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Registration No: DLF/PC/2026/0003

Source: Public

Camp Details

Camp Date

2026-09-01

Location

Bihar Rural Health Camp

Block

Gaya Sadar

OPD No

OPD-2026-003

Patient Details

Patient Name

Mohd. Aslam Khan

Age

Gender

Male

Father / Husband Name

Abdul Karim Khan

Mobile No

7654321098

Village / City

Gaya

Pincode

823001

Aadhaar No

4567 8901 2345

Full Address

Ward No 5, Gaya Town, Bihar

Date of Examination

2026-09-01

Height (cm)

172.00

Weight (kg)

65.00

BMI

21.97

Blood Pressure

110/70

Pulse (bpm)

Temp (°F)

98.40

SpO2 (%)

Blood Sugar (mg/dL)

85 mg/dL (Fasting)

Chief Complaint(s)

Cough for 2 weeks, mild fever, weight loss of 3kg in 1 month

Medical / Surgical History

No prior TB history, non-smoker

Allergies (if any)

No known allergies

General Examination

Thin built, mild pallor present, no cyanosis.

Systemic Examination

Decreased breath sounds on right upper lobe, crepitations heard.

Provisional Diagnosis

Pulmonary Tuberculosis (Suspected) - Sputum AFB and CBNAAT advised

Prescribed Medicines

Refer to RNTCP DOTS Center for Anti-TB Treatment after confirmation.

Investigations Advised

Sputum AFB (x3), CBNAAT, Chest X-ray PA view, CBC, ESR

General Advice

Avoid public gatherings, wear mask, take nutritious diet.

Referral & Follow up

Referred To (Hospital/Doctor)

District TB Center, Gaya

Reason for Referral

Suspected PTB - DOTS required

Follow Up Date

2026-09-08

Follow Up Remarks

Follow up with sputum reports

Counselled By

Dr. S. Mishra (MBBS, DTCD)

Counselling Date

2026-09-01

Summary Remarks

Patient with suspected PTB. Referred to RNTCP. Sputum sent for AFB.