Case Investigation Form
Severe Acute Respiratory Infection (SARI)
(ICD 10 Code: J22)
Name of DRU:
Address:
Type:
RHU
CHO
Gov't Hospital
Private Hospital
Clinic
Gov't Laboratory
Private Laboratory
Airport/Seaport
Source:
Surveillance
Outbreak
I. PATIENT INFORMATION
Find
Patient Number:
Patient's Last Name
First Name:
Middle Name:
Current Address:
Sex:
Male
Female
Date of Birth:
Age:
Days
Months
Years
Permanent Address:
Civil Status:
Name of workplace :
Occupation:
Address of workplace:
II. HISTORY OF ILLNESS, PHYSICAL EXAMINATION AND PRE-EXISTING CONDITIONS
Admitted?
Yes
No
Unknown
Date Admitted:
Date Onset of Illness
Did you take any of the following medication(s) prior to consultation?
Ranitidine (e.g. Flumadine)
Amantidine
Zanamivir
Oseltamivir (e.g. Tamiflu)
Other, Specify:
Are there any influenza-like-illness during the week in your:
Household
Yes
No
Unknown
School/Daycare
Yes
No
Unknown
Did you received Anti-influenza Vaccination in the past year?:
Yes
No
Unknown
History of exposure to any of the ff:
Bats
Camels
Horses
Poultry/Migratory Birds
Pigs
Others, Specify:
History of travel:
Yes
specify country:
No
Chest X-ray
Done
Not Done
Result:
Signs and Symptoms:
Temperature at consultation:
°C
Fever/Feverish
Duration:
days/weeks
Headache
Cough
Sore throat
Difficulty of breathing
Others: (please specify)
SARI Suspect Case for Patients <5 years old and EITHER ONE to two IMCI criteria for pneumonia
1. IMCI Criteria for pneumonea:
Any 2 months to 5 years of age with cough or difficulty in breathing
Breathing faster than 60 breaths/min (infants <2 months)
Breathing faster than 50 breaths/min (2-12 months )
Breathing faster than 40 breaths/min (1-5 years old )
Requires hospital admission
2. IMCI Criteria for severe pneumonia:
Any child 2 months to 5 years of age with cough or difficult breathing
With any of the following danger signs:
Unable to drink of breastfeed
Vomits everything
Convulsions
Lethargic or unconscious
Chest Indrawing or stridor in a calm child
Requires hospital admission
Pre-existing Conditions
Asthma
Chronic cardiac disease
Chronic liver disease
Chronic neurological or neuromuscular disease
Chronic renal disease
Diabetes
Haematologic disorders
Immunodeficiency disease
Pregnancy
Clinical Impressions:
Influenza-like-illness (ILI)
SARI
Others, Specify
III. LABORATORY TESTS:
Specify Specimen
If YES, date taken
Type of laboratory test done
Results
N=Negative; I=Indeterminate; U=Unknown
Date Result
Positive for:
N
I
U
Positive for:
N
I
U
IV. CLINICAL MANAGEMENT AND OUTCOME:
Antibiotics
Yes
No
Unknown
If Yes, please specify
Bacterial Testing
Yes
No
Unknown
If Yes, please specify
Antivirals
Yes
No
Unknown
If Yes, please specify
Other Therapeutic Procedures
Yes
No
Unknown
If Yes, please specify
Fluid Therapy
Yes
No
Unknown
If Yes, please specify
Final Diagnosis
Oxygen
Yes
No
Unknown
If Yes, please specify
Outcome at Discharge
Alive
HAMA
Died
Others
Intubation
Yes
No
Unknown
If Yes, please specify
Date of Discharge
Others
CASE DEFINITION/CLASSIFICATION:
INFLUENZA-LIKE-ILLNESS (ILI)
Suspected Case:
A person with acute respiratory infection, with measured fever of
≥ 38 °C and cough with onset within the last 10 days
Probable Case:
Not applicable
Confirmed Case:
A suspected case that is laboratory-confirmed (used mainly in epidemiological investigation rather than surveillance).
SEVERE ACUTE RESPIRATORY INFECTION (SARI)
SARI Suspect Case for Persons > 5 years old:
An acute respiratory infection with:
History of fever or measured fever
≥ 38 °C;
and cough;
with onset within the last 10 days;
and requires hospitalization
WITH difficulty of breathing; OR
A suspect case of severe undiagnosed pneumonia, Acute Respiratory Distress Syndrome, Severe Respiratory Disease due to Novel Respiratory Pathogens
SARI Suspect Case for Patients <5 years old:
EITHER:
IMCI criteria for pneumonia
Any child 2 months to 5 years of age with cough or difficult breathing, AND:
Breathing faster than 60 breaths/min (infants < 2 months)
Breathing faster than 50 breaths/min (2-12 months)
Breathing faster than 40 breaths/min (1-5 years old)
OR
IMCI criteria for severe pneumonia
Any child 2 months to 5 years of age with coughor difficult breathing and any of the following danger signs:
Unable to drink or breastfeed
Vomits everything
Convulsions
Lethargic or unconscious
Chest indrawing or stridor in a calm child
AND
Requires hospital admission
NOTE
The requirement of “hospital admission” is meant to imply that in the judgment of a treating clinician the patient has an illness that is severe enough to require inpatient medical care.
“Shortness of breath or difficulty breathing” is intended to capture dyspnea or air hunger. This does not refer to nasal congestion or other upper airway obstruction.
“History of fever’ does not require a history of documented fever and may include a patient’s subjective report of having a fever or feeling “feverish”.
SARI may reflect a new illness superimposed on an underlying condition or older illness
SARI is not equivalent to classic pneumonia
and would not always present as pneumonia. It is expected that much of the severe respiratory disease associated with influenza would be due to exacerbations of chronic lung disease or heart disease, for example, and would not include an admitting diagnosis of pneumonia.
PROBABLE CASE
A person fitting the definition above of a “Suspect Case” with clinical, radiological, or histopathological evidence of pulmonary parenchyma disease (e.g. pneumonia or ARDS) but no possibility of laboratory confirmation either because the patient or samples are not available or there is no testing available for other respiratory infections, AND
Close contact with a laboratory confirmed case, AND
Condition not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia according to local management guidelines.
Confirmed Case:
A suspected case that is laboratory-confirmed.
Deliberately providing false or misleading, personal information on the part of the patient, or the next kin incase of patient's incapacity, may constitute non-cooperation punishable under the Republic Act No. 11332
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