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Case recording and reporting

Learning objectives

By the end of this session, trainees are expected to be able to:

  • Use the standard case recording format

Facilitation technique recommended

  • Participants should use this form during the clinical practice session and fill in the variables when they clerk patients

Leishmaniasis Disease Form                         Center name:

Patient id:                                                                 

This form is completed by:

Initials: ____________                    Position: Physician:  Nurse:   Other, describe: ______________________

Date of completion of form (dd-mm-yyyy): __ __-__ __-__ __ _____ Data entered: Yes   No  by: ____________

PATIENT DEMOGRAPHIC INFORMATION

 

Patient Name: ________________________________                     Nationality: _____________________

 

Age:  ____                           Gender:  Male:    Female:                Occupation ____________________

 

Current Address: Village (kebele): _____________    DIstrict (Woreda): ____________   Region:__________________          

 

How long in the current address: _____ (months)       Original  Address: (District or kebele) ________________________    

 

BASIC CLINICAL INFORMATION AT ADMISSION

 

General condition : able to walk:    unable to walk:  

Number of months sick before treatment: ____

Presence of concomitant infection:

No:   Yes:    If yes specify:

           Tuberculosis                         Malaria           

           Diarrhea                               Pneumonia    

           HIV                                     Otitis media     

           Other specify  ________

                                                

Clinical conditions:  Fever                            Weight loss                 

                                Jaundice:                      Lymphadenopathy :   

                                 Vomiting:                              Bleeding:           

                                                    

Spleen size (cm)  _________ Haemoglobin (g/dl): _______Platelet count (if done)  _______

NUTRITIONAL STATUS AT ADMISSION

Weight (Kg): _____.___         Height (cm). ___. ________   B.M.I _____or  Wt/Ht_______            Oedema: Yes ∏  No  ∏

LEISHMANIASIS DIAGNOSIS

 

New case:       Relapse:  

 

 If relapse:  First                    Second: 

                  Other:  ___

 

DAT: Done:              Not done:              DAT   titre:___________

 

rk39:  Positive:         Negative:              Not done   

 

Aspirate: Done:        Not done:      

                                                            

Aspirate source:  Bone marrow :    Positive       Negative    

                            Spleen:                Positive       Negative    

                            Lymph nodes:     Positive       Negative  

                            skin slit :              Positive       Negative  

DISEASE CATEGORY

Visceral Leshmanaisis:                      

Cutaneous leishmansisis:                  

Mucocutaneous leishmaniasis:          

Post kala azar dermal leishmaniasis  

TREATMENT

 

Date started treatment (dd-mm-yyyy) : __ __-__ __-__ __ __ __

First treatment: SSG:   Ambisome:     Other: ______          No. of doses:  _____

                         SSG plus Paromoycin     No of doses:  _____      

Second treatment: SSG:   Ambisome:   Other ______       No. of doses:  _____

                                SSG plus Paromoycin     No of doses:  _____    

Toxicity during treatment:

Arrhythmia:                                   Pancreatitis:     

Jaundice:                                      Kidney failure:   

-Infusion related reactions ( chills, back pain and fever)

-Injection site pain

DISCHARGE STATUS

Initial cure:    Date of initial cure: (dd-mm-yyyy): __ __-__ __-__ __ __ __

Final cure:     Date of Final cure: (dd-mm-yyyy): __ __-__ __-__ __ __ __

Defaulter:     Date last seen (dd-mm-yyyy):       __ __-__ __-__ __ __ __

Referred:           Date referred: (dd-mm-yyyy):      __ __-__ __-__ __ __ _

Died:                 Date of death: (dd-mm-yyyy):    __ __-__ __-__ __ __ __

If patient died cause of death:_____________________________________

Test of cure :  Done      Not done      Site _____  Result ________

Discharge weight (kg): _____.___

Discharge spleen size(cm): _______

Discharge haemoglobin (g/dl): ______

Discharge WBC (cell/s/mcl: ______

Discharge Platelet (cells/mcl:____

Follow up at 6 months after treatment

 

    Cured                      Relapsed                              Died                                  Unknown      

Initial cure: eradication of parasites and improvement in clinical signs and symptoms (defervescence, weight gain, spleen size decrease) at the end of treatment

Final cure: initial cure followed by 6 months follow-up without relapse and absence of clinical signs and symptoms attributable to VL (defervescence, weight gain, spleen size decrease).

Remark: _________________________________________ 

Pdf available HERE.