IDCAP HIV/ART Clinical Observation Patient Form

Site #: Observer #: Triage status: Emergency identified by clinic team

Observation #:__________________
Trainee #: Date of visit (d/m/y): Emergency missed by clinic team Yes Yes No No NE NE Yes No Not Emergency

If emergency, stop observation and support trainee to manage patient. Then complete emergency case report. Language of patient during visit (other than English): ________ Translation? Gender of patient: F M I.Vital signs: Reported by other health professional before consultations?

Age of patient: _______ months (LT 5 years) ______years (GE 5 years)

Temperature _____C/F If no thermometer, febrile to touch Y N Current weight ____ kg Weight last visit _____kg Peak weight ______ kg Height _____cm BP______ Clinician washes hands before consultation? Yes No Clinician greets patient/friend warmly?

II.Current ART: Yes No NR Is result of HIV test confirmed positive? Yes No If yes, start date? (d/m/y)___/___/____ If yes, test? Ab (HIV antibody) Ag/PCR (child less than 18 months Medication: If current ART, regimen: 3TC AZT d4T TDF FTC NVP EFV NH NH Previous exposure to ARV? Yes No NR If Yes: Indication: PEP PMTCT Other_________ TB active ( intensive phase None None Yes Patient Y Y Y Y Y N N N N N NR NR NR NR NR continuation phase) CTX No SP NR Previous TB; Date (d/m/y)last dose__/__/___ NR CTX preventive Allergy to Medication: Additional history: If female, now pregnant: III.History Fever: Duration ______ days Coughing: Duration ______ days Night sweats: Weight loss: Specify % _____ Recent contact with someone who has TB: Abdominal pain Anxiety Breathing shortness of breath Burning, tingling, loss/change sensation Chest pain Other (specify)___________________________________________________ Other ________________________________ _ NR Suspected, not confirmed LNMP: ____/____/_____ Patient ART adherence: How many taken? How many prescribed? Side effects of drugs Specify____________ Karnofsky score ________pills ________pills Y N NR NR NR Previous OI (specify) ________________________ NH NH NH NH NH
Clinician

Clinician

NH NH NH NH NH

NH

NH

Able to work Ambulatory Bedridden % of the time:_____ No (Enter Y, N or V below.) Skin lesions Skin Rash Swallowing difficulty Vomiting Other (specify):

NH

Clinician asks patient about other current symptoms or concerns? Convulsions Depression Diarrhea
Duration _____days Blood? Y N

Yes

NH

Headache Loss of appetite Mouth problems Myalgias Nausea Skin itching

Fatique Genital problem

IV. Physical examination General Skin Mouth Lungs

Cardiovascular

normal agitation { pathy oedema pallorfat change(lipodystrophy) jaundice lymphadenowasting other___________________________

NE NE NE NE NE NE NE NE NE NE

{
{ { { {

normal abscess ecchymosis erythema herpes zoster scar Kaposi nodules papules pus pustules scaling vesicles wound other ____________________________ normal abscess candida gingivitis Kaposi other_______________________________________ ulcers

clear crackles dyspnea diminished in-drawing retractions rhonchi wheezes RR (only if cough or dyspnea)___________ other ________________ pulse_________ gallop murmur rub other___________________ normal abnormal sound ascites distended hepatomegaly mass organomegaly pregnancy splenomegaly tenderness other ________________________ For findings, note where______________ normal discharge tenderness ulcers other__________________ normal other_________________________________________________ benign coma confusion, disorientation focal deficit meningismus paresthesia seizure other__________________________ Specify exam and findings__________________________

Abdomen Genitalia
Muculo skeletal

Neuro
Other

V. Laboratory or imaging studies with results reviewed by clinician: Not available Not reviewed Ab(HIV antibody) Ag/PCR(child less than 18 months) Hemoglobin CBC(hemogram) CD4 CXR Creatinine Glucose HepB LFT (transaminases) Malaria BS Malaria RDT Pregnancy RPR TB sputum Viral load Other__________________ CD4 Result? ___________ Date (d/m/y) of last CD4 ____/____/_____ CD4 Result? ___________ Date (d/m/y) of CD4 ____/____/_____ CD4 Result? ___________ Date (d/m/y) of CD4 ____/____/_____ Describe abnormal or other clinically important results: ____________________________________________________________ What is the highest confirmed WHO clinical disease stage for this patient: I II III IV What is the basis for this staging decision? OI (specify)________________ Date (d/m/y) of staging diagnosis____/____/_____
Stop consultation and confer with trainee before completing the treatment plan.

VIII. PLAN: CTX: Start Stop Continue Positive prevention message: Yes No Recommend Mosquito Net: Yes No NA Refer: Where __________________________ OI Tx: Specify:_____________________________ Tx Other conditions (e.g. malnutrition): Specify ________________________________

ART: Continue Start Stop Modify If change, new regimen: 3TC AZT d4T TDF FTC NVP EFV Other_______________ Reason:_____________________________ Laboratory tests: ____________________________________ Radiology: CXR Other_____________ Date of next visit: ____/_____/________

Observation #:__________________ IDCAP Outpatient Clinical Observation Form for child less than 5 years
Site #: Observer #: Triage status: Emergency identified by clinic team Trainee #: Date of visit (d/m/y): Emergency missed by clinic team Not Emergency

If emergency, stop observation and support trainee to manage patient. Then complete emergency case report. Type of visit: New attendance F M Re-attendance Yes Yes No No NE NE

Language of patient during visit (other than English): ________ Translation? Gender of patient: I. Vital signs: Reported by other health professional before consultations?

Age of patient: _______ months Date of birth: (d/m/y):_________________________

Temperature _____C/F If no thermometer, febrile to touch Y N Current weight ____ kg height____cm Weight last visit ____kg Date last visit(d/m/y):___/___/___
Clinician washes hands before consultation? Clinician greets patient/friend warmly? Yes Yes No ear pain fever No

What are the childs complaints? cough/difficulty breathing diarrhea vomiting other (Specify)________________________________ II. History Does the patient have danger signs? Y N NR If yes, specify Convulsions Not able to drink/breastfeed Vomits everything Clinician Patient Fever? Duration Antimalarials before todays visit? Measles within the last 3 months? Ear pain? Duration Ear discharge? Duration HIV status? Y N NR NR NR NR NR NR NR NR NR NH NH NH NH NH NH NH NH Coughing? Duration Night sweats?

HIV exposed

Change in consciousness/lethargic Other______________________ Patient Y N NR NR NR NR NR NR NR NR NR NR

NH
Clinician

NH NH NH NH NH NH NH NH NH NH

_____days Y Y Y N N N

_____days Y Y Y Y N N N N

Weight loss? Specify % _____ Recent contact with someone who has TB? Diarrhea? Duration Blood? Vaccination card?

_____days Y N

_____days Y Y Y N N N

_____days Y N

Trainee asks patient about other current symptoms or concerns? If yes, specify response__________________________________________________

III. Physical examination

Danger Sign

none

lethargic

not able to drink or breastfeed

drinks eagerly/thirsty

NE NE NE NE NE NE NE NE NE

Growth General Skin CNS Ear Lungs

Abdomen

{ { { {

low weight for age against weight chart low weight for age not improving missed or lost developmental milestone normal eyes, red eyes, sunken jaundice lymphadenopathy oedema pallor runny nose restless, irritable wasting other____________________________ normal generalized rash other__________________________________ stiff neck

normal abnormal muscle tone abnormal reflexes other_______________________________________ normal pus/drainage swelling behind ear

other ________________ RR ___________

clear cough chest in-drawing stridor other ___________________________ normal abnormal pinch skin

other _____________________________

Other

Specify exam and findings__________________________

Stop consultation and confer with trainee. Complete remaining sections based on final diagnosis and treatment. Did trainee order laboratory investigations? Yes No If yes, did patient return with results? Yes No NA If yes, Describe abnormal results.__________________________________________________ VI. Diagnosis: Ear infection Measles One or more danger signs HIV infection Meningitis Anaemia HIV suspect Pneumonia Cough (no pneumonia) Malaria (uncomplicated) TB infection Diarrhea acute Malaria (complicated) TB suspect Diarrhea persistent Malnutrition (low weight for age) Other (Specify)_____________ Dysentery Severe malnutrition

Yes No If yes, what treatment was prescribed? ____ Route: oral parenteral (Refer to score sheet with Antimalarial codes) Antibiotic tx: Yes No If yes, what treatment was prescribed? ____ Route: oral parenteral (Refer to score sheet with Antibiotic codes) Tx other conditions (e.g. TB, malnutrition): Specify ________________________________

VII. Plan: Malaria tx:

CTX prophalaxis: Yes No NA Recommend Mosquito Net: Yes No Vitamin A: Yes No Update immunizations: Yes No Did trainee: Provide information to parent or guardian about diagnosis Explain treatment Provide instructions on how to complete treatment

NA

Yes Yes Yes

No No No

NA NA NA

Refer: Where __________________________ Radiology: CXR Other_____________ Date of next visit: ____/_____/________