Form Dhhs 1030 - Tuberculosis Epidemiological Record Page 2
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2Film #________________ Location where taken: ________________________
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CHEST RADIOGRAPH Date: ___/___/______
Check if end of treatment CXR
Result:
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Normal
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Abnormal
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Atelectasis
□ Nodules
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Cavity
□ Pleural effusion
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Granuloma
□ Pleural thickening
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Infiltrate
□ Scarring
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Mediastinal lymphadenopathy
Physician notes and examination:
Comments on CXR:
Prior Chest radiograph date: ____/___/______
Comparison:
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Improved
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No change
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Worse
CURRENT STATUS:
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No further TB f/u needed
Evaluation in progress
Latent TB
Suspected active TB
Confirmed active TB
ORDERS:
ALL PATIENTS ARE TO BE MONITORED PER NC STATE AND COUNTY TB POLICIES.
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Sputum x 3 for AFB, then x 2 q 2 weeks
Draw liver function tests monthly
Respiratory isolation
Close to TB follow up
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Treat for latent TB infection:
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Isoniazid _____ mg po x 9 months
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Daily, self-administered
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Twice-weekly, directly observed
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Rifampin _____ mg po x 4 months daily
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Self-administered
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Directly observed
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Isoniazid ____ mg + Rifapentine ____ mg po once-weekly x 12 weeks, directly observed
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Treat for active TB:
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For 2 weeks or ____ weeks:
Other orders:
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Isoniazid ______ mg po qd
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Rifampin ______ mg po qd
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Pyrazinamide _____ mg po qd
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Ethambutol ______ mg po qd
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B6 _____ mg po qd
THEN for the next 6 weeks:
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Isoniazid ______ mg po 2x/week
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Rifampin ______ mg po 2x/week
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Pyrazinamide _____ mg po 2x/week
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Ethambutol ______ mg po 2x/week
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B6 _____ mg po 2x/week
THEN for the next 18 weeks:
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Isoniazid ______ mg po 2x/week
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Rifampin ______ mg po 2x/week
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B6 _____ mg po 2x/week
Physician signature_____________________________________________________
Date_____________________
DHHS 1030 (Revised 03/13)
TB Control (Review 03/16)
Page 2 of 2
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