Infectious Diseases & Tropical Medicine
Tropical & infectious disease note template
A febrile-illness note built for endemic practice. It forces an explicit differential, records the diagnostic modality and its result in full, keeps weight-banded regimens and day-of-therapy intact, and prompts notification when the working diagnosis is reportable.
Best used for
- Undifferentiated fever clinics
- Malaria and enteric fever management
- Viral haemorrhagic fever screening
- TB DOTS treatment monitoring
Template structure
Each section shows what to document and a worked clinical example.
Fever duration and pattern, associated symptoms, drugs already taken (including unprescribed anti-malarials), and the exposure history that drives the differential: travel, rodent or bushmeat contact, contact with a person who bled or died of a febrile illness, mosquito net use, water source, known TB contact, and pregnancy status.
Example
Four days of fever with chills, headache and body pains. Two doses of unprescribed artemether-lumefantrine taken at home with no improvement. No travel outside the state, no rodent contact, no contact with a person who bled. Sleeps under a treated net most nights. Not pregnant, LMP three weeks ago.
Full vital signs, hydration and perfusion, pallor, jaundice, rash, bleeding from gums or puncture sites, splenomegaly, chest and abdominal findings. Record every diagnostic with its modality, specimen, result and quantity — RDT antigen target, thick and thin film species and parasite density, GeneXpert result with rifampicin resistance, blood culture sent, PCV, LFTs.
Example
T 39.2 C, HR 108, BP 106/68, RR 20, SpO2 98%. Mildly pale conjunctivae, no jaundice, no rash, no bleeding from gums or puncture sites. Spleen not palpable. mRDT positive (P. falciparum HRP2). Thick film: P. falciparum, 12,000 parasites/uL. PCV 31%. Blood culture sent.
Name the condition, its severity classification (uncomplicated versus severe malaria, drug-sensitive versus resistant TB), and the differentials still active with the test that will settle them. State explicitly whether viral haemorrhagic fever danger signs and epidemiological exposure were present or absent — that sentence is what protects the next clinician and the isolation decision.
Example
Uncomplicated Plasmodium falciparum malaria in a non-pregnant adult with mild anaemia. Enteric fever remains an active differential pending blood culture. No VHF danger signs and no epidemiological exposure elicited.
Give the regimen with drug, dose, weight band, frequency, total duration and today's day of therapy. Record which dose was observed in clinic. Add explicit return-immediately criteria in the patient's own terms, the review interval, and — where the diagnosis is notifiable under IDSR or national guidance — the notification made and to whom.
Example
Artemether-lumefantrine 80/480 mg twice daily for 3 days, day 1 of 3, first dose observed with fatty food. Paracetamol 1 g 6-hourly PRN. Return immediately for repeated vomiting, confusion, dark urine, bleeding or inability to drink. Review in 72 hours; if still febrile, treat as suspected enteric fever pending culture and re-screen VHF exposure. Not notifiable at present; reassess if culture or VHF screen changes the diagnosis.
Documentation tips
- Never write 'malaria positive' alone — record the test used, the species and the parasite density, because they change treatment and follow-up.
- Document the absence of VHF danger signs and exposures as deliberately as their presence; in outbreak settings that sentence is the audit trail.
- For TB, always record the regimen phase and the month of therapy, plus sputum conversion status at months 2, 5 and 6.
- Anti-malarial and anti-TB dosing is weight-banded — record the weight you dosed from, not just the dose.
- If the diagnosis is notifiable, put the notification in the plan; a note that supports surveillance is worth more than a report written from memory.
Frequently asked questions
- Which conditions is this template designed for?
- Malaria, enteric (typhoid) fever, tuberculosis, Lassa and other viral haemorrhagic fevers, cholera and acute watery diarrhoea, meningitis, measles, dengue and chikungunya, schistosomiasis and soil-transmitted helminths, and HIV with its opportunistic infections.
- Why does the template insist on parasite density?
- Density guides severity assessment and follow-up, and a repeat film only means something when the first one carried a number. 'Positive' alone cannot be compared to anything.
- How does it handle notifiable diseases?
- The plan section carries a notification line whenever the assessment names a reportable condition. The clinician makes the report; the note is the source document that supports it.
- Can ScribeMDPro draft this note from a consultation in Yoruba, Hausa or Swahili?
- Yes. The consultation is transcribed in the language spoken, dialect adapters handle local phrasing, and the structured note is drafted in clinical English for your review and signature.
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