Legionnaires Disease Chart Abstraction

Case ID# ____________ Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

SECTION I. SCREENING FOR SUSPECT LD CASES

MRN:________________________________________________________________

Encounter (FIN): _______________________________________________________

Gender: _______

DOB: _______________ Age: _____ Race/Ethnicity: _____________________

Type of Residence: □ Home □ LTCF □ Other ___________

Todays date: __ / __ / __

Date of admission: __ / __ / __

Abstractors initials: ________

Did any of the following develop >48 hours of admission (do not count if present on admission)?

1. Pneumonia symptoms? (Cough, shortness of breath)

□ Yes □ No (if yes, then continue to Section II)

2. Abnormal CXR / CT suggestive of pneumonia/infiltrate?

□ Yes □ No (if yes, then continue to section II)

3. Was another etiology identified (other than Legionella)?

□ Yes □ No (if yes, then stop)

Chart Abstraction Form – Legionnaires’ Disease

SECTION II. TYPE OF CASE

Information Source (check all that apply):

□ hospital chart

□ other (if other specify) ______________

1. Type of exposures to Hospital A during incubation period (check all that apply): □ Inpatient □ Outpatient □ Visitor □Volunteer □Employee

2. Case definition:

□ Confirmed Case □ Suspected Case □ Possible Case □ Subclinical case

3. Case Classification:

□ Definitely outbreak-associated □ Possibly outbreak-associated

□ Non-outbreak associated

If non-outbreak-associated, END HERE. Otherwise, continue to next page.

SECTION III. LEGIONELLA-SPECIFIC TESTING

1. Respiratory specimen collected and processed specifically for Legionella culture?

_____ Yes ______ No _____ Unknown

1. If YES,

Specimen type: (e.g., expectorated sputum, BAL, etc.) __________________

Collected Date: ____/____/ ____ Laboratory Name:____________________

Results:________________________________________________________

2. If NO,

Respiratory specimen collected for any culture?

_____ Yes ______ No _____ Unknown

If Yes,

Specimen type: (e.g., expectorated sputum, BAL, etc.) ____________________

Collected Date: ____/____/ ____ Laboratory: ___________________________

Results:__________________________________________________________

2. Urine specimen collected for Legionella urine antigen testing?

_____ Yes ______ No _____ Unknown

Collected Date: ____/____/ ____ Laboratory Name: ________________________

Results: ____________________________________________________________

3. Other Legionella testing? ________________________________________________

SECTION IV. MEDICAL HISTORY

□ COPD/Emphysema/Chronic Lung Disease

□ Diabetes

□ Congestive Heart Failure

□ History of stroke/CVA

□ Chronic Renal Insuffiency (CRI/CKD) or End-Stage Renal Disease (ESRD)

□ Cirrhosis / Liver Disease

□ Cancer (Type: ________________; Date of diagnosis __/__/__)

□ Organ Transplant (Type:__________________) Date of transplant: __ / __ / __

□ Bone Marrow Transplant; Date of transplant: __ / __ / __

□ HIV/AIDS, CD4 count: ____________ Date: __ / __ / __

□ Dementia

□ Taking systemic steroid

□ History of chemotherapy Date: __ / __ / __ (Is this 1^st cycle of induction chemo? □ Yes □ No)

□ History of radiation Date: __ / __ / __

□ History of pneumonia in prior year, Date: __ / __ / __

□ Other (___________________________)

□ Other (___________________________)

History of smoking: □ Yes □ No □ Unknown

If yes: □ Current □ Former □ Unknown

History of alcohol abuse: □ Yes □ No □ Unknown

History of other substance abuse: □ Yes □ No □ Unknown

Specify substance(s): _________________________________

SECTION V. SIGNS AND SYMPTOMS

□ Shortness of breath; Date of onset: __ / __ / __

□ Cough; Date of onset: __ / __ / __

□ Fever >100.5°F; Date of onset: __ / __ / __

□ Diarrhea (3 stools/24h); Date of onset: __ / __ / __

□ Nausea or Vomiting; Date of onset: __ / __ / __

□ Confusion (altered mental status); Date of onset: __ / __ / __

□ Other (____________);Date of onset: __ / __ / __

□ Other (____________);Date of onset: __ / __ / __

BEST SYMPTOM ONSET DATE: __ / __ / __

(If the patient did not have prior respiratory symptoms, choose, the onset date of cough or shortness of breath, whichever occurs first. Otherwise, use the earliest date when other symptoms suggestive of Legionella infection began.)

SECTION VI. RADIOGRAPHIC FINDINGS

Document any radiographic findings 14 days after onset of symptoms above. If multiple chest images are available, report the first for which evidence of pneumonia is noted.

□ Chest X-ray

If Yes, when and what were the findings?

Date: ____/____ / _____

□ Normal □ Abnormal

Result:

□ New Infiltrate □ Old / Unchanged Infiltrate □ Indeterminate □ Consolidation □ No infiltrate □ Not available / Unknown

Findings (impression): _____________________________________________________

□ CT Scan

If Yes, when and what were the findings?

Date: ____/____ / _____

□ Normal □ Abnormal

Result:

□ New Infiltrate □ Old / Unchanged Infiltrate □ Indeterminate □ Consolidation □ No infiltrate □ Not available / Unknown

Findings (impression): _____________________________________________________

SECTION VII. VITAL SIGNS

Highest O2 demand (FiO2): _______________________ Date (earliest):__________________

Pulse ox (lowest recorded): ________________ Date: _____________________

Tmax: _____________________ Date ______________________

SECTION VIII. LABORATORY VALUES
TEST	Result	Date
WBC (lowest)		____ / ____ / ____
% Neutrophils		____ / ____ / ____
% Lymphocytes		____ / ____ / ____
WBC (highest)		____ / ____ / ____
Hemoglobin (lowest)		____ / ____ / ____
Platelets (lowest)		____ / ____ / ____
Na (lowest)		____ / ____ / ____
Cr (highest)		____ / ____ / ____
Required dialysis	□ Yes □ No
AST (highest)		____ / ____ / ____
ALT (highest)		____ / ____ / ____
Total bilirubin (highest)		____ / ____ / ____
Ferritin (highest)		____ / ____ / ____
CRP (highest)		____ / ____ / ____
ESR (highest)		____ / ____ / ____

SECTION IX. INVASIVE PROCEDURES Document procedures done 14 days prior to the onset of symptoms above
Procedure name	Date
□ NG/OG tube placement	____ / ____ / ____
□ ET/OT/Other Intubation	____ / ____ / ____
□ Lumbar puncture	____ / ____ / ____
□ Thoracentesis	____ / ____ / ____
□ Paracentesis	____ / ____ / ____
□ Bronchoscopy	____ / ____ / ____
□ Central line placement	____ / ____ / ____
□ Arterial line placement	____ / ____ / ____
□ Other___________________	____ / ____ / ____
□ Other___________________	____ / ____ / ____

SECTION X. ANTIBIOTICS / IMMUNOSUPPRESION REGIMENS
Antibiotic / immunosuppressive therapy	Dose	Route	Start Date	End Date	Check if continued as outpatient
□ Levofloxacin (Levoquin)
□ Moxifloxacin
□ Ciprofloxacin (Cipro)
□ Azithromycin (Zithromax)
□ Erythromycin
□ Rifampin
□ Rifapentine
□ Linezolid
□ Tetracycline
□ Doxycycline
□ Quinupristin/ dalfopristin (Synercid)
□ Chemotherapy regimen (specify): ___________
□ Radiation therapy (specify): ___________
□ Systemic steroids (specify): ___________
Other (specify): ___________
Other (specify): ___________
Other (specify): ___________
Other (specify): ___________

SECTION XI. CLINICAL OUTCOMES

□ ICU Stay

1. If ICU stay,

   1. Number of days in ICU: __________ (count days where any time was spent in ICU)

DISPOSITION:

□ Still Hospitalized

□ Transferred to another facility (list:________________________________________)

□ Discharged Home

□ Unknown

□ Deceased

2. If deceased,

   1. Date of death: __________ (mm/dd/yyyy)

   2. Was a post-mortem examination performed? ___Yes ___No ____Unknown

      1. If yes, are tissue specimens available? ____ Yes ____No ____ Unknown

DISCHARGE DIAGNOSIS

□ Legionellosis

□ Pneumonia

If yes, Etiology: ____________________ Lab Test(s): _______________________

□ Other Dx: _________________________________________________________________

SECTION XII. EXPOSURES

□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____

□ ICU stay; if yes # of days in ICU___________ days

□ Intubated

Discharge diagnosis: □ Legionellosis □ Pneumonia; etiology:_____________________

□ Other diagnosis; specify: _______________________________

□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____

□ ICU stay; if yes # of days in ICU___________ days

□ Intubated

Discharge diagnosis: □ Legionellosis □ Pneumonia; etiology:_____________________

□ Other diagnosis; specify: _______________________________

□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____

□ ICU stay; if yes # of days in ICU___________ days

□ Intubated

Discharge diagnosis: □ Legionellosis □ Pneumonia; etiology:_____________________

□ Other diagnosis; specify: _______________________________

OUTPATIENT VISITS to Hospital A or associated clinics (including rehab visits)

Did patient have any outpatient visits during the 2-10 days prior to symptom onset?

_____ Yes _____ No _____ Unknown

If yes, list location of visits and name of clinic:

Name of Campus	Clinic (e.g., Primary Care, Cardiology)	Building	Room#	Date(s) of Visit

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Public reporting burden of this collection of information is estimated to average 90 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)