Name: _Jennifer Salcedo_ Age:_5 years old_ HC:_127cm_ Weight:_17.

85_kg Temprerature:_38_oC Date:_November 10, 2021_

What are the child’s problems? _May lagnat, inuubo at may sipon_ _✓_ Initial Visit ___Follow-up visit

CHECK FOR GENERAL DANGER SIGNS: ___ Yes _✓_ No

___ Not able to drink or breastfeed ___ Convulsions during this illness
___ Vomits Everything ___ Lethargic or Unconcious

COUGH OR DIFFICULT BREATHING? _✓_ Yes __ No

Gaano na katagal? _4_ Days Counted _84_ Beats per minute __ Fast breathing __ Chest indrawing
__ Stridor ___ Wheeze

If wheeze, ask: ___ Wheeze before this illness ____Wheeze for more than 7 days ___ Frequent cough at night
___ Treatment for asthma at present

DIARRHOEA? __ Yes _✓_ No For how long? _____ days

___ Blood in the stool How much / what fluid mother has given: _____

General condition: ___ Lethargic or unconscious ___ Restless or irritable ___ Sunken eyes
__ Not able to drink/drinking poorly ___ Drinking eagerly, thirsty

Pinched abdomen skin goes back: __ Normal ___ goes back slowly ___ goes back very slowly (> 2 secs)

FEVER (by history or feel or 37.5°C or above)? _✓_ Yes ___No Fever for how long?_4_ days

___ Stiff neck ___ Bulging fontanelle

Malaria Risk. If malaria risk: Malaria Test: __ Positive __ Negative __Not done

MEASLES? ___ Yes _✓_ No

__ Fever ___ Measles rash __ Runny nose, or Cough or Red eyes ___ Contact with measles Pneumonia
__ Symptomatic HIV infection __ Cornea clouded ___ Deep mouth ulcers ___ Mouth ulcers ___ Eyes draining pus
EAR PROBLEM? __Yes _✓_ No
___ Ear pain __ Wakes child at night? ___ Pus seen draining from ear.
Ear discharge reported: for _____ days ___ Tender swelling behind the ear

SORE THROAT? _✓_Yes __ No _✓_ Runny nose _✓_ Cough __ Rash

CHECK FOR MALNUTRITION All children

Weight MUAC Weight for Height/length Oedema of both feet
__ Very Low Weight __ < 11.5cm __ z-score < -3 __ Yes _✓_ No
__ Losing weight __ ≥11.5 and < 12.5cm __ z-score ≥-3 and -2
__ Weight gain unsatisfactory _✓_ 12.5cm or more _✓_ z-score ≥ 2 or more
_✓_ Weight gain satisfactory Ht:_____

CHECK FOR ANAEMIA All children

___ Severe Pallor ___ Some Pallor _✓_ No Pallor
If pale, Haemoglobin measured _______ gm / dl

CONSIDER HIV INFECTION All children

Has the child had an HIV test? If yes, what was the result? __ Positive HIV test __ Negative HIV test
If Test Positive: is child on ART? __ Yes __ No
If no test, has the mother had an HIV test? __ No test __ Positive HIV test __ Negative HIV test

And: __ Pneumonia now __ Unsatisfactory weight gain __ Persistent diarrhoea now or in past 3 months __ Oral thrush
__ Ear discharge now or in the past __ Parotid enlargement __ Low weight for age
__ Enlarged glands in 2 or more of: neck, axilla or groin

TB RISK ___ Close TB contact ___ Cough for 3 weeks ___ Loss of weight ___ Fever for 7days
___ Not growing well

All children with HIGH RISK OF TB or RISK OF TB must have full TB assessment and be classifified

ASSESS CHILD’S FEEDING if anaemia, not growing well or age < two years
How are you feeding your child?_Sinusubuan_
__ Breastfeed: ____ times during the day. Breastfed during the night
__ Given other milk: ______________ type. Using ________to give the milk.
Other milk given __________ times per day. Amounts of other milk each time:__________
__ Given other food or fluids. These are:___________

These given _3_ times per day. Using ___________ to give other fluids.
_✓_ Feeding changed in this illness. if yes, how? _Mula sa ordinaryong kanin at ulam naging lugaw ang
kanyang Kinakain_
If Not Growing Well: How large are the servings? __
__ Own serving given. Who feeds the child and how? _________________

CHECK IMMUNISATION STATUS AND GIVE ROUTINE TREATMENTS

Birth ✓ BCG ✓ OPV0 Vitamin A

6 weeks ✓ DaPT-IPV-HB-Hib1 ✓ OPV1 ✓ RV 1 ✓ PCV1 _✓_ Yes __ No
Underline those 10 weeks ✓ DaPT-IPV-HB-Hib2
that have been 14 weeks ✓ DaPT-IPV-HB-Hib3 ✓RB 2 ✓ PCV2 Mebendazole
given. 6 months ✓Measles 1 _✓_ Yes __ No
Tick those 9 months __PCV3
already given 12 months __Measles 2
18 months ✓ DaPT-IPV-HB-Hib4
6 years __ Td

ASSESS OTHER PROBLEMS:

TREAT THE SICK YOUNG INFANT (HEALTH TEACHING)

Refer any child who has a danger sign, even if no other severe classifification.
Name: ____________________________________________ Signature: __________________

Designation: ________________________________________ SANC no: _________________ Contact no: ______________________