National TB Elimination Program Date Printed: 29-09-2021

Treatment Card Copy

Patient Information Episode ID: 20665709

Name : KARAN GHATKA Address : DHAMNI CHARIPADA Pincode : 396050

Age : 22 Ward/Village : CHARIPADA Landmark : -

Sex : Male Taluka/Mandal : DHARAMPUR Mobile No : 9512738278

Occupation : Agriculture, fishery and related labour Town/City : DHAMNI Aadhar No : -

Economic Status : BPL State : Gujarat Area : Tribal

Contact Person

Name : - Address : - Mobile No : -

Treatment Supporter Home visit details

Name : - Initial Home Visit by : -

Designation : - Home Visit Date : -

Mobile No : - No. of visits before diagnosis of current episode : -

Treatment Details

Date of onset of first symptom : -

Investigations Lab Lab No Sample sent Test DST
Disease Classification : Pulmonary (ZN / FM / CBNAAT to CDST Result Result
/ Liquid C / Solid C) (date)
Type of Patient : New
Pre-treatment
Basis Of Diagnosis : Microscopy ZN and Fluorescent
End of Intensive Phase
History Of Previous ATT : No
End of Treatment
Source Of Treatment : Public

Previous Regimen : -

Comorbidity

HIV Status : Non-Reactive Diabetes Status : Non-diabetic Other Comorbidity : -

CPT Delivered On : - RBS : 104

Initiated On ART : - Initiated On ADT : -

Date & ART No : - - Date & ADT No : -

Contact Tracing

No of household contacts
7

7
No Screened

No With Symptoms
2

0
No Evaluated

No Diagnosed
2

2
No Put on treatment
Addiction Related Information Treatment Phase

Current Tobacco User : Positive Date of initiation of Intensive Phase : 14-09-2021

Tobacco Type : Smokeless Date of initiation of Continuation Phase : -

Linked for cessation : Yes Dosage frequency : -

Status of Tobacco use at end of treatment : Quit Drug formulations : -

H/o Alcohol intake : No Drug packaging : -

Linked for deaddiction : - Dosages FDC/Combipack : -

Height : 160

Adherence

Type of Adherence : 99DOTS

Month/year 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

Sep - 2021

Digitally Confirmed Dose Missed Dose Manually Confirmed Missed Dose Manually Confirmed Dose

Retrieval Actions for Missed Doses Details of adverse events

Date By whom Whom contacted Reason for Outcome of Date of adverse Details of Action Taken Duration for management Outcome of
missed doses retrieval action event symptomps of adverse event adverse event

Post treatment follow up clinical & sputum

Follow up Clinical Sputum CXR Impression Findings :

Nutrition support :
6 months of Rx
(if any, give details)

12 months of Rx

18 months of Rx

24 months of Rx

Treatment outcome : On Treatment

Treatment outcome date : 28-02-2022

Remarks :

This is print out generated from Nikshay Signature of the MO with date:__________________