 (MH 1050) BOTSWANA NATIONAL TUBERCULOSIS PROGRAMME 28 Transfer/Moved1 A Sputum Examination for AFB At month Date of Collection Result4 Extrapulmonary Site2:_____________________ 30/05/05 P+++ (pretreatment) 0 31/05/05 0 P+++ New 31/05/05 P+++ 0 N 02/08/05 2 6 05/12/05 N 8 Date Month 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)

  2. No. Expected No. Screened 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 CONTINUATION PHASE CONTACT SCREENING CULTURE & SENSITIVITY REPORTS TREATMENT OUTCOMES CHEST X-RAY Date Month 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)

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