Medical Chart Abstraction

` Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Appendix I: Medical Chart Abstraction

Please note that this medical chart review form has 13 pages and contains two parts:

Part A: demographic information about the child who was ill with neurological signs following respiratory illness

Part B: medical information from the hospital chart of the child following admission for neurological signs

Date of chart abstraction: ________________ (MM/DD/YYYY)

Name of person completing form: _________________________________________________________

Name and address of institution where this form was completed:

_____________________________________________________________________________________

_____________________________________________________________________________________

Part A: Demographic information for case-patient admitted with neurological signs following respiratory illness

First Name: ____________________________ Last (Family) Name: _________________________

Date of Birth: __________________ (MM/DD/YYYY) Sex: Female Male Unknown

Race: Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White

(More than one box can be checked)

Ethnicity: Hispanic Non-Hispanic

First name of parent/guardian: _____________________________________

Last (Family) name of parent/guardian: ______________________________

Contact telephone number: ________________________________________

Email address: ___________________________________________________

Residence address: __________________________________________________________________

__________________________________________________________________________________

Part B: Medical chart of case-patient admitted with neurological signs following respiratory illness

Medical record number: __________________________________

Patient’s First Name: ______________________________________

Patient’s Last (Family) Name: _______________________________

Patient’s date of birth: __________________ (MM/DD/YYYY)

Admission date to hospital of initial presentation: ______________________ (MM/DD/YYYY)

Transfer date from hospital of initial presentation: ______________________ (MM/DD/YYYY)

Admission date to secondary facility: ______________________ (MM/DD/YYYY)

Transferred from:

Hospital name: ____________________________________________________________

Transferred to:

Hospital name: ____________________________________________________________

Please describe any patient information available from a referring facility, if applicable:

Did the patient have any underlying medical conditions? Yes No Unknown

If yes, please describe:

Are outpatient visits prior to becoming ill noted in the chart? Yes No Unknown

If yes, please describe:

Is family history of neurologic illness, including seizures, noted in the chart? Yes No Unknown

If yes, please describe:

Please list any medications prescribed to the patient before hospitalisation (e.g. OTC meds used by parents, medications discontinued prior to hospitalisation):

Medication	Dose and route	Date Started (MM/DD/YYYY)	Place of administration

Signs and Symptoms

Date of first clinical symptoms: ___________________ (MM/DD/YYYY)

As part of this illness, does the patient have or has the patient had any of the following:

Fever

Fever (>38 °C)………………………………………………………….. Yes No Unknown

If yes, what was the highest temperature? _______ °C

Temperature <35 °C…….………………………………………….. Yes No Unknown

If yes, what was the lowest temperature? _______ °C

Rash

Skin rash……..………………………………………………………….. Yes No Unknown

If yes, please describe (eg. Location, type {maculopapular, vesicular} etc):_______________________

___________________________________________________________________________________

___________________________________________________________________________________

Redness on feet or hands ………………………………………… Yes No Unknown

Ulcers or lesions in mouth……………………………………….. Yes No Unknown

Neurologic

Focal seizures/convulsions…….……………………………. Yes No Unknown

Generalized seizures/convulsions…….…………………….. Yes No Unknown

Intractable seizures/convulsions…….…………………..….. Yes No Unknown

Myoclonic jerk..………………………………………………………. Yes No Unknown

Tremors.…………………………………………………………………. Yes No Unknown

Limb weakness/monoparesis………………………………….. Yes No Unknown

Stiff neck..……………………………………………………………….. Yes No Unknown

Bulging fontanelle (if infant).………………………………………………….. Yes No Unknown

Lethargy………………………………………………………………….. Yes No Unknown

Irritability.……………………………………………………………….. Yes No Unknown

Inconsolable crying…………………………………………………. Yes No Unknown

Cranial nerve palsy………………………………………………….. Yes No Unknown

Respiratory

Cough (dry, productive).….…………..………………………….. Yes No Unknown

Secretions……………………………………………………………….. Yes No Unknown

Runny nose.…………………………………………………………….. Yes No Unknown

Sneezing………………………………………………………………….. Yes No Unknown

Difficulty breathing………………………………………………….. Yes No Unknown

Wheezing.……………………………………………………………….. Yes No Unknown

Rales/crackles/crepitations.…………………………………….. Yes No Unknown

Tachypnea (as assessed and recorded by provider)… Yes No Unknown

If yes, please indicate rate ___________ (RR/min)

Frothy secretions from mouth..……………………………….. Yes No Unknown

Hemoptysis.…………………………………………………………….. Yes No Unknown

Respiratory failure.………………………………………………….. Yes No Unknown

Oxygen given.………………………………………………………….. Yes No Unknown

If yes, how was it administered? _______________________________________________________

Intubation……………………………………………………………….. Yes No Unknown

Retractions, nasal flaring..……………………………………….. Yes No Unknown

Cardiovascular

Bradycardia (as assessed and recorded by provider).. Yes No Unknown

If yes, please indicate rate ___________ (HR/min)

Tachycardia (as assessed and recorded by provider).. Yes No Unknown

If yes, please indicate rate ___________ (HR/min)

Variable heart rate (tachy/brady)……………………………. Yes No Unknown

Cyanosis………………………………………………………………….. Yes No Unknown

Mottled skin……………………………………………………………. Yes No Unknown

Arrhythmia.…………………………………………………….……….. Yes No Unknown

Abnormal heart sounds.………………………………………….. Yes No Unknown

If yes, please describe ________________________________________________________________

Hypotension/shock………………………………………………….. Yes No Unknown

Gastrointestinal

Vomiting………………………………………………………………….. Yes No Unknown

Watery stools………………………………………………………….. Yes No Unknown

Constipation..………………………………………………………….. Yes No Unknown

Abdominal distention.…………………………………………….. Yes No Unknown

Abdominal pain……………………………………………………….. Yes No Unknown

Jaundice………………………………………………………………….. Yes No Unknown

Poor feeding………………………………………………………… .. Yes No Unknown

Others

Conjunctivitis.………………………………………………………….. Yes No Unknown

Bleeding.………………………………………………………………….. Yes No Unknown

Persistent crying………………………………………………………. Yes No Unknown

Lymphadenopathy.………………………………………………….. Yes No Unknown

Please describe any other symptoms not listed above, or any of note:

Laboratory Exams

Please list here all laboratory findings from admission:

Specimen Collection Date (MM/DD/YYYY)	Specimen type	Test type	Results (include reference range)
	Serum	AST(SGOT), ALT(SGPT), GGT
	Serum	T. BILI, direct bili
	Serum	BUN, creatinine
	Serum	Glucose
	Serum	Creatinine Kinase
	Serum	Sodium
	Blood	HB/HCT
	Blood	WBC
	Blood	Neutros
Specimen Collection Date (MM/DD/YYYY)	Specimen type	Test type	Results (include reference range)
	Blood	Bands
	Blood	Lymphs
	Blood	Monos
	Blood	EOS
	Blood	PLTS
	Blood	Culture
	Blood	ANC
	Blood	LDH
	Blood	CRP
	Blood	ESR
	NP/OP/Throat	Culture
	Rectal/stool	Culture
	Eye	Culture
	Vesicle	Culture
	Urine	Culture
	Urine	UA
	CSF	Opening pressure
	CSF	RBC
	CSF	WBC
	CSF	Neutro
	CSF	Lympho
	CSF	EOS
Specimen Collection Date (MM/DD/YYYY)	Specimen type	Test type	Results (include reference range)
	CSF	Protein
	CSF	Glucose
	CSF	Gram stain
	CSF	Culture
		HPeV3-specific PCR
		Enterovirus-specific PCR
		HSV-specific PCR
		Other virus PCR
Please describe below any other unusual laboratory results at admission

Radiologic Exams

Please describe here all radiological exams requested:

Exam date (MM/DD/YYYY)	Test type	Results
	CXR
	CT
	MRI
	Echocardiography
	Ultrasound
	EEG
	Plain abdominal radiographs

Medication and Treatment

Was the patient placed in the intensive care unit (ICU)? Yes No Unknown

If yes, admission date: ________________ Discharge date: ________________ (MM/DD/YYYY)

Please list any medications prescribed to the patient in hospital:

Medication	Dose and route	Date Started (MM/DD/YYY)	Date Stopped (MM/DD/YYY)

Please describe any other treatment regimens or interventions provided to the patient in hospital

(e.g. supplemental oxygen, respiratory therapy, supplemental feedings, PRN meds etc):

Do not include intravenous fluids

Discharge

Is patient still in hospital? Yes No If no, discharge date: __________________(MM/DD/YYYY)

Status upon discharge: ________________________________________________________________

Died: Yes No Unknown If yes, date of death ___________________ (MM/DD/YYYY)

Discharge diagnosis: __________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Other information

Please describe here any other information that you feel may be important or unusual, with regard to the patient’s stay in hospital:

End of medical chart abstraction form

Public reporting burden of this collection of information is estimated to average 60 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 (0920-1011)