Sanfe Bagar Clinic Records System
Logistics
 Intake Card
 Laboratory Requisition Form
 Referral to Higher-Level Facility Form
 Death Certificate
Routine Follow-up
 General Visit Brief Note
 Active Problem List
 Medication List
 Diagnostics List
Maternal and Reproductive Health
 OB High-Risk Screening Form
 Antenatal Record
 Antenatal Visits Notes
 PMTCT Intake and Follow-up
 Pregnancy Social History Screening Form [Filled out by VHW outside of clinic]
 Delivery Record
 Partograph
 Family Planning Evaluation
Pediatrics
 Live Newborn Record
 Routine Infant and Child Care [Nepal National Form]
 IMCI: 1 week to 2 months
 IMCI: 2 months to 5 years
 VCTC Form [Nepal National Form]
Miscellaneous
 ARV Intake and Follow-up [Nepal National Form]
 DOTS Forms [Nepal National Form]
 Uterine Prolapse Evaluation—[Use PHECT Form]
 STD Evaluation Form [Nepal National Form]
IP:
□□□□□□□□
Name:
____________
Intake Card
DOB: ____/____/____
Age:
Address:
Marital status: never married
Father’s Name:
Husband’s Name:
VDC:
Nearest Phone No.:
currently married
Mother’s Name:
Other Relative:
widow
divorced
Visit Dates:
____/____/____
Reason for Visit:
_____________________
Visit Dates:
____/____/____
Reason for Visit:
_____________________
____/____/____
_____________________
____/____/____
_____________________
____/____/____
_____________________
____/____/____
_____________________
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_____________________
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_____________________
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____/____/____
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____/____/____
_____________________
____/____/____
_____________________
____/____/____
_____________________
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Laboratory Requisition Form
Date: ____/____/______
Haematology
Haemoglobin
WBC with differential
Platelets
Chemistry
Serum Glucose
Serum Creatinine
Serum SGPT/AST
Serum SGOT/ALT
Serum Bilirubin
Urine Dip, Pro/Glu/Ket
Urine Dip, Nine-Panel
CSF Protein
CSF Glucose
Immunodiagnostics
Urine Pregnancy Test
HIV VCT
RPR
Microbiology
KOH Prep
Vaginal
Other tissue:
Gram Stain
CSF
Serum
Sputum
CSF cell count
Sputum AFB Microscopy
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Laboratory Requisition Form
Date: ____/____/______
Haematology
Haemoglobin
WBC with differential
Platelets
Chemistry
Serum Glucose
Serum Creatinine
Serum SGPT/AST
Serum SGOT/ALT
Serum Bilirubin
Urine Dip, Pro/Glu/Ket
Urine Dip, Nine-Panel
CSF Protein
CSF Glucose
Sanfe Bagar Medical Clinic
Immunodiagnostics
Urine Pregnancy Test
HIV VCT
RPR
Microbiology
KOH Prep
Vaginal
Other tissue:
Gram Stain
CSF
Serum
Sputum
CSF cell count
Sputum AFB Microscopy
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Referral Form to Higher-Level Facility
To be completed by Sanfe Bagar Clinic:
DOB: ____/____/____
Age:
VDC:
Nearest Phone No.:
Address:
Father’s Name:
Mother’s Name:
Husband’s Name:
Other Relative:
Date of Referral: ____/____/____ Time:
Traveling by:
Bus Jeep Tractor
Foot Other:
Traveling with: Family Member:_____________
Healthworker:_________________
Primary Reason for Referral:
Emergent treatment for life-threatening condition
Emergent treatment for non-life-threatening acute condition
Treatment of non-emergent, non-acute condition requiring further evaluation
Present Diagnosis/Chief Complete/Unresolved issue:
Condition of Patient:
Stable
Acutely ill; mortality <5%
Intubated
NG tube
IV fluids
Acutely ill; mortality >5%
Other:
To be completed by Referral Center following discharge:
Date of Discharge: ____/____/____ Time:
Traveling by:
Bus Jeep Tractor
Foot Other:
Traveling with: Family Member:_____________
Healthworker:_________________
Condition of Patient:
Stable with no residual morbidity
Stable with significant residual morbidity
Perished; if so, please complete the death certificate on the bag of this form
Major Clinical Findings:
History:
Physical Exam:
Laboratory:
Imaging:
Final Diagnoses:
Treatments Administered:
Post-hospitalization recommendations:
Return to Sanfe clinic in ______days
Comments/criticisms on this referral (How can our Clinic improve referral?):
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Sanfe Bagar Clinic Death Certificate
Date: ____/____/______
Time of Death: _______
Cause of Death
Approximate
Interval Between
Onset and Death
Disease or condition
directly leading to
death:
Due to/Consequence of:
Mode of Dying (e.g.,
heart failure, respiratory
failure)
Antecedent cause/comorbid conditions:
Other significant
conditions contributing
to death but not related
to the disease or
condition causing it:
If Female:
If an infant < 1 month
old:
□Not pregnant
□Not pregnant, but pregnant within 42 days of death
□Pregnant at the time of death
□Pregnancy status unknown
Birth weight:_________ g
If exact weight not
known:
□2500 g or more
□less than 2500 g
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Brief General Visit Note
Date: ____/____/______
Please list relevant past medical and surgical history on the problem list.
Please note laboratory results on diagnostics list.
Chief Complaint/Current Concerns:
Brief History of Present Illness:
ROS:
Physical Exam:
Assessment/Plan:
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Medical History and Problem List
Active/Major Problems
Date First
Condition
Diagnosed
Interventions/To Do List
Minor/Inactive Problems Including Surgical/Obstetric/Medical History
Date First
Condition
Diagnosed
Interventions/To Do List
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Current Medication List
To be filled out be administrator based on clinician’s written order.
Medication
Sanfe Bagar Medical Clinic
Date First
Prescribed
Indication
Date
Terminated
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Laboratory Diagnostics List
To be filled out by the laboratory technician
Test
Date
Date
Date
Date
Date
Hgb
Urine Pro
Urine Glu
Urine Ket
RPR
HIV
FBS
AST
ALT
Creatinine
Tot Bili
Dir Bili
Ind Bili
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Sanfe Bagar Clinic High-Risk Pregnancy Screening Form
Yes
OBSTETRIC HISTORY
1. Previous stillbirth or neonatal loss?
No
2. History of 3 or more consecutive spontaneous abortions?
3. Birthweight of last baby < 2500g?
4. Birthweight of last baby > 4500g?
5. Last pregnancy: hospital admission for hypertension or pre-eclampsia/eclampsia?
6. Previous surgery on reproductive tract? Specify:
(Myomectomy, removal of septum, cone biopsy, classical CS, cervical cerclage)
CURRENT PREGNANCY
7. Diagnosed or suspected multiple pregnancy?
8. Age less than 16 years or greater than 40 years?
9. Isoimmunization Rh (-) in current or in previous pregnancy?
10. Vaginal bleeding? Specify:
11. Pelvic mass? Specify:
12. Diastolic blood pressure 90mm Hg or more at booking?
GENERAL MEDICAL
14. Insulin-dependent diabetes mellitus?
15. Renal disease?
16. Cardiac disease?
17. Known 'substance' abuse (including heavy alcohol drinking)?
18. Any other severe medical disease or condition? Specify:
Specify outcome of each obstetric event (live birth, stillbirth, abortion, ectopic,
hydatidiform mole)
Date
Outcome
Birth Weight Sex Complications
Duration of EBF
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Antenatal Record
Preferred Timing of Visits: <16 weeks, 24-28wks, 30-32wks, 36-38wks
Age:
G___P___T___P___A___L___
Age of First Menstruation:
Menstrual Duration:
days
Frequency: _____days
Regular
LMP:
EDC:
Present Visit Concerns/Problems/Symptoms:
Irregular
Allergies:
NKA
st
1 Visit Labs (do at first contact regardless of gestational age)
DATE:
/
/
Blood Type:
Hb:
RPR:
HIV:
HBsAg:
24-28 week Glucose Challenge Test (5O grams):
DATE:
/
/
1-hour Post-Test BS:
If >140 mg/dL, 3-hour Oral Glucose Tolerance Test (100 grams):
DATE:
/
/
FBS (<105):
1-hr (<190):
2-hr (<165):
3-hr(<145):
Speculum Exam (1st or 2nd Visit, depending upon the patient)
DATE:
/
/
Gonorrhea:
Chlamydia:
Pap Smear:
Other tests:
Clinical Findings
Height:_____metres Intake BMI:_____
Date
POG
Weight
BP
HR
RR
Fundus
FHR
Edema
Proteinuria
To Do List
Tetanus Toxoid:
Booster <10years
TT given 1st Visit
TT given 2nd Visit
nd
rd
Fe / Folic acid Given
Mebendazole Given (Once 2 /3 Trimester)
Nutrition Support (BMI <17)
PMTCT (see PMTCT form)
Others:
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Antenatal Visit Notes
1st Visit Notes:
Assessment:
Plan:
RTC: ______ weeks
2nd Visit Note:
Assessment:
Plan:
3rd
RTC: ______ weeks
Visit Note:
Assessment:
Plan:
RTC: ______ weeks
4th Visit Note:
Assessment:
Plan:
RTC: ______ weeks
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
PMTCT Follow-up Form for HIV+ Pregnant Women
This is for summary of PMTCT only. Please utilize the comprehensive HIV and ARV
follow-up forms, as for all HIV-infected patients. Please utilize the antenatal care
forms as for all pregnant patients.
CD4 Count:
Clinical Stage:
I
Antepartum Regimen:
Intrapartum Regimen:
Postpartum Regimen:
Neonatal Regimen:
II
TLC:
III
IV
HAART
AZT 300mg Twice Daily starting at ___ weeks
Nevirapine 200mg Once
AZT 300mg/3TC 150mg Once
HAART
AZT 300mg/3TC 150mg BID for 7 days
nevirapine 6 mg tablet once
AZT 4mg/kg BID x ___days
PMTCT Notes:
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Pregnancy Social History Screening Form
Social history
What type of work do you do?
Do you have any health problems that you think might be related to your work?
Are you currently exposed to chemicals, dusts, metals, radiation, noise or repetitive
work?
How much money did the household make last month: ________
How much money did the household make last year: ________
Land (Ropanis):________ (Aanas)________
How much time has husband spend away from Achham? months___years___
Where?
India Nepal Other:
Husband education Illiterate
Up to 5th standard Up to 10th Beyond 10th
Your education
Illiterate
Up to 5th standard Up to 10th Beyond 10th
Caste:
Religion:
Water source
River
Well
Outside Tap
Hand Pump
Other:
With what fuel do you cook?
Wood
Kerosine
Gas
Cow Dung Electric
heater
Electricity
Yes
No
Toilet method 1: toilet 2: stream 3: river 4: field 5: jungle
Tobacco (chewing):
current; amount: _____ ever; quit:_____
never
Tobacco (smoking):
current; amount: _____ ever; quit:_____
never
Violence Screening:
How often does your partner, parent, sibling, or other individual (specify:_________
Physically hurt you
Never
Rarely
Sometimes
Fairly Often
Frequently
Insult or talk down to you
Never
Rarely
Sometimes
Fairly Often
Frequently
Threaten you with harm
Never
Rarely
Sometimes
Fairly Often
Frequently
Scream or curse at you
Never
Rarely
Sometimes
Fairly Often
Frequently
Scoring:
Never=1; Rarely=2;Sometimes=3; Fairly Often=4; Frequently=5
Total Score:
[Score>10 considered positive]
Sexual history
What methods do you use to protect yourself from HIV?
None Male Condom Female Condom
Partner Testing
Other:
What methods of contraception do you use?
None Male Condom Female Condom
IUD OCPs :Depot Other:
What concerns or questions do you (or your partners) have about sex?
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Delivery Record: Intake
Age:
G___P___T___P___A___L___
EDD:
POG:
Current symptoms:
Risk Factors:
Delivery Record: Summary
Date of Delivery:
Location: Clinic Home Other:
Duration of Labor:
1st:
2nd:
3rd:
Mode of Delivery: SVD CS/Referred
Nuchal Cord: ____times
Placenta:
Spontaneous
Manual Extraction
Anesthesia:
None Pudendal
Local
Total Crystalloid:
ml
EBL:
ml
Medications during Labor:
Oxytocin
Misoprostol Magnesium Sulfate
Complications/Postpartum Course:
Blood Pressures:
Sepsis: Yes
Antibiotics:
PPH: Yes
Oxytocin:
Methergonovine:
Misoprostol:
PP Crystalloid:
ml
Perineum:
Intact
1°
2°
3°
Repair: None Performed
Uterus Hard/Round:
Yes
No
Voided:
Yes
Retention Vulva:
Condition at Discharge: Stable Referred
Sanfe Bagar Medical Clinic
Newborn Status:
Livebirth Stillbirth: Fresh Stillbirth: macerated
Sex: Male Female
Gestational Age at Delivery: _______weeks
APGAR at 1 minute: ____ APGAR at 5 minutes: ____
Weight:___________kg
Length:_______cm
Congenital Malformations:
Feeding:
Well
With Difficulty
Family Planning
Inform of the next camp for male vasectomy
Options immediately post-partum:
Lactational amenorrhea
IUP (placed within 48 hours or at 4 weeks)
Condoms
Spermicide
Delay six weeks:
Depo-Provera
Diapragm
Delay six months:
Combined OCP:
Combined injectable:
Notes:
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Modified WHO Partograph of pre-labor through Active Labor
Hours
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Notes:
Active Labor Started:
200
190
180
Fetal Heart Rate
170
160
150
140
130
120
110
100
90
80
Moulding
Amniotic Fluid
Moulding: 1= sutures apposed; 2= sutures overlapped but reducible; 3=sutures overlapped,reducible.
-----------|
ROM: I=Membrane intact; C=Clear fluid; M=Meconium-stained; B=Blood-stained
10
9
Cervical Dilation in cm (plot x)
8
7
|-------------
Descent of head;
|----- 0 =>pubic symphysis, ----|
5 = crowning (plot O)
6
Contractions per 10
minutes
<20 sec:
20-40 sec:
>40 sec:
5
4
3
2
1
0
5
4
3
2
1
U/L
Drops/min
Oxytocin
Other Medications
BP= |< >|
200
Maternal Vitals; pulse= •
IV Fluids [LR or NS]
160
190
180
170
150
140
130
120
110
100
90
80
Temperature [C]
Urine
{
protein
ketones
volume
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Live Newborn Record
Sex: Male Female
Gestational Age at Delivery: _______weeks
APGAR at 1 minute: ___APGAR at 5 minutes: ___ Feeding: Well
With Difficulty
Weight:___________kg
Length:_______cm
Danger Signs
Fast breathing (>60RR).
Slow breathing (<30 RR).
Severe chest in-drawing
Grunting
Convulsions.
Floppy or stiff.
Fever (temperature >38ºC).
Temperature <35ºC
Umbilicus draining pus
Umbilical redness extending to skin.
>10 skin pustules or bullae, or
swelling, redness, hardness of skin.
Bleeding from stump or cut.
Pallor.
Risk Factors:
Mother HIV+
Mother RPR+
Mother active TB <2 months ago
Other Clinical Signs:
yellow skin on face <24hrs
yellow skin on palms/soles >24hrs
eye swollen/draining pus
red umbilicus without extension
<10 pustules
Club foot
Cleft lip/palate
unusual appearance
open tissue on head, abdomen, back
bruises, swelling on buttocks
swollen head/bump
abnormal leg position after breech
asymmetric movement/paralysis
ROM >18 hours, maternal fever
>38°C, or mother receiving antibiotics
Assessment:
possible serious infection
low birth weight (1500-2500 g)
preterm (32-36 weeks)
very low birth weight (<1500 g)
very preterm (<32 weeks)
mild hypothermia (35-36.4°C)
neonatal jaundice
severe hypothermia (<35°C)
conjunctivitis
mother unable to care for baby
twin birth
malformation:
birth injury:
well baby
Interventions/Plan:
dextrose
LR
0.9%NS _____ ml
nasogastric suction
bag-mask resuscitation
Infant warmer
BCG
OPV
HBV
vitamin K 10mg
benzathine penicillin 50000 U/kg x1
ceftriaxone 50mg/kg x1
gentamycin __mg/kg Q24H x__days
ampicillin 50mg/kg Q12H x __ days
tetracycline 1% eyes x __ days
nevirapine 6 mg tablet once
AZT 4mg/kg BID x ___days
RTC:
Sanfe Bagar Medical Clinic
Refer to:
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
Family Planning/Reproductive Health Evaluation
Contraindications to Combined OCPs
Absolute
arterial/venous thrombosis
severe hypertension
valvular heart disease
ischemic heart disease
hyperlipidemia
focal migrane
active liver disease
cholestatic jaundice in pregnancy
liver ademoma/carcinoma
active undiagnosed vaginal bleed
breast or endometrial cancer
Plan:
Relative
current smoker
obesity
varicose veins
epilepsy
bronchial asthma
depression
age > 35 years
gall bladder disease
IUD
LAM
Depot Provera
Ethinylestradiol/levonorgesterel
Male condoms
Ethinylestradiol/norethisterone
Follow-up:
Three Months
Current Complaints
Six Months
Current Complaints
One Year
Current Complaints
Symptoms
Nausea/vomiting
Mastalgia
Weight gain
Chloasma
Breakthrough
bleeding
Acne
Vaginal dryness
Leucorrhea
Difficult Adherence
Exam:
BP
Pelvic
Breast
Symptoms
Nausea/vomiting
Mastalgia
Weight gain
Chloasma
Breakthrough
bleeding
Acne
Vaginal dryness
Leucorrhea
Difficult Adherence
Exam:
BP
Pelvic
Breast
Symptoms
Nausea/vomiting
Mastalgia
Weight gain
Chloasma
Breakthrough
bleeding
Acne
Vaginal dryness
Leucorrhea
Difficult Adherence
Exam:
BP
Pelvic
Breast
Assessment/Plan:
Assessment/Plan:
Assessment/Plan:
Husband to do vasectomy?
Sanfe Bagar Medical Clinic
YES
NO Next vasectomy camp:___/___/___
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
IMCI: SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Age: ____ HR:____bpm
RR:____bpm Temp: ___°C Fever:
Weight: ______ kg Weight-for-age is low: YES NO
What are the infant’s problems?
Initial IMCI visit
Follow-up IMCI Visit
Check for possible bacterial infection
Has the infant had convulsions?
YES NO
Severe chest indrawing YES NO
Nasal flaring YES NO
Grunting YES NO
Bulging fontanelle
YES NO
Pus draining from the ear
YES NO
Umbilicus: red or draining pus?
YES NO
If yes, does the redness extend to the skin? YES
Many or severe pustules?
YES NO
Lethargic or unconscious?
YES NO
Infant’s movements: less than normal?
YES
Check for diarrhea and dehydration
Does the infant have diarrhea?
YES NO
For how long? _______ Days
Is there blood in the stools?
YES NO
Lethargic or unconscious?
YES NO
Restless or irritable?
YES NO
Sunken eyes: YES NO
Pinch the skin of the abdomen. Does it go back:
YES
NO
NO
NO
>2 sec
1-2 sec
<1 sec
Check for malnutrition and feeding difficulty
Is there any difficulty feeding? YES NO
Is the infant breastfed? YES NO
If Yes, how many times in 24 hours? _____ times
Does the infant usually receive any other foods or drinks?
YES NO
If Yes, how often? ____ per day _____ per week
Has the infant breastfed in the previous hour? YES NO If NO, observe
breastfeed for 4 minutes. Attachment: NOT AT ALL
POOR GOOD
Chin touching breast YES NO
Mouth wide open YES NO
Lower lip turned outward YES NO
More areola above than below the mouth YES NO
Suckling effectively NOT AT ALL
POOR
Good suckling
Ulcers or white patches in the mouth (thrush) YES NO
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
IMCI: SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Notes:
Diagnoses:
likely severe bacterial infection
local bacterial infection no bacterial infection
severe dehydration some dehydration no dehydration
severe persistent diarrhea dysentery
feeding problem/low weight
no feeding problem
thrush
Other:
Clinic-based Interventions:
Fluid Resuscitation
ORS: ___ packets
Ringer’s Lactate: _____ ml/kg; ____ ml total by:
Other:
IV
NGT
Medications
Diazepam 10mg/2ml solution (0.1 ml/kg) IM ___ml x ___doses
Paraldehyde (0.3-0.4 ml/kg) per rectum ____ml x ___doses
Phenobarbital 200 mg/ml solution (20 mg/kg) ____ml x ___doses
Prednisone 2mg ____mg ____ x ___days
Cotrimoxazole Syrup 40/200mg in 5ml ____ml x ___days
Cotrimoxazole Tablet 20/100mg ____tabs ____ x ___days
Tetracycline 250mg Cap ____caps ____ x ___days
Amoxicillin 125mg in 5ml ____ml ____ x ___days
Amoxicillin 125mg disp tab ____tabs ____ x ___days
Vitamin A ___IU x ____ doses
Ceftriaxone 250mg IM x ____ doses
Paracetamol 100 mg ____ _____ x ___days
Albendazole 400 mg PO x1
Gentamicin (2.5 mg/kg) IM x ____ doses
Benzylpenicillin (50 000 units per kg) IM x ____ doses
Other:
Plan for home:
Vitamin Supplement
Iron
Limit animal milk feeding to 50 ml/kg/day: ____ ml
Other:
RTC:
Sanfe Bagar Medical Clinic
Refer to:
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
IMCI: CHILD AGE 2 MONTHS UP TO 5 YEARS
Age: ____ HR:____bpm
RR:____bpm Temp: ___°C
Weight: ______ kg Weight-for-age is low: YES NO
What are the infant’s problems?
Initial visit
Follow-up Visit
Check for general danger signs
Unable to drink/breastfeed
YES NO Vomits everything
Convulsions
YES NO
Lethargic/unconscious
YES
YES
NO
Check breathing problems
Cough
YES NO For how long? _______ Days
Difficulty breathing YES NO For how long? _______ Days
Rapid breathing YES NO Chest indrawing YES NO Stridor
NO
YES
Check for diarrhea and dehydration
Does the infant have diarrhea?
YES NO For how long? _______ Days
Is there blood in the stools?
YES NO Lethargic or unconscious?
YES
Restless or irritable?
YES NO
Sunken eyes: YES NO
Offer child fluid.
unable to drink
drinking poorly
drinking eagerly
Pinch the skin of the abdomen. Does it go back: >2 sec 1-2 sec
<1 sec
NO
NO
Assess malaria/measles risk
Fever: YES NO For how long? ___ Days Present everyday: YES NO
Malaria risk (travel to terai, India): YES NO
Measles within the last three months: YES NO
Stiff neck YES
NO
Rash YES
NO All over body YES
NO Describe:
Runny nose
YES
NO Cough YES
NO Red eyes
YES
NO
Mouth ulcers YES
NO Are the ulcers deep, extensive YES
NO
Pus draining from eye YES
NO Clouding of cornea YES
NO
Check for ear infection
Ear pain YES
NO For how long? ___ Days
Ear discharge YES
NO For how long? ___ Days
Pus draining from ear
YES
NO Tenderness behind ear
YES
NO
Check for malnutrition and anemia
Visible severe wasting YES NO Palmar pallor Severe Mild
None
Pedal edema
YES
NO
Is there any difficulty feeding? YES NO
Is the infant breastfed? YES NO
If Yes, how many times in 24 hours? _____ times
Does the infant usually receive any other foods or drinks?
YES NO
If Yes, how often? ____ per day _____ per week Which foods:
During the illness, has the child’s feeding changed? YES NO
Sanfe Bagar Medical Clinic
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal
IP:
□□□□□□□□
Name:
____________
IMCI: CHILD AGE 2 MONTHS UP TO 5 YEARS
Notes:
Diagnoses:
very severe disease
severe pneumonia
pneumonia cough/cold without pneumonia
severe dehydration some dehydration no dehydration
severe persistent diarrhea
persistent diarrhea dysentery
very severe febrile disease malaria fever: malaria unlikely
severe measles measles with eye/mouth complications measles
mastoiditis acute ear infection chronic ear infection
severe malnutrition severe anemia anemia low weight thrush
Clinic-based Interventions:
Fluid Resuscitation
ORS: ___ packets
Ringer’s Lactate: _____ ml/kg; ____ ml total by:
Other:
IV
NGT
Medications
Diazepam 10mg/2ml solution (0.1 ml/kg) IM ___ml x ___doses
Paraldehyde (0.3-0.4 ml/kg) per rectum ____ml x ___doses
Phenobarbital 200 mg/ml solution (20 mg/kg) ____ml x ___doses
Prednisone 2mg ____mg ____ x ___days
Cotrimoxazole Syrup 40/200mg in 5ml ____ml x ___days
Cotrimoxazole Tablet 20/100mg ____tabs ____ x ___days
Tetracycline 250mg Cap ____caps ____ x ___days
Amoxicillin 125mg in 5ml ____ml ____ x ___days
Amoxicillin 125mg disp tab ____tabs ____ x ___days
Vitamin A ___IU x ____ doses
Ceftriaxone 250mg IM x ____ doses
Paracetamol 100 mg ____ _____ x ___days
Albendazole 400 mg PO x1
Gentamicin (2.5 mg/kg) IM x ____ doses
Benzylpenicillin (50 000 units per kg) IM x ____ doses
Other:
Plan for home:
Vitamin Supplement
Iron
Limit animal milk feeding to 50 ml/kg/day: ____ ml
Other:
RTC:
Sanfe Bagar Medical Clinic
Refer to:
Haat Bazaar, Siddeswor VDC Ward #1, Achham, Nepal