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At the start of a sick child (2 months to 5 years) consultation
• Ask the mother what the child’s problems are.
• Determine if this is an initial or follow-up visit for this problem.
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IMCI Case Management
Danger signsMain Symptoms
Nutritional statusImmunization status
Other problems
Need to Refer
Specific treatment
Homemanagement
ClassificationFocused
Assessment
Identify treatmentTreat
Counsel caretakersFollow-up
Treatment
Counsel & Follow-up
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Check for general danger signs
Ask:• Not able to drink or
breastfeed,• Vomits everything, • Convulsions, orLook:• Abnormally sleepy or difficult
to awakenNeed to Refer
(except in severe dehydration)
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Ask about the main symptoms
• Cough or difficulty in breathing
• Diarrhea• Fever• Ear problem
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Cough or difficulty in breathing
Ask:• For how long?Look:• Count RR• Chest indrawing• Stridor
The child must be
calm.
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SEVERE PNEUMONIA OR VERY SEVERE DISEASE
1st dose of antibiotic Vitamin A Breastfeeding/sugar water URGENT REFERRAL
Any general danger sign or Chest indrawing or Stridor
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PNEUMONIA
Antibiotic for 5 days Relieve cough with safe remedy Advise mother on danger signs Follow up in 2 days
Fast breathing2 – 12 months old: ≥ 50/minute1 year or older: ≥ 40/minute
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NO PNEUMONIA: COUGH OR COLD
If cough ≥ 30 days refer to hospital for assessment
Relieve cough with safe remedy Advise mother on danger signs Follow up in 5 days if no improvement
No signs of pneumoniaor a very severe disease
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Diarrhea: Classify
For dehydration
Persistent diarrhea
Blood in the stool
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SEVERE DEHYDRATION
2 or more of the following: Abnormally sleepy/difficult to wake Sunken eyes Not able to feed/drinking poorly Skin pinch goes back very slowly
Classify for dehydration
Plan C
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IV treatment within 30 minutes
IV fluid: LRS 100 ml/kg body weight(in 6 hrs for infants; 3 hrs for children)
Plan C: To treat dehydration quickly
NO
NO
Oresol/NGT
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Oresol p.o.
Plan C: To treat dehydration quickly
NO
NO
Oresol/NGT
URGENT REFERRAL
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SOME DEHYDRATION
2 of the following: Restless, irritable Sunken eyes Drinks eagerly, very thirsty Skin pinch goes back slowly
Classify for dehydration
Plan B
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Age < 4 mos 4-12 mosAmount 200-400 400-700
Determine the amount (in ml) of Oresol to be given in 4 hours
= weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Plan B: Treat some dehydration with ORS
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Age 12 mos-2 yrs
2-5 yrs
Amount 700-900 900-1400
Determine the amount (in ml) of Oresol to be given in 4 hours
= weight of the child (in kg) X 75, or if weight is unknown, use this chart.
Plan B: Treat some dehydration with ORS
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Show the mother how to give Oresol to the child: frequent sips from a cup
If the child vomits, wait for 10 minutes.Then continue, but more slowly.
Continue breastfeeding if the child wants to breastfeed.
If the child develops puffy eyelids, stop ORS.
Plan B: Treat some dehydration with ORS
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After 4 hours: Reassess the child & classify for
dehydration. Select appropriate plan. Begin feeding the child in the health
center.
Plan B: Treat some dehydration with ORS
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NO DEHYDRATION
Not enough signs to classify as SEVERE DEHYDRATION orSOME DEHYDRATION
Classify for dehydration
Plan A
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Give extra fluid.
Plan A: Treat diarrhea at home
Up to 2 yrs
50 – 100 ml after each LBM
2 -4 yrs 100 – 200 ml after each LBM
Continue feeding. Know when to return.
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Persistent diarrhea: 14 days or more
• Treat dehydration• Give Vitamin A• Refer to hospital
+ Dehydration=severe persistent diarrhea
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Persistent diarrhea: 14 days or more
• Advise regarding feeding
• Give Vitamin A• Follow up in 5 days
No dehydration=persistent diarrhea
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Blood in the stool = dysentery
• Oral antibiotic for shigella for 5 days
• Follow up in 2 days
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Fever: (history/temperature 37.5°C or above)
Malaria risk?
Measles now or w/in last 3 mos
Dengue risk?
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Fever: Ask about malaria risk
• Residing in endemic area?OR:• Travel & overnight
stay in endemic area, or• Blood transfusion
w/in past 6 mos
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Malaria risk +
• Blood smear• Ask: Duration of fever?
Present everyday?• Look: Stiff neck
Runny noseOther signs of
measles
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Malaria risk + any general danger sign or stiff
neck
• Quinine (under med. supervision)
• 1st dose of antibiotic, Paracetamol
• Urgent referral
Very severe febrile disease/malaria
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Malaria risk +, blood smear +No runny nose, no measles
• Oral antimalarial• Paracetamol• Follow up in 2 days• > 7 days fever hospital for
assessment
Malaria
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No malaria riskAny general danger sign or stiff
neck
• 1st dose of antibiotic, Paracetamol
• Urgent referral
Very severe febrile disease
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Measles now or w/in last 3 mosClouding of cornea or
Deep or extensive mouth ulcers
• 1st dose of antibiotic, Vitamin A• Urgent referral
Severe complicated measles
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Measles now or w/in last 3 mosPus draining from the eye or
Mouth ulcers
• Vitamin A• Tetracycline eye
ointment• Gentian violet• Follow up in 2 days
Measles with eye orMouth complications
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Measles now or w/in last 3 mosNo other signs
Vitamin A
Measles
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If there is Dengue risk
Bleeding gums, nose, in vomitus or stools
Black vomitus or stoolsPersistent abdominal painPersistent vomitingSkin petechiaeSlow capillary refillNo signs, but fever > 3 days
Tourniquet test
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Slow capillary refill• Indicates poor skin perfusion• Press down firmly with your
finger on the sternum for 5 seconds and release. (Alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds.
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Any of the danger signsor + tourniquet test
• If skin petechiae, persistent abdominal pain or vomiting, or + tourniquet test only signs, give ORS
• Any other signs of bleeding Plan C
• Urgent referral• Do not give aspirin
Severe Dengue hemorrhagic fever
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Ear problem:tender swelling behind ear
• 1st dose of antibiotic• Paracetamol for pain• Urgent referral
Mastoiditis
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Ear discharge < 14 days orEar pain
• Antibiotic for 5 days• Paracetamol for pain• Wicking• Follow up in 5 days
Acute ear infection
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Ear discharge for 14 days or more
• Wicking• Follow up in 5 days
Chronic ear infection
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Visible severe wasting or Edema on both feet orSevere palmar pallor
• Vitamin A• Urgent referral
Severe malnutrition or severe anemia
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Some palmar pallor orVery low weight for age
• Assess for feeding problem• Pallor: iron & Mebendazole in
children > 2 yrs• Wt for age very low: Vitamin
A
Anemia or very low weight for age