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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