Form #3121-R - Tuberculosis Services (Page 3 of 3) in pdf

Name of client____________________________________________

DOB____________________

#3121-R, Tuberculosis Services continued, p. 3

Reason for Review: Continuation/review

Follow up/Adverse Event

Window Period Prophylaxis

Treatment Completion



Other

Health Department: ________________________________________________________

Phone:_________________________________

CURRENT DRUG REGIMEN

TREATMENT COURSE

Date RX Started:_______________

 DOT

# Months on Therapy _____

# Doses to date ___________

Non-DOT

Daily

Twice Weekly

Other _____________________________

Anticipated length of treatment ________________________

Anticipated completion date ___________________________

 Isoniazid ________________________

 Rifampin __________________________

Treatment interruptions: Date stopped _________________

 Pyrazinamide ____________ ________

 Ethambutol ________________________

Date re-started _________

# Doses missed ____________

 Rifapentine_______________________

Reason therapy stopped:

 Other _________________________________________________________________________

 Medical adverse reactions

 Liver Enzymes elevated

 Patient non-adherence

 Provider reasons

 Other____________________________________________

Comments:

Date Completed _______________________ SIGNATURE _

___________________________________________________________________________

CHEST RADIOGRAPHY &

IMAGING STUDY

INITIAL

Interpretation

FOLLOW-UP

Normal Not doneUnknown

 Not done

 Unknown

Date _________________

Abnormal :

Date _____________________

Chest views_______________

 Pleural Effusion

Chest views_______________

CT scan__________________

 Evidence of Miliary TB

CT scan/imaging______________

 MRI __________________

 Cavitary

Remarks:

Status  Stable  Improving Worsening Unknown

 Non-cavitary:

Consistent with TB

 Inconsistent with TB

Treatment:

Site of TB Disease (select all that apply):

Diagnosis:

Classification:

Do not treat

 Latent TB Infection

 0 No exposure, not infected

Pulmonary

Pleural

Laryngeal

Treatment complete

Lymphatic:Cervical

Laboratory confirmed TB

 I Exposure, no infection

Refer to private Physician for diagnosis and/or

Lymphatic: Intrathoracic

case

 II TB Infection, no disease

treatment

Lymphatic: Axillary

Clinical TB case

 III Current TB disease

 Start or continue window period prophylaxis

Lymphatic: Other

Recurrent TB case within

 IV Previous TB disease

Discontinue window period prophylaxis

Lymphatic: Unknown

12 months after completion

 V TB suspected

Start or continue treatment for LTBI

Bone and/or Joint

of therapy

Discontinue treatment for LTBI

Genitourinary Meningeal

Nontuberculous

 Start or continue treatment for active TB disease

Peritoneal

Mycobacterial Disease

Discontinue treatment for active TB disease

Site not stated

Other ________________

Other _________________________

Other____________________________________

PHYSICIAN RECOMMENDATIONS

Medication: Initial Continuation  Change of medications /  Daily  Twice weekly  Other _____________________

 DOT  Self administer

 Isoniazid 300 mg ____ tab(s) (_____ mg) PO _____days/wk X _____ doses

 Isoniazid 300 mg ______tab(s) (______mg) PO BIW X ________ doses

 Rifampin 300 mg _____ cap(s) (_____mg) PO ___days/wk X ____doses

 Rifampin 300 mg ______ cap(s) (________ mg) PO BIW X ________ doses

 Pyrazinamide 500 mg _____ tab(s) (______mg) PO ____days/wk X ___ doses

 Pyrazinamide 500 mg ______ tab(s) PO (_______ mg) BIW X ______ doses

 Ethambutol 400 mg ____ tab(s) (______mg) PO ___days/wk X ____ doses

 Ethambutol 400 mg ______tab(s) (_______mg) PO BIW X ________ doses

 Pyridoxine 25 mg 1 tablet PO ______days/wk X ___ ___ doses

 Pyridoxine 50 mg 1 tablet PO _______days/wk X _____ doses

 Pyridoxine 50 mg 1 tablet PO BIW X _____ doses

 Other ________________________________________________________________________________________________________________________________

Recommendations: None

 Hospitalization

 Send old X-rays

 Send medical records

 Repeat TST (mo./yr._________)

 Repeat Chest-X-ray (mo./yr.___________)

 Re X-ray as clinically indicated

 Sputum AFB Smear/Culture daily X3 then weekly until sputum conversion, then monthly

 Sputum culture sensitivity

 2 month sputum conversion

Perform baseline labs:

 AST

 ALT

 Liver profile

 Bilirubin

 Alkaline phosphatase

 CBC with platelet count

 Serum uric acid

 Serum creatinine  Hepatitis B & C profile

 HIV counseling & testing

 CD4+count

Perform monthly labs:

 AST

 ALT

 Liver profile

 Bilirubin

 Alkaline phosphatase

 CBC with platelet count

 Serum uric acid

 Serum creatinine

 Baseline and monthly visual acuity testing and red/green color discrimination

 Other _________________________________________________

Comments:

Date Review Completed ___________________

SIGNATURE

_________________________________________________________________________

GA DPH TB Unit

Form 3121-R (Rev. 01/2016)

Form #3121-R - Tuberculosis Services Page 3

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