LAMPIRAN 2
FORMAT SIASATAN KES IBU HAMIL HIV POSITIF
NEGERI KEDAH DARUL AMAN
BIODATA
IBU HAMIL SUAMI / PASANGAN
NAMA
UMUR
BANGSA / WARGANEGARA
(JK WNA)
GRAVIDA / PARITI
LNMP / EDD
PEKERJAAN
TARIKH SARINGAN HIV
TARIKH PENGESAHAN HIV
FAKTOR RISIKO JANGKITAN
HIV
TARIKH NOTIFIKASI
**STATUS HIV ( NYATAKAN)
SEJARAH KEHAMILAN IBU (CURRENT PREGNANCY)
TARIKH POA CATATAN
BOOKING
RAWATAN ARV ( & NAMA
UBAT)
CD4 COUNT SEBELUM /
SEMASA MENGANDUNG
VIRAL LOAD
PELAN JAGAAN IBU
ANTENATAL
RUJUKAN KEPADA
FMS
F/UP DI KLINIK
ANTENATAL
RUJUKAN KE ID
COMPLIANCE
TERHADAP
RAWATAN & F/UP
KAUNSELING SEX
SELAMAT ,
PEMBERIAN
CONDOM
MASALAH YANG -
DIKENALPASTI &
PENGENDALIAN
PENGENDALIAN SUAMI / PASANGAN
TARIKH MASALAH YANG DIKENALPASTI PENGENDALIAN MASALAH &
CATATAN
UJIAN-UJIAN LAIN
UJIAN IBU HAMIL SUAMI / PASANGAN CATATAN
HEPATITIS B
HEPATITIS C
HIV
HVS C&S
GC SMEAR
VDRL / TPHA
TOXO IGG
SPUTUM AFB
CXR
OGTT/FBS
HB
LFT
RENAL FUNCTION
KELAHIRAN / MAKLUMAT PENGENDALIAN BAYI
NAMA BAYI
NO MYKID /JANTINA / BERAT LAHIR
MODE OF DELIVERY
TEMPAT KELAHIRAN
INTRAPARTUM AZT
PELAN JAGAAN
ARV (RAWATAN) KETIKA DISCAJ
FEEDING REPLACEMENT
STATUS HIV
PCR 1 (TARIKH & KEPUTUSAN)
PCR 2 (TARIKH & KEPUTUSAN)
PCR 3 (TARIKH & KEPUTUSAN)
PEMBERIAN IMUNISASI
PEMBERIAN PROFILAKSIS BACTRIM
JAGAAN IBU LEPAS BERSALIN
RUJUKAN KE PPHIV / ID LINIC
STATUS RAWATAN ARV
ISONIAZID PROFILAKSIS (IPT)
KONTRASEPTIF
SOKONGAN SOSIAL
PENGENDALIAN KONTAK ( ANAK-ANAK, DLL)
RUJUKAN KEPADA DR
UJIAN HIV & KEPUTUSAN
IMUNISASI
KELEMAHAN DALAM PENGENDALIAN
LAMPIRAN 3
FORMAT SIASATAN KES IBU HAMIL TPHA POSITIF
NEGERI KEDAH DARUL AMAN
MOTHER’S HISTORY
NAME
AGE
RACE/NATIONALITY
GRAVIDA / PARITY
LNMP / EDD
JOB
PROBLEM IDENTIFIED
HIV STATUS
RISK FACTOR FOR SYPHILIS
DATE OF NOTIFICATION FOR SYPHILIS
SYPHILIS STATUS
CLINICAL STAGING
DATE POA CATATAN/REGIME
BOOKING
RPR TEST
RPR RESULT
TPPA/TPHA TEST
TPPA/TPHA RESULT
TREATMENT 1 ST DOSE
TREATMENT 2ND DOSE
TREATMENT 3RD DOSE
RESULT
DATE POA NOTES
/REGIME
RPR TEST 1 MONTH POST TREATMENT
RPR RESULT 2 MONTH POST TREATMENT
RPR RESULT 3 MONTH POST TREATMENT
RPR RESULT 4 MONTH POST TREATMENT
TREATMENT 2ND CYCLE
TREATMENT 1 ST DOSE
TREATMENT 2ND DOSE
RAWATAN 3RD DOSE
RPR TEST 1 MONTH POST 2ND CYCLE OF TREATMENT
RPR TEST 2 MONTH POST 2ND CYCLE OF TREATMENT
RPR TEST 3 MONTH POST 2ND CYCLE OF TREATMENT
RPR TEST BEFORE DELIVERY
OTHERS
TEST RESULTS
HEPATITIS B
HEPATITIS C
HIV
HVS C&S
GC SMEAR
TOXO IGG
SPUTUM AFB
CXR
OGTT/FBS
HB
LFT
RENAL FUNCTION
OTHERS
FATHER’S HISTORY
NAME
AGE
RACE/NATIONALITY
JOB
HIV STATUS
DATE OF RPR /TPHA
RESULT RPR / TPHA
DATE OF TREATMENT
TREATMENT REGIME
CHILD’S HISTORY
NAME
CHILD'S IDENTIFICATION
DATE OF DELIVERY / POA
BIRTH WT/ TYPE OF DELIVERY
DELIVERY OUTCOME
DATE OF RPR /TPHA AT DELIVERY
RESULT RPR / TPHA AT DELIVERY
DATE OF TREATMENT
TREATMENT REGIME
CLINICAL SIGNS FOR CONGENITAL
SYPHILIS
CHILD’S INVESTIGATIONS
TEST DATE RESULT
LONG BONE X RAY
CSF- VDRL
CSF-WBC
WBC/ PROTEIN COUNT
RPR 3RD MONTH
RPR 6TH MONTH
RPR 8TH MONTH
RPR 12TH MONTH
RPR 18TH MONTH
RPR 25TH MONTH
CASE CLASSIFICATION
(EG. NOT A CASE /
CONFIRMED CASE / PROBABLE CASE /
SYPHILITIC STILLBIRTH) OTHERS
SORT FALL & CONCLUSION
