Acut

edi
arr
hoealdi
seases
Pr
ofoma
Name:

Age:

Sex:

I
nfor
mant
: mot
her
/fat
her
/gr
andpar
ent
s/guar
dian

Rel
aiabl
it
y:

Addr
ess : [
forf
oll
owupofcase,t
otr
acksour
ce,
endemi
cdi
sease]

Resi
dence:r
ural
/ur
ban

Near
estheal
thf
aci
l
ity
:

Fami
lydet
ail
s

Ty
peoff
ami
l
y–nucl
earf
ami
l
y/3gener
ati
onf
ami
l
y/j
ointf
ami
l
y

Tot
almember
soft
hef
ami
l
y=

[Link] Name Age/sex Relat

ion Educat
ion Occupat
io I
ncome Remar
ks
to t
he n per
head of month
the
househol
d

Modi
fi
edkuppusamyscal
e

Educat
ion–

Occupat
ion–

Fami
l
yincomepermont
h–

Cl
ass–

Fami
lyt
ree
Chi
efcompl
aint
s

Passageofl
oosest
ool
s-noofepi
sodes,
dur
ati
on

Fev
er–dur
ati
on

Vomi
ti
ng–noofepi
sodes,
dur
ati
on.

H/
oofpr
esent
ingi
ll
ness

H/
oloosest
ool
s

● Dur
ati
on
● Onset
● NoofEpi
sodes
● Natur
e[watery
,mucoid,bloody
][wat
ery–r
otav
irus,
bloody–shi
gel
l
ady
sent
ery
,
r
icewaterst
ools–cholera]
● Foul
smel
l
ing/nonf
oul
smel
l
ing
● Bl
oodst
ained/nonbl
oodst
ained(t
odi
ff
erent
iat
edi
arr
hoeaordy
sent
ery
)

H/
ofev
er

● Onset
● Dur
ati
on
● I
nter
mit
tent
/cont
inuous[i
nter
mit
tent-v
iral
fev
er,
cont
inuous-bact
eri
alf
ever
]
● (
Inbet
weent
heepi
sodesoff
evert
hechi
l
disnor
mal
-vi
ral
fev
er,
toxi
c-bact
eri
alf
ever
)
● Degr
ee[
highgr
ade-bact
eri
al,
lowgr
ade-v
iral
]
● Associ
ati
onwi
thchi
l
lsandr
igor
s[t
orul
eoutmal
ari
a]

H/
ovomi
ti
ng

● Onset
● Noofepi
sodes
● Foul
smel
l
ing/nonf
oul
smel
l
ing
● Nat
ureofv
omi
tus[sol
i
d,semi
sol
i
d]

H/
oincr
easedt
hir
st[t
ocl
assi
fyasmi
l
ddehy
drat
ion]

H/
oref
usal
off
ood[sol
i
dandsemi
sol
i
d][t
ocl
assi
fyassev
eredehy
drat
ion]

H/
opai
nful
mict
urat
ion[t
orul
eoutassoci
atedut
i]

H/
opassageofwor
msi
nst
ool
s[t
orul
eoutpar
asi
ti
ccausesofdi
arr
hoea]

H/
olet
har
gy/dr
owsi
ness/conv
ulsi
ons[t
ocl
assi
fyassev
eredehy
drat
ion]

H/
odecr
easedur
ineout
put[t
orul
eoutsev
eredehy
drat
ion]

H/
oofabdomi
nal
cramps/per
sist
entcr
ying[t
orul
eoutdy
sent
ery]
H/
owei
ghtl
oss(t
oasseswast
ing)

H/
ofai
l
uret
ogai
nwei
ght(t
oassessmal
nut
ri
ti
on)

Tr
eat
menthi
stor
y:

H/oanyant
ibi
oti
c/drugint
akeforthetreat
mentofdi
arr
hoea(ant
ibi
oti
cinduceddi
arr
hoea,
l
opi
rami
decausespar
aly
tici
l
leusi
nchil
dren)

H/
osweet
eneddr
inks,
car
bonat
edbev
eragesi
ntakef
ort
reat
mentofdi
arr
hoea.

Pasthi
stor
y:

H/
osi
mil
arepi
sodesi
npast[atwhi
chage,
overt
hecount
erdr
ugst
reat
menti
fany]

H/
oofanypr
evi
oussur
ger
ies

H/
omeasl
es/j
aundi
ce/epi
l
epsy

Ant
enat
alhi
stor
y;

Pr
egnancyr
egi
ster
edat.
..
..
..
..
..
..
..
..PHC/medi
cal
col
l
ege

Pr
egnancyconf
ir
medbyUPTathome/PHC

2dosesofTdt
akenornot

I
FAt
abl
etst
akenr
egul
arl
yornot

H/
oanemi
aGDM PI
Hdur
ingpr
egnancy

AnyH/
oradi
ati
onex
posur
e

AnyH/
odr
ugi
ntake

NoofANv
isi
sts=

Nat
alhi
stor
y

Fi
rst
/second/
thi
rd/
four
thchi
l
d

Pl
aceofdel
i
ver
y

Modeofdel
i
ver
y[i
fLSCS-r
eason]

Pr
eter
m/t
erm [i
fpr
eter
m-r
easons]

Cr
iedi
mmedi
atel
yatbi
rt
hornot

Bi
rt
hwei
ght(
nor
mal
/lowbi
rt
hwei
ght
)

Meconi
um passedwi
thi
n24hour
sofbi
rt
hornot

NI
CUadmi
ssi
oni
fany
[causef
oradmi
ssi
on]
Postnat
alhi
stor
y

Br
east
feedi
ngi
nit
iat
edwi
thi
n..
..
..
..
..hour
s/day
s

Excl
usi
vebr
eastf
eedi
nggi
venf
or.
..
..
..
..
..
..
..weeks/mont
hs

Supplement
aryf
eedsst
art
edaf
ter
..
..
..
..
..
..
..
..
.weeks/mont
hs[whatsuppl
ement
aryf
eeds
st
arted]

Pr
elact
eal
feeds

Br
eastf
edf
orhowmanyt
imesaday

Dev
elopment
alhi
stor
y

Dev
elopmentupt
oageornot

Age Motor Language Adapti

ve Socio per
sonal
dev
elopment devel
opment devel
opment devel
opment

6t
o8weeks - - - Looksatmot
her
andsmil
es

3mont
hs Hol
ds head - -
er
ect

4t
o5mont
hs - Li
steni
ng Begi
nstor each Recogni
zes
outf
orobj
ects mother

6t
o8mont
hs Sit
s wi
thout Exper
iment
ing Transf
ersobj
ect Enjoy
shi
deand
suppor
t wit
hnoises handtohand seek

9t
o10mont
hs Cr
awl
i
ng I
ncr
easi
ng Rel
eases Suspi
cious of
r
angesofsound obj
ects st
rangers

10 t
o 11 Stands wi
th Fi
rstwor
ds - -
mont
hs support

12 t
o 14 Wal
kswi
debase - Bui
l
ds -
mont
hs

18 t
o 21 Walks nar r
ow Joi
ningwor
ds Begi
nning t
o -
mont
hs base,begi
nning expl
ore
torun

24mont
hs Runs Shor
tsent
ences Dr
ybyday

Chi
l
denr
oll
edi
nAnganwadi
ornot

I
mmuni
zat
ionhi
stor
y
I
mmuni
zedupt
oageornot[i
fnotr
easonsf
ornoti
mmuni
zed]

● Atbi
rt
h–BCG,
OPV,
Hepat
it
isB
● 6t
hweek–OPV,
Pent
av ent,
al Rot
avi
rus,
IPV
● 10t
hweek–OPV,
Pent
av ent,
al Rot
avi
rus
● 14t
hweek-
OPV,
Pent
av ent,
al Rot
avi
rus,
IPV,
● 9compl
etedmont
hst
o12mont
hs–MR,
vit
ami
nA
● 16t
o24months-DPTboost
er,
MR,
OPVboost
er,
vit
ami
nA[t
hen1doseev
ery6
mont
hsupt
o5years]
● 5t
o6y
ear
s–DPTboost
er
● 10y
ear
sand16y
ear
s–TT/TD

Mar
it
alhi
stor
y

Mar
ri
edatt
heageof.
..
..
..

Mar
ri
edsi
nce.
..
..
..
.year
s

Consai
ngunous/nonconsai
gunousmar
ri
age

Degr
eeofconsai
ngui
ty

H/
ocont
racept
iveusage

Fami
lyhi
stor
y

H /o of diabetes mell
itus,hyper
tension,bronchial ast
hma,epi
l
epsy
,tuber
cul
osi
s,
car
diov
ascul
ardiseaseoranyothermedicali
ll
nessi
nf amil
ymembers

Economi
chi
stor
y

Tot
alf
ami
l
yincome=

Sav
ings/debt
s

Anyheal
thi
nsur
ance

Shgenr
oll
ment

Rat
ioncar
dcol
our

Di
ethi
stor
y

Nooff
eedsi
naday=

Ti
ming Food Quant
it
y Ener
gy[i
nkcal
] Pr
otei
ns [ i
n
gr
ams]

Mor
ning

Lunch
 Ev
eni
ng

Di
nner

Tot
al

Recommended Act
ual
int
ake Def
ici
t/excess
amount

Cal
ori
eint
ake

Pr
otei
nint
ake

Fr
uit
stakenr
egul
arl
y/not[
whi
chf
rui
t]

Commonl
yusedoi
l

Sal
tint
ake

Foodt
aboos,
foodbel
eif
s

Env
ironment
alhi
stor
y

Housi
ng

Ownhouse/r
enthouse

Puccahouse/kucchahouse/semi
puccahouse

Noofl
i
vingr
ooms=

Noofwi
ndows =

Ov
ercr
owdi
ngpr
esent/noov
ercr
owdi
ng

Adequat
eli
ght
ingpr
esent
/not

Adequat
event
il
ati
onpr
esent/not

Ki
tchen

Separ
ateki
tchenpr
esentornot

LPGst
ove/ker
osenef
uel
/bur
ntwoodf
orf
uel

I
ndoorai
rpol
l
uti
onpr
esentornot

Ut
ensi
l
skeptcl
eanornot

Foodi
temskeptcov
eredornot

Wat
ersuppl
y
Sour
ceofwat
ersuppl
y[cor
por
ati
on/panchay
atwat
erorbor
ewat
er]

Fr
equencyofwat
ersuppl
y

Modeofwat
ersuppl
y[t
hroughpi
pel
i
nest
ap,
handpumps,
wel
l
s]

Boi
l
ingofdr
inki
ngwat
er

Fi
l
ter
ingofdr
inki
ngwat
er

St
orageofwat
er[i
ncov
eredut
ensi
l
s/openv
essel
s]

Wast
edi
sposal

Soli
dwaste– collect
edbymuni ci
palcorpor
ati
ononcei
nev
ery.
..
..
.day
s/di
sposedi
n
backyar
d/di
sposedinmuni
cipal
i
tydust
bine

Wast
ewat
er–dr
iveni
ntobacky
ard/dr
iveni
ntosewage

Sani
tar
yfaci
li
ty

Separ
atet
oil
etpr
esentornot

Openai
rdef
ecat
ion

Mosqui
toandf
li
esbr
eedi
ngsi
tes

Cl
osedsewagesy
stem

Pet
s/ani
mal
s

Useofmosqui
tonet
s

Exami
nat
ion

Gener
alexami
nat
ion

Al
ert
, awake, consci
ousness, or
ient
ati
on, pal
l
or, j
aundi
ce, cy
anosi
s, cl
ubbi
ng,
l
ymphadenopat
hy,
pedal
edema

Vi
tal
s

Temper
ate =

Pul
ser
ate =

Respi
rat
oryr
ate=

Bl
oodpr
essur
e =

Ant
hropomet
ry

Wei
ght=

Hei
ght/l
engt
h=
(
Ploti
nWHOgr
owt
hchar
tandassesst
unni
ngorwast
ing)

I
nfer
ence:

Headci
rcumf
erence=

Chestci
rcumf
erence=

Mi
dar
m ci
rcumf
erence= (
wit
hinf
erence)

Headt
ofootexami
nat
ion

Head-ant
eri
orf
ont
anel
l
etobechecked

Ey
e–nor
mal
/sunken

Tongue–nor
mal
/dr
y

Ski
n–r
etr
act
ionseen[
goesbackaf
terl
esst
han2seconds/mor
ethan2seconds]

Tr
unk–chestwal
ldef
ormi
tyt
obechecked

Abdomen– shape,
umbi
l
icusposi
ti
ont
obechecked

Geni
tal
s–

Spi
ne–

Ext
remi
ti
es–

Sy
stemi
cexami
nat
ion

Abdomen

I
nspect
ion

Di
stended/notdi
stended

Umbi
l
icusnor
mal
inposi
ti
on/
not

Vi
sibl
epul
sat
ion

Engor
gedv
eins

Al
lquadr
ant
smov
esequal
l
yinr
espi
rat
ion/not

Pal
pat
ion

Sof
tandnont
ender
/tender
nesspr
esent

or
ganomegal
ypr
esent
/not

Per
cussi
on

Li
verdul
l
ness
 Fr
eef
lui
d

Auscul
tat
ion

Nor
mal
bowl
andbl
addersoundshear
d

Car
diov
ascul
arsy
stem –S1,
S2hear
d,nomur
mur

Respi
rat
orysy
stem –nor
mal
vesi
cul
arbr
eat
hsoundshear
d

Cent
ral
ner
voussy
stem –nof
ocal
neur
ologi
cal
def
ici
t

Cl
ini
cosoci
aldi
agnosi
s

A...
..
..
.y
ears/mont
hsol dchil
d...
..
..
..
..
...
..
..
..
..
.broughtbyhis/
her
,mot her
/fatherbel
ongtoa
..
..
..
..
..
..
..
..
.t
ypeoff amilyof..
..
..
..
..
..
..
.cl
assi sdi agnosedtohaveacutediarr
hoealdi
sease
wi
th/withoutdehy
dr at
ion..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
...
..
..
..
..
..
..
..
.ar
etheri
skf
actorsseen.

I
nvest
igat
ions

● Compl
etebl
oodcount
,haemogl
obi
n
● St
ool
exami
nat
ion
● Ser
um el
ect
rol
ytes
● Ser
um Ant
igendet
ect
ion

Management

● Or
alr
ehy
drat
ionsol
uti
on[acut
ewat
erydi
arr
hoeawi
thmi
l
ddehy
drat
ion]
● I
ntr
avenousr
ehy
drat
ion-r
ingerl
act
ate[sev
eredehy
drat
ion]
● Appr
opr
iat
efeedi
ng–cont
inuebr
eastf
eedi
ng
● Chemotherapy–[whenthecauseofdiar
rhoeai
sCholer
a–dr
ugofchoi
cei
s
doxi
cycl
ine,t
etr
acy
cli
ne,
TMP- SMX,er
ythr
omy ci
[Link]
gel
l
a–dr
ugofchoi
cei
s
ci
prof
loxaci
n].
● Zincsupplement
ati
on–10mgzi ncf
orinf
antsl
esst
han6monthsofagefor10
to14day s.20mgz incf
orchi
l
drenol
derthan6monthsf
or10t
o14day s
● Vi
tami
nAsuppl
ement
ati
on

Adv
ice

Tot
hei
nfor
mant

Regar
dingor
s

● Thepacketsofor
alrehy
drat
ionsoluti
onar
eav
ail
abl
eatal
l sub
PHC,
cent
res,
hospi
tal
s,andchemistshops.
● Mixthecont
entsofthepacketi
nto1l
i
tre[5cups]ofboi
ledandcool
eddr
inki
ng
wateri
nacleanvessel
.Stor
eanduseitfor24hour
sonly
.
● Giv
eORSint easpoonev
ery2mi
nut
esorasf
requentsi
psi
ncupsorasmuchas
he/shedr
inks.
 ● Aftereachst
oolgiv
e50t
o100ml
-chi
l
disl
esst
han2y
ear
s,100t
o200ml
–chi
l
d
aged2t o10year
s.

● I
fchi
l
dvomi
tswai
tfor10mi
nut
esandt
hent
rygi
vi
ngsl
owl
y.
● Av
oidsweet
eneddr
inks,
car
bonat
edbev
erages,
commer
cial
frui
tjui
ces.
● Gi
vesi
mpl
eandeasi
l
ydi
gest
abl
efoods,
nev
erwi
thhel
dthef
ood.

War
ningsi
gns

● Chi
l
dbecomesdr
owsy
,col
dsweat
y,comat
ose
● Ur
ineout
putdecr
eases
● Ref
usal
tof
eed/notabl
etodr
ink
● Eyessunken,
tongueski
ndri
edout
Reporti
mmediatel
ytohospi
tal
ifanyoft
heabov
esi
gnsar
epr
esent

Tof
ami
lyandcommuni
ty

● Maint
ainsani
tat
ion–cl
eanwat
ersuppl
y,f
oodhy
giene,
avoi
dopenai
rdef
ecat
ion,
per
sonalhygi
ene.
● Pr
eventenv
ironment
alcont
ami
nat
ions
● I
mmuni
zat
ionagai
nstr
otav
irus,
measl
es

● Enr
oll
thechi
l
dinAnganwadi

Pr
event
ion

Lev
el Pr
imary [ heal th Secondary [ ear
ly Terti
ary[disabi
li
ty/
pr
omotion ,speci
fi
c diagnosi
s/ rehabi
li
tat
ion]
pr
otect
ion] screeni
ng/
tr
eatment]

I
ndi
vi
dual Fai
l
ed ORS, zi
nc gi
ven / I
ntr
avenous
fai
l
ed r
ehydrat
ion

Fami
l
y Envi
ronmental
sani
tati
on, personal
hygi
ene,
Immunizat
ion
agai
nst r
otavir
us,
measles

Communi
ty Heal
th educat
ion at
PHC

Pr
ogr
amme

I
MNCI
UI
P

I
CDS

RBSK