Variables

Modalities

Choice

General informations

Age (month):

Gender

1. Male

2. Female

/___/

Religion

1. Animist

2. Jéhovah’s witness

3. Catholic

4. Evangelical

5. Islamic

6. Other (specify)

/___/

Résidences

1. Porto-Novo

2. Adjohoun

3. Adjarra

4. Avrankou

5. Misserete

6. Sakete

7. Pobe

8. Dangbo

9. Azowlisse

10. Aguegues

11. Other (specify)

/___/

Father’s profession

1. Civil servant / employee

2. Trader

3. Worker /craftsman

4. Pupil/ student / apprentice

5. Unemployed

6. Other (specify)

/___/

Mother’s occupation

/___/

Clinical informations

Date and time of admission

Admission mode

1. Referred

2. Not referred

/___/

If referred, specify the referral center

Mode of transport

1. Motorcycle

2. Car

3. Ambulance

/___/

Reason fo radmission

1. Pallor

2. Seizure

3. Coma

4. Agitation

5. Fever

6. Respiratory distress

7. Digestive disorders

8. Icterus

9. Edema

/___/

10. Anxiety

11. Headache

12. Delirium

13. Inability to drink

14. Ostéo-articular pain

15. Others (specify)

Onset of symptoms before admission

Assessment before admission

1. Hémoglobin level………….

2. Hématocrit………….

3. VGM ……………

4. MCHC ………….

5. NB ……………

6. TDR ………….

7. GE/DP …………….

Personal history

Low birth weight

1. Yes

2. No

/___/

Febrile seizure

1. Yes

2. No

If yes, specify the age of the 1st attack /___/

/___/

Epilepsy

1. Yes

2. No

/___/

Vaccination status not up to date

1. Yes

2. No

/___/

Growth retardation

1. Yes

2. No

/___/

Family history

Father

1. Epilepsy

2. Febrile seizure

3. Other (specify)

/___/

Mother

/___/

Siblings

/___/

Physical examination

Weight (Kg)

Size (cm)

Pallor

1. Not

2. Moderate

3. Severe

/___/

Respiratory distress

1. Yes

2. No

/___/

Coma

1. Yes

2. No

/___/

If coma, specify

Blantyre score = /5 or Glasgow score = /15

Kernig sign

1. Yes

2. No

/___/

Brudzinski sign

1. Yes

2. No

/___/

Tachycardia

1. Yes

2. No

/___/

Dehydration

1. Yes

2. No

/___/

Jaundice

1. Yes

2. No

/___/

Edeme

1. Yes

2. No

/___/

Other

Description of the seizure

Duration

1. Less than 15 min

2. More than 15 min

/___/

Number

1. One during 24 h

2. Recurrent in 24 h

/___/

Type

1. Partial

2. Généralized

3. Rolling eyes

4. Clonic

5. Tonic

6. Tonic-clonic

/___/

Post-critical anomaly

1. Coma (score)

2. Hemiplegia

3. Strabismus

4. None

/___/

Other

Extra-neurological signs

ENT infection

1. Yes

2. No

/___/

Digestive infection

1. Yes

2. No

/___/

Pneumonia

1. Yes

2. No

/___/

Other

Paraclinical parameters

GE/DP

1. Yes

2. No

If, yes DP =

/___/

Lumbar punction

1. Clear

2. Trouble

3. Hématic

4. PL not done

5. If, PL done, specify CSF ECB results:

/___/

· GR =

· GB =

· Germes =

· Glycorrachie

Proteinorrachie

NFS

· Hb =

· Hte =

· VGM =

· TCMH =

· CCMH =

· NB =

· PNN =

· Lympho =

CRP

EEG

Hemoglobin electrophoresis

Fond d’œil

Others

Cause of fever

Treatment

Treatment before admission

1. Yes

2. No

/___/

Traditional treatment

1. Yes

2. No

If yes, specify:

/___/

Modern treatment

1. Yes

2. No

If yes, specify:

· Nature:

· Dose:

· Duration:

· Place:

/___/

Treatment during hospitalization

Antipyretics

1. Yes

2. No

/___/

Valium

1. 1 times

2. 2 times

3. 3 times

4. No

/___/

Gardenal

1. Yes

2. No

/___/

Rivotril drops

1. Yes

2. No

/___/

Etiological treatment of fever

Immediate recurrence

1. Yes

2. No

If yes, the number:

EVOLUTION

Duration of hospitalization

Healing without sequelae

1. Yes

2. No

/___/

Recovery with sequelae

1. Yes

2. No

If yes, specifyr:

/___/

Exit against medical advice

1. Yes

2. No

/___/

Evasion

1. Yes

2. No

/___/

Transfer

1. Yes

2. No

/___/

Death

1. Yes

2. No

/___/

If death, specify

1. Before treatment

2. Despite the well-conducted treatment

3. During the first hour of hospitalization

4. During the 2nd hour of hospitalization

5. During the 3rd hour of hospitalization

6. During the 24 hours of hospitalization

7. During the 48 hours of hospitalization

8. After 48 hours of hospitalization /___/

/___/