LEPROSY RECORDS & FORMS

Tuberculosis and Leprosy Control Programme Ethiopia

Leprosy Patient Record Card
Patient's name Name of the health facility:
Age (in yrs): Sex: M F Occupation:
Region: Zone/subcity/Sp. Woreda: Woreda:
Kebele/farmers' association: Leprosy diagnosed: Yes No
Type of leprosy: PB MB Date of starting treatment: Unit lep. Nr:
Distance home to HF (in hrs walk or km):

History of the patient Method of case finding

Main complaints: V = Voluntary
Duration: C = Contact

Previous Rx for leprosy (including duration): S = Survey

Examination of the skin

Characteristics of the skin lesions
Sensory loss in lesion Present Absent
Number of skin lesions 1 to 5 6
Leprosy nodules Present Absent

Examination of the nerves

Nerve Ulnar Median Peroneal P. tibial
Palpation R L R L R L R L
Enlarged
Tender
write: + if nerve is thick and /or tender
write: ++ if nerve is very thick and / or very tender

Skin smear done only for difficult cases

Date: Result:
Draw visible lesions (patches) on this body map
Sensation Testing (ST)
Is there sign of nerve damage: Yes No Mark V where sensation is present
If yes, duration in months: Mark X (with red ink ) where sensation is lost
If the duration is < 6 months, give steroids or refer.
Mark any wound: Right Left

Eyes Voluntary Muscle Testing ( )

Visual acuity: Write: S=strong, W =weak
Counting fingers P=paralysed open crack:
at 6 meters
R L ( )
R L Eye closure
Can Lid gap in mm
count
5th finger clawing of digits:
Cannot Thumb up (c)
count Foot up
bone loss or absorption:
Disability grades ( )
R 0, 1 or 2 L on this map of
Eye hands & feet
Hand
Foot

Remarks:

Reviewer: Signature: Date:

 Review at completion of treatment
(Use the section at the bottom of this page when steroids are indicated for this patient)

Voluntary Muscle Testing Eyes Sensitivity Testing (ST)

Visual acuity: Mark any wound ( ) Right Left
Write: S=strong, W=weak P=paralysed
Counting fingers open crack ( )
R Test L at 6 meters clawing of digits ( c)
Eye closure R Test L bone loss or absorption
Lid gap in mm can ( ) on this map
5 th finger count of hands & feet
Thumb up cannot
Foot up count Mark V where sensation is
present
Is there deterioration (worsening of VMT/ST) ?
Yes No

If yes, duration in months: Mark X (with red ink) where

sensation is lost
If the duration is < 6 months, give steroids or refer.
Remarks:

Disability grade (0, 1 or 2) at the time of General condition at RFT

release from treatment (RFT) (I = improved S = same D = deteriorated)

R L R L
Eye Eye To assess the general condtion at
RFT you must compare the disability
Hand Hand
grade and VMT/ST status at
Foot Foot diagnosis with the status at RFT.

Remarks:

Signature: Name: Date:

Field treatment with steroids for new nerve damage:

If any of the symptoms and signs listed are present, please refer the patient.
If all are negative, start steroids according to the guideline in the manual.

Symptoms and signs Yes No Dosage of Duration

Date
prednisolone (in weeks)

1. Pregnant

2. Cough > 2 weeks

3. Blood stained sputum

4. Diabetic patient

5. Deep ulcer

6. Osteomyelitis