Scribd
Upload
484 views1 page

AFP Form

This document contains an acute flaccid paralysis case investigation form used by the Ministry of Health in Malaysia. The form collects information on the patient's demographics, symptoms, medical history, immunization history, physical examination findings, preliminary diagnosis, laboratory test results, follow up examination, and final diagnosis. It is used to investigate possible cases of polio and gather the necessary clinical and epidemiological data.

Uploaded by

Serenity Zay's
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
484 views1 page

AFP Form

This document contains an acute flaccid paralysis case investigation form used by the Ministry of Health in Malaysia. The form collects information on the patient's demographics, symptoms, medical history, immunization history, physical examination findings, preliminary diagnosis, laboratory test results, follow up examination, and final diagnosis. It is used to investigate possible cases of polio and gather the necessary clinical and epidemiological data.

Uploaded by

Serenity Zay's
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

ACUTE FLACCID PARALYSIS CASE INVESTIGATION FORM

Ministry of Health, Malaysia Nationality


1 CASE ID: PLACE Residential Address: 2 REFERRAL: REPORTING Child initially seen at: Date of report to EPI/MOH _____|_____|_____ Attending physician: Person reporting: Tel. No.: Date first seen: Name:
Father's Name: Mother's Name:

Malaysian

Non-Malaysian

Specify Country of Origin:


Gender: District: DOB: State: ___|____|___ Age: Hosp. Regist. No.:

Report from where? (Institution) Remark: 3 HISTORY PHYSICAL EXAMINATION Onset of paralysis (date): Main history source: At onset (paral) : PAST HISTORY (last 30 days): Injections? Recent trauma or animal bite? Any existing neurologic disease? Any recent travel? (Specify below) Similar case among contact? Remark: 4 PRELIMINARY DIAGNOSIS Name of investigator: Address of investigator 5 IMMUNIZATION HISTORY / ORI Immunization card available? Yes / No Main reason for not fully immunized: AFP Yes | No | Unkn Yes | No | Unkn Yes | No | Unkn Yes | No | Unkn Yes | No | Unkn 1. Parent 2. Chart

No. of days to maximum paralysis: 3. Doctor / Nurse

Fever: Y / N / Unk | Diarrhoea: Y / N / Unk | Cough/Cold: Y / N / Unk | Other:__________________ ON EXAMINATION (date: ____|____|____) FLACCID Paralysis? Meningeal sign (stiff neck): Paralysis symmetric/asymm? Deep tendon reflexes: Any sensory loss? Yes | No | Unkn Yes | No | Unkn symmetric | asymm Norm. | Red. | Abs. Yes | No SITE OF PARALYSIS: (Grade mot. strength: 0-abs to 5-full) left arm left leg ____ ____ right arm ____ right leg face: yes / no ____

respir: yes / no

others (specify):__________________________

1. Poliomyelitis | 2. Guillain-Barre | 3. Tranverse Myelitis | 4. Traum. Neuritis | 5. Myasthenia Gravis | 6. Viral Myositis 7. Periodic Paralysis | 8. Demyelinating Disease | 9. Cord Compression Disease | 10. Others (Specify): Date: _____|_____|_____ Signature:

Total no. of OPV doses received:________

1. not informed 2. illness 3. refusal 4. unknown 5. others (specify):______________________


OPV6 ___|____|___ OPV7 ___|____|___ Last OPV ___|____|___

Dates: OPV1 ___|____|___ OPV2 ___|____|___ OPV3 ___|____|___ OPV4 ___|____|___ OPV5 ___|____|___

LAB INFO Stool 1 Yes / No Stool 2 Yes / No Remarks:

Date collected: ____|____|____ ____|____|____

Date sent: ____|____|____ ____|____|____

Date rec. IMR: ____|____|____ ____|____|____

Pes. CPE (IMR): ____|____|____ ____|____|____

IMR: PV-Type ____|____|____ ____|____|____

Date sent to Ref.: ____|____|____ ____|____|____

Ref - Lab. Result: wild / vacc. | T: 1 | 2 | 3 wild / vacc. | T: 1 | 2 | 3

FOLLOW-UP Date: ____|____|____

Case examined >= 60 days after onset paralysis? Yes / No If not seen, why not? ___________________________________

Date of examination:

____|____|____

Paralysis/ weakness still present? Yes / No

Site of residual paralysis: Right leg: Y / N | Left leg: Y / N | Right arm: Y / N | Left arm: Y / N | Face: Y / N | Other (specify):_______________________ Ability to walk: Remarks: 8 FINAL DIAGNOSIS; DATE: 1. CONFIRMED 2. DISCARDED Remarks: ____|_____|____ (CONFIRMED POLIO or discarded as polio; Expert Review Committee) Residual paralysis: Yes / No | Death: Yes / No | Lost to follow-up: Yes / No 1. Cannot walk 2. Walks with assistance 3. Limps 4. Walk normally Exam. Physician:

> Virus isolation Yes / No |

1. Guillain-barre | 2. Transverse myelitis | 3. Traumatic neuritis | 4. Unknown | 5. Other (specify):_________________________________

NOTE: Please Fax AFP Case Investigation form to: 1. Nearest DISTRICT HEALTH OFFICE 2. Dr Christina Rundi, Epidemiology Unit, Sabah Health Department (Fax: 088-217 740) 3. Dr Nor Zahrin binti Hasran, Disease Control Division, MOH (Fax 03-8889 1013) 4. Virology Department, Institute for Medical Research (IMR) KL (Fax: 03-2693 6323) (sent adequate STOOL SAMPLES) Second AFP Case Investigation Form should be sent after 60 days with follow-up result to the above fax

http://cdc.jknsabah.gov.my/Borang.htm

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy