DR-TB Patient Treatment Log Book

REPUBLIC OF KENYA MINISTRY OF HEALTH DR-TB Patient Treatment Log Book Patient Name: Patient Reg. No.: VERSION 2016

DR-TB treatment outcome summary Outcome Mark one Date Cured Died Failed Defaulted Transferred out

DR-TB (Category IV) Treatment Card Registration group County: 1 Sub-County: 2 3 Names: 4 5 6 DR-TB serial number: Date of Registration: Sub-County DR-TB Registration number: 7 Mobile phone number: Male Age: Female Start date No. (If unknown, put year) HIV information Used second line drugs: Yes HIV testing done: Date of Birth: / / If positive, on ARVs: Yes Patient supporter name: No Results: Pos Physical Address: CD4 count: Initial weight (kg): Height (cm): BMI/BMI for Age/Z score: ART Patient No: Pulmonary Extrapulmonary ARV = Antiretrovirals Both Date started: / / Date Started / / CPT = cotrimoxazole preventive therapy If Extrapulmonary, specify site: TB Symptoms Indicate Regimen: Past Medical History Diabetes mellitus Chronic renal insufficiency Chronic hepatitis or cirrhosis Convulsions, epilepsy Cardiovascular disease Psychiatric history Savere malnutrition Other Other medications used Neg Viral Load: If positive on CPT: Yes/No or N/A Cough Current Medication Other lung diseases Current medication Sputum Fever Shortness of breath Night sweats Wheight loss Tick as applicable Outcome No Don t Know If yes tick as applicable in the table below No ART Regimen Telephone Number: Type of TB Yes Date of test: / / Occupation: Previous tuberculosis treatment episodes New (Primary MDR-TB) Relapse Return after default After failure of first line (Cat 1 or 3) After failure of retreatment (Cat 2) Transfer in Other (previously treated without known outcome status) Nearest school/church/mosque: Sex: Select only one Am Amikacin Km Kanamycin Cm Capreomycin Cfx Ciprofloxacin Ofx Ofx Lfx Levofloxacin Mfx Moxifloxacin Gfx Gatifloxacin Pto Prothionamide Eto Ethionamide Cs Cycloserine PAS Para aminosalicilic acid

Anthroprometric Measurements Comments Not Done NC FS MN ND

SCTLC

Month Sputum smear microscopy No. Date* Sample No. Result Sputum smear microscopy Month No. Date* Sample No. Result Culture Month No. Date* Sample No. Result Culture Month No. Date* Sample No. Result Prior** Prior** 0 13 0 13 1 14 1 14 2 15 2 15 3 16 3 16 4 17 4 17 5 18 5 18 6 19 6 19 7 20 7 20 8 21 8 21 9 22 9 22 10 23 10 23 11 24 11 24 GENEXPERT Results (tick where applicable) RESISTANT No AFB seen 1-9 AFB per 100 HPF 0 Scanty (Report no of AFB) 10-99 AFB per 100 HPF + 1-10 AFB per HPF ++ >10 AFB per HPF +++ Notation method for recording cultures No growth reported Fewer than 10 colonies Report no. of colonies 10-1000 colonies + More than 100 colonies ++ Innumerable or confluent growth +++ 12 12

AUDIOMETER FOLLOW UP TOOL Month 0 1 2 3 4 5 6 7 8 9 10 11 12 Date FREQUENCY(dbl) Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left 500 1,000 2,000 3,000 4,000 6,000 8,000 COMMENTS

RIGHT EAR 8,000 8,000 7,500 7,500 7,000 7,000 6,500 6,500 6,000 6,000 5,500 5,500 Frequency (dbl) Frequency (dbl) LEFT EAR 5,000 4,500 4,000 3,500 5,000 4,500 4,000 3,500 3,000 3,000 2,500 2,500 2,000 2,000 1,500 1,500 1,000 1,000 500 500 0 1 2 3 4 5 6 7 8 Month of Treatment 9 10 11 12 0 1 2 3 4 5 6 7 8 Month of Treatment 9 10 11 12

DR-TB DRUG SIDE EFFECT MONITORING FORM Intensive phase - Adverse effect (indicate grading*) Month/Date Month of treatment Management Date side effect was detected Abdominal pain Constipation Decreased hearing Depression Diarrhea Dizziness Fatigue Fever Headache Joint pain Nausea Psychosis Rash Skin colorization Tinnitus Tremors Vision changes Vomiting Others (list) * Grading: 1 = mild; requiring no intervention 2 = moderate; requiring palliative intervention ** Indicate in the first column the month of treatment that intensive phase ended 3 = severe; requiring change in treatment Outcome

DR-TB DRUG SIDE EFFECT MONITORING FORM Continuation phase - Adverse effect (indicate grading*) Month/Date Month of treatment Management Date side effect was detected Abdominal pain Constipation Decreased hearing Depression Diarrhea Dizziness Fatigue Fever Headache Joint pain Nausea Psychosis Rash Skin colorization Tinnitus Tremors Vision changes Vomiting Others (list) * Grading: 1 = mild; requiring no intervention 2 = moderate; requiring palliative intervention ** Indicate in the first column the month of treatment that intensive phase ended 3 = severe; requiring change in treatment Outcome

DR-TB REGIMEN (Date treatment started and dosage (mg), change of dosage, and ceasation of drugs) Drug INH R Z E High Dose-INH KM AM CM LFX MFX ETO PTO CS Pas BDQ DEL CFZ LZD AMX/CLAV IMP Date treatment started Initial Dosage Date of Dosage revision Adjusted Dose Reason for adjusting dosage Date drug was stopped Reason for stopping the drug

Daily observation of drug intake (One table per month) Reason for missed drug Month Date 1 2 3 4 5 6 7 8 9 10 11 12 13 INH R E Z High Dose-INH AM KM CM LFX MFX PTO ETO CS PAS AMX/CLAV LZD CFX BDQ DLM IMP Mark in the boxes O Daily Observed N Not Supervised X Drug not taken Comments: 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Daily observation of drug intake (One table per month) Month Date 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 INH Reason for missed drug R E Z High Dose-INH AM KM CM LFX MFX PTO ETO CS PAS AMX/CLAV LZD CFX BDQ DLM IMP Mark in the boxes O Daily Observed Comments: N X Not Supervised Drug not taken