ARV Baseline Assessment (Doctor) Free State H314 Print Form Pediatric HIV Care and Treatment Programme Treatment Site and Patient Information Date Encounter number Treatment Site Referring Assessment Site Date of Birth Patient's Full Name Yes Barcode for Blood Tests Female Male Site File No. ID No. No Persal No. HIV History Previous ARV Exposure: HIV first diagnosed From Where Transferred in or Private MTCT Nevirapine MTCT AZT None ---- Was Previous treatment Other (if yes, complete Innapropriate Appropriate Indicate previous ARV's taken: DRUG DURATION DRUG DURATION DRUG DURATION 3TC (Lamivudine) (months) NVP (Nevirapine) (months) Ritonavir (months) D4T (Stavudine) (months) AZT (Zidovudine) (months) Ritonavir/Lopnavir (Kaletra) (months) EFV (Efavirenz) (months) ddI (Didanosine) (months) Other 1 (months) Other 2 (months) ABC (Abacavir) Fluconazole Hospitalisation in last 6 months: No Yes if yes how many times? Pre-treatment CD4 result % Date (Choose all that apply) Opportunistic Infection Prophylaxis: Cotrimoxazole cells/ul If yes, give value Pre-treatment CD4 known? INH Dapsone Prophylaxis Discontinued None of These Reason(s): Hospitalisation 1 Date Duration (nights) Hospitalisation 2 Date Duration (nights) Hospitalisation 3 Date Duration (nights) (cells/ul) / % Date www.fs.gov.za Part 2: Clinical Stageing Stage 3: Stage 1: Asymptomatic Moderate unexplained malnutrition not adequate responding to standard therapy Persistent generalized Lymphadenopathy Unexplained persistent diarrhoea (14d or more) Unexplained persistent fever (intermittentor constant for longer than one month) Stage 2: Hepatosplenomegaly Oral candidiasis (outside neonatal period) Papular pruritic eruptions Oral hairy leukoplakia Seborrhoeic dermatitis Acute necrotizing ulcerative Gingivitis / periodontitis Extensive human papilloma virus infection Pulmonary TB Extensive molluscum contagiosum Severe recurrent presumed Bacterial pneumonia Fungal nail infection Recurrent oral ulcerations Unexplained anaemia (<8g/dl), and or neutropenia (<500/mm3) and thrombocytopenia (<50 000/mm3) for more than one month Lineal gingival erythema (LGE) Chronic HIV-associated lung disease including bronchiectasis Angular cheilitis Symptomatic lymphoid interstitial pneumonitis (LIP) Parotid enlargement Herpes Zoster Recurrent or chronic RTI's (otitis media, otorrhoea, sinusitis) Stage 4: Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy HIV Encephalopathy CMV infection (CMV retinitis or infection of organ other than liver, spleen or lymph nodes onset at the age one month or more) Pneumocystis Pneumonia Recurrent severe presumed bacterial infections (eg empyema, pyomyositis,bone or joint infection, meningitis exc. pneumonia Chronic herpes simplex infection (orolabial or cutaneous for more than one month's duration) Extrapulmonary cryptococcosis including meningitis Any disseminated endemic mycosis (e.g. extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis) Cryptosporidiosis Extrapulmonary TB Isosporiasis Kaposi's sarcoma Disseminate non-TB mycobacteria infection Oesophageal candidiasis Candida of trachea, bronchi or lungs CNS Toxoplasmosis (outside the neonatal period) Visceral herpes simplex infection Acquired HIV-associated rectal fistula Cerebral or B cell non-Hodgkins lymphoma Progresive multifoca leukoencephalopathy HIV-associated cardiomyopathy or HIV-associated nephropathy TB History Previous TB Treatment 1 (months) If Yes, how many times treated? Treatment 2 (months) TB Status (choose one) If yes, months On TB Treatment---------- Was Sputum sent? TB Symptoms No TB Treatment & no symptoms Mantoux Pos Yes No Sputum 1 pos neg Sputum 2 Neg www.fs.gov.za Physical Examination Temperature oC Blood Pressure / Weight kg Features Pripheral Neuropathy beats/min Pulse Rate mmHG Height Yes cm BSA m2 No Plan ARV Treatmen: Delay ARV's Start Drug Readiness Training Start ARV's Delay ARV's: Give reasons (Choose all that apply) Acute TB < 2 nonths treatment TB not yet excluded Acute Illness ---------- give details Other ------------- give details Baseline Investigation Done: Investigation: Results: Date: CD4 Mantoux Sputum for AFB FBC/Hb Triglycerides Random Glucose ALT Viral load Random Cholesterol CXR U and E Follow up Appointment ARV start date Encounter Created by Date Captured: Data Captured by: www.fs.gov.za