Appendix II
QUESTIONNAIRE
Identification:
Name_________________________
Study number__________________
Date of admission_______________
IP No:…….…..……
A: Demographic characteristics of the child:
1. Sex…………..[
]
1= Male
2= Female
2. Age (in months) __________________
3. Birth order…..[
] 1=First, 2=Second, 3=Third, 4=Forth, 5=>Fifth
4. Present address____________________
5. Next of kin ...[ ] 1=Mother, 2=Father, 3=Aunt, 4=G/mother, 5=Other specify
B: Demographic characteristics of the caretaker:
1. Age (years)_________________________
2. Sex…………………………..[
]
1=Male
2=Female
3. Relationship to the child…….[
]
1=Mother 2=Father 3=Other (specify)
4. Level of education…..[ ] 1=Primary 2=Secondary 3=Tertiary 4=None,
5=Others (specify)________________
C: Associated symptoms on admission
1. Duration of diarrhoea ……..….[
] 1=less than 14days 2=more than 14 days
2. Frequency of stools/24hrs…….[
]
3. Consistency of stools……….....[ ]
1=Loose 2=Watery 3=Mucoid
4. Presence of blood in stool…….[ ]
1=Yes
2=No
5. History of Vomiting…………..[
]
1=Yes
2=No
6. Antibiotics use during diarrhoea?..............[ ]
1=Yes
2=No, 3=Not sure
7. If antibiotic(s) was used which one?.......................,..........................,.....................
8. Use of local herbs at home…….[ ]
1=Yes
2=No
9. Episodes of diarrhoea in last 3 months……[
]
1=None 2=One 3=≥2
10. Immunization status...[
]
1=Uptodate, 2=Partial, 3=Not Immunized,
4=Not sure
11. Immunization card present?.............[ ]
1=Yes
2=No
12. Presence of fever…………....…..…[
]
1=Yes
2=No
13. Abdominal distension……………...[
]
1=Yes
2=No
14. Convulsions…………………..……[
]
1=Yes
2=No
15. Cough……………………………... [
]
1=Yes
2=No
16. Swelling of feet on admission……...[ ]
1=Yes
2=No
D: Past medical history
1. Number of previous hospital admissions……..[ ] 1=Once 2=Twice 3= ≥ 3
2. For what reason was the child admitted (specify)? __________________
3. Measles in the last 3 month…………….....[
] 1=Yes
2=No, 3=Not sure
4. Has the child ever been tested for HIV?.....[
] 1=Yes, 2=No, 3=Not sure
1
5.
If yes in (4) above, what was the result of the test?........[
]
1=Negative
2=Positive, 3=Don’t know
6. Is the child on ARVs?............[
]
1=No 2=Yes
3=Don’t know
7. If yes (in 6 above), which drugs…………….,………………,………………
8. Duration of ARVs (if applicable) in months_________________
E: Feeding practices:
1. Was the patient ever breastfed?......[ ]
1=Yes
2=No
3=Don’t know
2. If no (in 1 above), why?.................[
]
1=Medical advice 2=No breast milk
3=PMTCT,
4=Others (specify)_______________
3. Is the child still breastfeeding?...........[ ]
1=Yes
2=No
3=Don’t know
4. If No (in 3 above), why?.......[
]
1=Child refused
2=No breast milk
3=Diarrhoea, 4=Weaned, 5=PMTCT
6=Other (specify)_______________
5. How long ago was breast feeding stopped (specify)?________________
6. When was cow’s milk/formula feeds introduced? (age in months)_______
7. Has the child ever had problems with milk feeds?................[ ] 1=Yes 2=No
8. If yes (in 7 above), which problem?..........[
]
1=Profused diarrhoea
2=Abdominal distension
3=Others (specify)----------------------9. At what age did this problem first appear?______________(Age in months)
10. If diarrhoea (in 8 above), did you have to stop the milk?.....[ ] 1=Yes 2=No
11. Which therapeutic feed(s) is the child currently on?............[
]
1=F-75
2=F-100, 3=Porridge, 4=Soya,
5=Yoghurt
12. Effect of starting therapeutic milk…………..[ ] 1=Developed diarrhoea
2=Diarrhoea worsened
3=Abdominal distention
4=No effect
F: Physical examination:
a). General examination:
1. Axillary temperature _________oC
2. Bipedal oedema……..…….[
]
1=Present
2=Absent
3. Visible severe wasting…….[
]
1=Present
2=Absent
4. Degree of dehydration…….[
]
1=No dehydration 2=Some 3=Severe
5. Pallor………………....[ ]
1=None 2=Mild
3=Moderate 4=Severe
6. Oral thrush………....…[
]
1=Yes
2=No
7. Lymphadenopathy…....[
]
1=Yes
2=No
8. KS lesions…………. ..[ ]
1=Yes
2=No
9. Perianal excoriation......[
]
1=Yes
2=No
b) Anthropometry:
1. Weight ……………………kg
2. Height/length……………..cm
c) Nutritional status
1. Wt/Ht…………….….% of NCHS (………Z score)
2. Ht/Age………………% of NCHS (……….Z score)
G: Systemic examination:
Central nervous system (CNS)
1. Conscious?..................[
]
1=Yes
2=No
2. Localizing sign?..........[ ]
1=Yes
2=No
Abdominal examination:
1. Distension………….…[ ]
1=Yes
2=No
2
2. Bowel sounds.……..…[
]
1=Normal
2=Scanty 3=Absent
3. Palpable liver................[
]
1=Yes
2=No
4. Palpable spleen…….…[
]
1=Yes
2=No
5. Palpable Kidneys……..[
]
1=Yes
2=No
Cardiovascular system:
1. Pulse rate______beats/min….[ ] 1=Normal, 2=Tachycardia, 3=Bradycardia
2. Pulse volume……….... [ ]
1=Normal 2=Small 3=Thready 4=Large
3. Murmurs……………....[
]
1=Yes
2=No
4. Heart failure…………...[
]
1=Yes
2=No
Respiratory system:
1. Respiratory rate____breaths/min...[ ] 1=Normal, 2=Tachypnea, 3=Bradypnea
2. Chest indrawing……….[
]
1=Yes
2=No
3. Percussion note………..[
]
1=Normal 2=abnormal
4. Crepitations……………[
]
1=Yes
2=No
5. Rhonchi………………..[
]
1=Yes
2=No
6. Bronchial breathing…....[
]
1=Yes
2=No
H. LABORATORY RESULTS
HIV: 1=Pos,
2=Neg,
SEROLOGY
3=Not known
DNA PCR
STOOL ANALYSIS:
i) Consistency:
1=Watery, 2=Loose, 3=Semi formed,
4=Mucoid
ii) pH
1: <5.5 2: >5.5
iii) Reducing sugar: 1=Nil, 2=Trace, 3=1+, 4=2+, 5=3+, 6=4+
iv) Fat globules:
1=Present,
2=Absent
v) Ova/cysts
1=Present,
2=Absent
CONSISTENCY pH
REDUCING
FAT
OVA/CYSTS
SUBSTANCE GLOBULES
1=Present/Positive
2=Absent/Negative
PARASITE/YEASTS WBC
PUS CELLS
CULTURE
(Bacterial)
MODIFIED
ZN
3