NONCARDIAC
No
Yes
Unknown
Arthralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Aseptic meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Gall bladder hydrops . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Hearing loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Hepatitis or hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Iritis or uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Meatitis or sterile pyuria . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Myalgia or myositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Other (specify): _______________________________
0
■■
1
■■
9
■■
CARDIAC
No
Yes
Unknown
Coronary artery aneurysms
diameter of aneurysm: ______mm
0
■■
1
■■
9
■■
Other aneurysms (specify): __________________________
0
■■
1
■■
9
■■
Coronary artery dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Aortic regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Congestive heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Mitral regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Myocardial ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Myocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Pericarditis or pericardial effusion . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
A. EKG
0
■■
1
■■
2
■■
3
■■
4
■■
9
■■
______
__ __
/
__ __
/
__ __ __ __
B. ECHO
0
■■
1
■■
2
■■
3
■■
4
■■
9
■■
______
__ __
/
__ __
/
__ __ __ __
C. ANGIOGRAM
0
■■
1
■■
2
■■
3
■■
4
■■
9
■■
______
__ __
/
__ __
/
__ __ __ __
(Yrs) (Mo.)
No
Yes
Unknown
2. Oral mucosal changes (erythema of lips or oropharynx, . .
0
■■
1
■■
9
■■
strawberry tongue, or drying or fissuring of the lips)
3. Peripheral extremity changes (edema, erythema, . . . . . . .
0
■■
1
■■
9
■■
or generalized or periungual desquamation)
4. Rash
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
5. Cervical lymphadenopathy
>
1.5 cm diameter
. . . . . . . . .
0
■■
1
■■
9
■■
No
Yes
Unknown
Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
Date of fever onset :
Number of days febrile: ___ ___
Fever
>
5 days . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
1. Bilateral conjunctival injection . . . . . . . . . . . . . . . .
0
■■
1
■■
9
■■
1
■■
Hispanic/Latino
0
■■
Not Hispanic/Latino
0
■■
NO
1
■■
YES
9
■■
Unk
__ __
/
__ __
/
__ __ __ __
(mm/dd/yyyy)
__ __
/
__ __
/
__ __ __ __
(mm/dd/yyyy)
Kawasaki Syndrome Case Report
8. DOES THE PATIENT HAVE RECURRENT
KAWASAKI SYNDROME?
IF YES, list onset date of prior
Kawasaki Syndrome episode:
5. Was the patient
hospitalized?
Please fill in the blank or check the answer for each question
– PATIENT INFORMATION/DEMOGRAPHICS –
Patient's Initials:
Residence:
City:
County:
State:
Age at Onset:
Date of Birth:
Form Approved
OMB 0920-0009
CDC CASE#
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
2. Race:
1. Ethnicity:
(25)
3. Sex:
(58-59)
(5-7)
(13-14)
(8-10)
(11-12)
(15-16)
– CLINICAL OUTCOMES –
– SIGNS,SYMPTOMS, AND DIAGNOSTIC CRITERIA –
– CARDIAC STUDIES –
TREATMENT:
REPORTED BY:
PLEASE MAIL COMPLETED FORM TO:
0
■■
NO
1
■■
YES
9
■■
Unk
5
■■
3
■■
2
■■
4
■■
American Indian/Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
9
■■
Unk
9
■■
Unk
1
■■
White
6
■■
Other
9
■■
Unk
1
■■
Male
2
■■
Female
(First, Middle, Last)
(50-51)
(52-53)
(54-57)
(74-75)
(76-77)
(78-81)
(90-91)
(92-93)
(94-97)
(106-107) (108-109)
(110-113)
(41-42)
(43-44)
(45-48)
__ __
/
__ __
/
__ __ __ __
(28-29)
(30-31)
(32-35)
(17-18)
(19-20)
(21-24)
(1-4)
4. Date of Onset
of Symptoms:
7. Outcome:
9.
10.
11.
12.
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).
__ __
/
__ __
/
__ __ __ __
________________ ___ ___ ___
_________________ ___ ___
(mm/dd/yyyy)
(mm/dd/yyyy)
(27)
(36)
(39)
(49)
(60)
(61)
(62)
(64)
(63)
(65)
(40)
0
■■
NO
1
■■
YES
9
■■
UNK
0
■■
NO
1
■■
YES
9
■■
UNK
__ __
/
__ __
/
__ __ __ __
(mm/dd/yyyy)
(136-137) (138-139)
(140-143)
(135)
(144)
(37-38)
(72-73)
(71)
(87)
(103)
(70)
(86)
(102)
(69)
(85)
(101)
(68)
(84)
(100)
(67)
(83)
(99)
(66)
(114)
(115)
(116)
(117)
(118)
(119)
(120)
(121)
(122)
(123)
(124)
(125)
(126)
(127)
(128)
(129)
(130)
(131)
(132)
(133)
(134)
(82)
(98)
(88-89)
(104-105)
(26)
CDC 55.54 Rev. 06/2003
Kawasaki Syndrome Case Report
6. If YES, number of
days hospitalized:
1
■■
Alive, no known sequelae
2
■■
Dead
3
■■
Alive with sequelae (specify): _______________________________
(mm/dd/yyyy)
Coronary
Coronary
# Wks after
Normal
Artery
Artery
Other
Unknown
illness
Not done
Results
Aneurysms
Dilatation
Abnormalities
Results
onset
The criteria for a case are:
Fever
>
5 days unresponsive to antibiotics, and at least four
of the five following physical findings with no other more
reasonable explanation for the observed clinical findings:
1) bilateral conjunctival injection,
2) oral changes,
3) peripheral extremity changes,
4) rash,
5) and cervical lymphadenopathy (at least one lymph node
>
1.5 cm in diameter).
If the fever disappears due to intravenous gamma globulin (IVGG) therapy before the
fifth day of illness, a fever of <5 days duration fulfills fever criterion for case definition.
Check the results for each study
type (A-C), and list the number of
weeks after illness onset that the
study was done. If multiple studies
were done, report the results that
showed coronary artery aneurysm
or dilatation for the first time.
Date of first test
showing coronary artery
aneurysm or dilatation
COMPLICATIONS
Check or list whether complications were associated with this illness.
13. WAS INTRAVENOUS GAMMA
GLOBULIN (IVGG) GIVEN? . . . . . . . . . . . . . . . .
Name:
______________________________________
Address:
______________________________________
______________________________________
Phone No. ( )
____________________________
Date:
IF YES, date of first IVGG treatment:
IF YES, was IVGG started before the fifth day
of illness while the patient was still febrile?
Division of Viral and
Rickettsial Diseases
Mailstop A-39
Centers for Disease Control
and Prevention
Atlanta, GA 30333
Kawasaki Syndrome Surveillance
__ __
/
__ __
/
__ __ __ __
(mm/dd/yyyy)
9
■■
Unk
Specify
| File Type | application/pdf |
| File Title | CDC55.54 Kawasaki Syndrome6 |
| Author | maw2 |
| File Modified | 2006-01-05 |
| File Created | 2003-07-10 |