Download Paediatric Crohn`s disease Activity Index

Paediatric Crohn’s disease
Activity Index
1 Week ending
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for (patient’s full name)
years Sex
Age
Male
Female
Each parameter in this table must be assigned a value.
Score
Abdominal pain
No abdominal pain
Mild; no interference with Activities of Daily Living (ADL)
Moderate/severe; daily, nocturnal, interferes with ADL
0
5
10
Stools/day
0–1 liquid, no blood
≤ 2 semi-formed + small blood or 2–5 liquid
≥ 6 liquid stools, gross blood, or nocturnal diarrhoea
0
5
10
General function
Well, no limitations of activities
Below par, occasional difficulty with activities
Very poor, frequent limitation of activities
0
5
10
Weight gain (or voluntarily stable/reduction)
Weight loss < 10% (or involuntarily stable)
Weight loss ≥10%
0
5
10
< 1 channel decrease from previous percentile
1 to < 2 channel decrease from previous percentile
≥ 2 channel decrease from previous percentile
or
≤ -1 standard deviation from normal
-1 to < -2 standard deviation from normal
≥ -2 standard deviation from normal
0
5
10
Abdomen
No tenderness or mass
Tenderness, or mass without tenderness
Tenderness, involuntary guarding, definite mass
0
5
10
Peri-rectal disease
None, asymptomatic tags
1–2 indolent fistula, scant drainage, non-tender
Active fistula, drainage, tenderness, or abscess
0
5
10
Extra-intestinal†††
None
1 manifestation
≥ 2 manifestations
0
5
10
Examination
Weight
Height† (at diagnosis)
Height velocity††
0
5
10
Laboratory
M/F 6–10 years: ≥ 33
M 11–14 years: ≥ 35
F 11–19 years: ≥ 34
M 15–19 years: ≥ 37
M/F 6–10 years: 28–32
M 11–14 years: 30–34
F 11–19 years: 29–33
M 15–19 years: 32–36
M/F 6–10 years: < 28
M 11–14 years: < 30
F 11–19 years: < 29
M 15–19 years: < 32
2.5
ESR (mm / hr)
< 20
20–50
> 50
0
2.5
5
Albumin (g / L)
≥ 35
31–34
≤ 30
0
5
10
TOTAL
PCDAI
SCORE
Haematocrit (%)
M = Male
F = Female
† Height-channel represents lines on the standard
†† Height velocity is calculated from measurements
below (minus to) normal
†††
0
5
percentile chart eg 10 – > 25 – > 50 percentile is 2 channels difference
over last 6–12 months in cm / year compared to standard deviation
Extra-intestinal implies fever of > 38.5ºC over 3 days over last week, arthritis, uveitis, Erythema nodosum or Pyoderma gangrenosum
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• the information I have provided in this form is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
Prescriber’s full name
Prescriber’s signature
Date
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PB090.1503 (formerly 4197)
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