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Date: February 24, 2011 Childs Name: A.B. Age: 3 y/o Sex: F Weight: 12.5 kg Temperature: 36.4 C Address: Purok 4, Sevilla, City of San Fernando, La Union, 2500 ASK: What are the childs problems? Cough Initial visit: Follow-up visit: ASSESS: (Encircle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General Danger Signs NOT ABLE TO DRINK OR BREAST FEED Present? ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN VOMITS EVERYTHING YES____NO CONVULSIONS (during the present illness) DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES NO For how long? 3days Count the breaths in one minute 44 breaths per minute. Fast breathing? Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze. DOES THE CHILD HAVE DIARRHEA? YES______ NO_______ For how long? ____________days condition. Is the child: Is there blood in the stool? difficult to awaken? Look at the childs general Abnormally sleepy or Restless or irritable? Look for sunken eyes. Offer the child fluid. Is the Not able to drink or Drinking eagerly, Pinch the skin of the Very slowly (longer

child: drinking poorly? thirsty? abdomen. Does it go back: than 2 seconds)?

Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C YES___ NO___ Decide malaria risk: FEEL Does the child live in malaria area? feel for stiff neck Has the child visited or stayed overnight in malaria in runny nose the past 4 weeks? If malaria risk, obtain a blood smear (+) (Pf) (Pv) (not done) LOOK and Look or Look for

L ook for signs of MEASLES For how long has the child have fever? ______days Generalized rash and If more than 7 days, has fever been present everyday? One of these : cough, runny nose or red eyes Has the child has measles within the past 3 months?

If the child has measles now or If yes, are they deep and extensive?



Look for mouth ulcers. last 3 months Look for pus

draining from the eyes.

Look for clouding of the cornea. ASSESS DENGUE HEMORRHAGIC FEVER LOOK AND FEEL ASK: Look for bleeding from the nose or gums. Has the child had any bleeding from the Look for the skin petechiae. nose or gums or in the vomitus or stools? Feel for cold and clammy extremities. Has the child had black vomitus or black Check capillary refill._2_seconds. stools? Perform tourniquet test if child is 6 Has the child has persistent abdominal months or older AND has no other signs pain? AND has fever for more than 3 days. Has the child had persistent vomiting? DOES THE CHILD HAVE AN EAR PROBLEM? YES_____NO______ Is there an ear pain? Look for pus draining from the ear. Is there ear discharge? Feel for tender swelling behind the ear. If yes, for how long? ______days THEN CHECK FOR MALNUTRITION Look for visible severe wasting MUAC less than 115 mm. Look for edema of both feet. Determine weight for age. Very low? Not very low? THEN CHECK FOR ANEMIA Look for palmar pallor. Severe palmar pallor? Some palmar pallor? CHECK THE CHILDS IMMUNIZATION STATUS? Encircle immunizations needed today? BCG HEP B1 DPT 1 OPV 1 HEP B2 DPT 2 OPV 2 MEASLES DPT 3 OPV 3 HEP B3 CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older. Is the child six months or age or older? YES______NO______ Has the child received Vitamin A in the past 6 months? YES______NO______ CHECK FOR DEWORMING STATUS for children 12 months or older. Is the child 12 months of age or older? YES______NO_______ Has the child received albendazole/mebendazole for the past 6 months? YES_____NO_____ ASSESS CHILDS FEEDING if child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Do you breastfeed your child? YES______NO______

Return for next Immunization on _______________ (Date)

Vitamin A needed today YES____NO_____ Albendazole/Mebendazole needed today YES____NO_____ Feeding Problems

If yes, how many times in 24 hours?_____times. Do you breastfeed during the night? YES____NO_____ Does the child take any other foods or fluids? YES _____NO______ If yes, what food or fluids? _______________________________________________________________________ How many times per day?______times? What do you use to feed the child? ______________________________________________________________ If very low weight for age, how large are the servings? _______________________________________ Does the child receive his/her own servings?________ Who feeds the child and how? ___________________________________________________________________ During the illness, has the childs feeding changed? YES_____NO______ If yes, how? ___________________________________________________________________________ _____________ ASSESS CARE FOR DEVELOPMENT: Ask questions about how the mother cares for her child. Compare the mothers answer to the Recommendations for Care for Development for the childs age. How do you play with your child? _______________________________________________________________ How do you communicate with your child? ____________________________________________________ ASSESS OTHER PROBLEMS

Care for Development Problems