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.