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Philippine Integrated Disease
Surveillance and Response Case Investigation Form
Severe Acute Respiratory Infection (SARI)
(ICD 10 Code: J22)
Name of DRU: Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address: Gov’t Lab. Private Lab. Airport/Seaport Others_________
Source: Surveillance Outbreak
I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:
Complete Address: MM DD YY Age:
Days
Male Date of
Sex: Months
Female Birth:
Years
Occupation: Name of Workplace:
Address of Workplace:
II. HISTORY OF ILLNESS, PHYSICAL EXAMINATION AND PRE-EXISTING CONDITIONS
Admitted? MM DD YY MM DD YY
Date Admitted/ Date Onset of
Yes No Unknown Seen/Consult Illness
Did you take any of the following medication(s) Are there any influenza-like-illness during
prior to consultation? the week in your:
Did you received Anti-influenza
Ranitidine (e.g. Flumadine)
Household Vaccination in the past year
Amantidine Yes No Unknown
Zanamivir Yes No Unknown
Oseltamivir (e.g. Tamiflu) School/Daycare
Others: (Please specify) ________________ Yes No Unknown
History of exposure to any of the ff:
History of travel: Chest X-ray
Bats Poultry/Migratory Birds Done Not Done
Camels Pigs Yes (specify country) ____________ Result: _________________
Horses Others:____________________ No
2. IMCI criteria for severe pneumo-
SARI Suspect Case for Patients < 5 years
Temperature at consultation:___ C old and
0 EITHER ONE of the two IMCI criteria nia
for pneumonia
Any child 2 months to 5 years
Fever/ Feverish of age with cough or difficult
Duration:_____ days/weeks 1. IMCI Criteria for pneumonia:
breathing
Headache
Cough Any 2 months to 5 years of age with With any of the following danger
Signs and Sore throat cough or difficult breathing signs:
Symptoms: Difficulty of breathing Breathing faster than 60 breaths/min
(infants < 2 months) Unable to drink or breastfeed
Others: (Please specify)
_____________________ Breathing faster than 50 breaths/min (2- Vomits everything
12 months)
Convulsions
Breathing faster than 40 breaths/min (1-
5 years old)
Lethargic or unconscious
Requires hospital admission. Chest indrawing or stridor in a
calm child
Requires hospital admission.
Asthma Chronic renal disease Clinical Impression:
Chronic cardiac disease Diabetes
Influenza-like-illness (ILI)
Pre-existing Chronic liver disease Haematologic disorders
Conditions Chronic neurological or neuro- Immunodeficiency diseases SARI
muscular disease Pregnancy Others, specify:
III. LABORATORY TESTS:
Specify If YES, date tak- Type of laboratory Results
Date result
Specimen en test done N=Negative; I=Indeterminate; U-Unknown
MM DD YY MM DD YY
Positive for: N I U
MM DD YY MM DD YY
Positive for: N I U
DOH-EB-PIDSR-SARICIF-REV0
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Case Investigation Form
Severe Acute Respiratory Infection (SARI)
IV. CLINICAL MANAGEMENT AND OUTCOME
Yes No Unknown Yes No Unknown
Antibiotics If Yes, please specify Bacterial Testing If Yes, please specify
_______________ _______________
Yes No Unknown Yes No Unknown
If Yes, please specify Other Therapeutic
Antivirals If Yes, please specify
_______________ Procedures
_______________
Yes No Unknown
Fluid Therapy If Yes, please specify Final Diagnosis
_______________
Yes No Unknown Alive HAMA Died
Oxygen If Yes, please specify Outcome at Discharge Others (specify) __________
_______________
Yes No Unknown
Intubation If Yes, please specify Date of discharge
_______________
Others
CASE DEFINITION/CLASSIFICATION:
INFLUENZA- LIKE-ILLNESS (ILI)
Suspected case: A person with acute respiratory infection, with measured fever of ≥38°C and cough with onset within the last
10 days.
Probable case: Not applicable
Confirmed case: A suspected case that is laboratory-confirmed (used mainly in epidemiological investigation rather than
surveillance).
SEVERE ACUTE RESPIRATORY INFECTION (SARI)
SARI Suspect Case for Persons > 5 years old:
An acute respiratory infection with:
-history of fever or measured fever of ≥ 38 C°;
-and cough;
-with onset within the last 10 days;
-and requires hospitalization
-WITH difficulty of breathing; OR
-A suspect case of severe undiagnosed pneumonia, Acute Respiratory Distress Syndrome, Severe Respiratory Disease
due to Novel Respiratory Pathogens
DOH-EB-PIDSR-SARICIF-REV0
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Case Investigation Form
Severe Acute Respiratory Infection (SARI)
CASE DEFINITION/CLASSIFICATION: (Continued)
SARI Suspect Case for Patients < 5 years old:
EITHER:
IMCI criteria for pneumonia
Any child 2 months to 5 years of age with cough or difficult breathing, AND:
Breathing faster than 60 breaths/min (infants < 2 months)
Breathing faster than 50 breaths/min (2-12 months)
Breathing faster than 40 breaths/min (1-5 years old)
OR:
IMCI criteria for severe pneumonia
Any child 2 months to 5 years of age with cough or difficult breathing and any of the following danger signs:
Unable to drink or breastfeed
Vomits everything
Convulsions
Lethargic or unconscious
Chest indrawing or stridor in a calm child
AND
Requires hospital admission.
Notes:
The requirement of “hospital admission” is meant to imply that in the judgment of a treating clinician the patient has an ill-
ness that is severe enough to require inpatient medical care.
“Shortness of breath or difficulty breathing” is intended to capture dyspnea or air hunger. This does not refer to nasal con-
gestion or other upper airway obstruction.
“History of fever” does not require a history of documented fever and may include a patient’s subjective report of having a
fever or feeling “feverish”.
SARI may reflect a new illness superimposed on an underlying condition or older illness
SARI is not equivalent to classic pneumonia and would not always present as pneumonia. It is expected that much of
the severe respiratory disease associated with influenza would be due to exacerbations of chronic lung disease or heart
disease, for example, and would not include an admitting diagnosis of pneumonia.
PROBABLE CASE
A person fitting the definition above of a “Suspect Case” with clinical, radiological, or histopathological evidence of pulmonary
parenchyma disease (e.g. pneumonia or ARDS) but no possibility of laboratory confirmation either because the patient or
samples are not available or there is no testing available for other respiratory infections, AND
Close contact with a laboratory confirmed case, AND
Condition not already explained by any other infection or etiology, including all clinically indicated tests for community-
acquired pneumonia according to local management guidelines.
CONFIRMED CASE: A suspected case that is laboratory-confirmed.
DOH-EB-PIDSR-SARICIF-REV0