Variables | Modalities | Choice | ||
General informations | ||||
Age (month): |
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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 |
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Admission mode | 1. Referred 2. Not referred | /___/ | ||
If referred, specify the referral center |
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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) |
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Onset of symptoms before admission |
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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) |
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Size (cm) |
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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 |
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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 |
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Extra-neurological signs | ENT infection | 1. Yes 2. No | /___/ | |
Digestive infection | 1. Yes 2. No | /___/ | ||
Pneumonia | 1. Yes 2. No | /___/ | ||
Other |
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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 |
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NFS | · Hb = · Hte = · VGM = · TCMH = · CCMH = · NB = · PNN = · Lympho = | |||
CRP |
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EEG |
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Hemoglobin electrophoresis |
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Fond d’œil |
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Others |
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Cause of fever |
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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 |
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Immediate recurrence | 1. Yes 2. No If yes, the number: |
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EVOLUTION | ||||
Duration of hospitalization |
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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 /___/ | /___/ | ||