11.

ARI CASE (UNDER 5)

1. GENERAL INFORMATION:
Name Age Sex
Address
Informant Reliability
2. PRESENTING COMPLAINTS:
Fever nunning nose, cough, sore throat, difficulty in breathing ,car problem

3. HISTORY OF PRESENT ILLNESS

FEVER:
Onset
Duration
Type
Grade
Diumal variation
Associated with
COUGH: continuous / intermittent
with sputum/ without sputum
Other complaints:

4. PAST HISTORY
H/o Previous hospitalization
H/o Exanthematous fever
H/o wheeze, difficulty in breathing
Ho recurrent vomiting
Ho passing worms in motion
Ho recurrent URI
. H o ear discharge
H/o jaundice
H/o Contact with TB
H/o mouth ulcers
H/o Nasal flaring ( when the nose widens as the child breaths in)
H/o similar illness in sibling/peers

5. ANTENATAL HISTORY ( for child< l yr)

Registered yes /no
Immunization: TTI TT 2 TT booster
No. of antenatal visit 3 or more
H/o IFA tablets intake 100/ 200/ more
.HWo fever with rash yes/ no

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 Bencficiary of ICDs
H/o exposure to
yes/ no
ionizing
radiation yes / no
.
History suggestive of
Pregnancy Induced
6. NATAL HISTORY( for child<
. Birth order
1 yr) Hypertension/CGestational Diabetes Meilitus
Gravida
Term/ pretem /para.Aiving. ../abortion
Nature of delivery normal
Institutional /home delivery instrumental/ caesarean
If home delivery ---conducted by
trained dai / doctor / untrained
7. POSTNATAL HISTORY
person, delivery kit used or not

Weight at birth
Baby cried immediately after birth
yes /no
Any complication of the new borm
Exclusive breast feeding :NICUTemperature/diarrhoea
Colostrum given yes/no
Artificial feeding/Prelacteal feeds given yes/no
Any h'o any infection

8. Immunization history:
Immunization card-present/absent

Fully immunized / partially immunized/

unimmunized
Vaccine
Age
Birth 6 weekss
Primary vaccination 10 weeks 14 weeks 9-12 months
BCG
Oral polio
DPT
emophilius Influenzae type B
iepatitis B
Measles first dose
Booster Doses
DPT Oral polio Measles second
+

dose 16 to 24 months

5 years
etanus toxoid (TT) At10 years and again at 16 years
Vitamin A 9,18, 24, 30, 36,42, 48, 54, 60 months
PTegnant women
Tetanus toxoid (PW) 1 dose As early as possible during pregnancy (first contact)
2 dose I month after 1* dose
Booster If previously vaccinated, within 3 years

9. Family history:

No. of family members/ Type of family

Any H/o consanguineous marriage

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 H/o similar complaints in family members/siblings/peers
Details of family:

Name of Relationship Income

Marital
S.No family Age Sex to head of Education Occupation per
status
members family month

Type of family: Nuclear/ Joint/ Extended nuclear

Per capita Income/ month =
totalincome ofthefamily =Rs. °°°°°*° *°

Total no of family members

According to modified Kuppusamy scale the family belongs to . . . . .

10. Dietary history:

Prelacteal feeds
Breast feeding initiation
Duration of exclusive breast feeding

When started on complementary feeds/what?

Whether sending the child to ICDS - whether active beneficiary of ICDS ?

24 hour recall method

Energy Proteins
Name Morning Afternoon Evening Night
(K Cal) (gms)

Energy requirement Energy intake Energy deficit

Protein intake Protein deficit

Protein requirement

11. Environmental history:

Type of house: pucca/ kutcha
Overcrowding present or not:
Toilet: present/absent Type: sanitary /non sanitary Disposal: septic tank/ sewer
system/ open drain/ others
Ventilation: satisfactory/ not satisfactory
Lighting: satisfactory/ not satisfactory
.Kitchen: separate/not Fuel for abs nt
cooking:.. .. Exhaust for smoke:...present /

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 Source of drinking water.
followed......
..

.Storage... ...Disinfection method

Waste water disposal (sullage)
of
--

soakage pit yes/ no

Presence
.
rodents/cockroaches/mosquito,ly breeding/pet animals
12. GENERAL EXAMINATION
Conscious, Comfortable, Oriented, Built, Nourishment, Fever, Anemia
(pallor), Jaundice (icterus),
Cyanosis, clubbing. Thyroid, edema/Pedal edema, Generalized
lymphadenopathy. Any toxic look in the
child? Alert or restless? Drowsy or comatose? Cold extremities?
Any congenital anomalies
Head to foot examination:

General appearance : Normal buil/'thin

built/sickly
Shape ofthe head: normal
Anterior fontanelle: normal or sunken
Eyes: sunken, conjunctiva dry
Nose flaring of alar nasi, normal breathing present?
Mouth: dry lips, tongue dry
Chest: chest indrawing present or normal chest wall movements
Abdomen : normal bowel sounds heard, any distension
Skin turgor: on pinching does it
go back slowly? (>2 seconds)
Thrist: increased?
Edema in dependent parts:
Urine flow: normal or decreased
Any signs of PEM present: flag sign, rachitic changes, mottled teeth etc
Vital Signs: Pulse: Temperature: RR:
Nutritional Assessment:
IAP Degree of malnutrition (based on weight for age)
Length/height_
Mid arm
(Mclaren/ Waterlow classification)
circumference (1 5 years): -

Head circumference (<l

Chest circumference (<l
year): _

year))_
13. SYSTEMIC EXAMINATION
AAMINATION OF THE RESPIRATORY SYSYTEM
Stridor -present/ absent
Chest Indrawing -present/ absent
uscultation -: breath sound --vesicular/ bronchial
Rhonchi present/ absent

EXAMINATI OF THE ABDOMEN; Organomegaly present /absent

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 EXAMINATION OF THE CARDIOVASCULAR SYSYTEM: S1 ,S2 heard
No murmur
EXAMINATION OF THE CNS normal

SUMMARY WITH POSITIVE AS WELL AS NEGATIVE FINDINGS...

PROVISIONAL DIAGNOSIS -- AR/Pneumonia / Severe Pneumonia/ No Pneumonia / severe diseae

TREATMENT - according to national program guidelines (standard case management)

ADVICE &CARE
INTERVENTION TO THE FAMILY - Look for similar case in the family and treat them (sibling in the

family)
INTERVENTION TO THE COMMUNITY --Look for similar case in the community and treat them

Immunization /vit A supplementation for children

Health education

NATIONAL PROGRAM .....objective / strategies..

HOW WILL YOUCONFIRM THE DIAGNOSIS
No Pneumonia Pneumonia Severe pneumonia| Very severe disease
cough and cold)
Signs No chest No chest Chest indrawing+ Not able to drink
indrawing indrawing Cyanosis + Convulsions
No
fast breathing Fast breathing+ Nasal flaring+ Abnormally sleepy
(<50-2monthsto Stridor
12 months) Severe malnutrition
(40 -12months
to 5 years)

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