Respiratory Illness Hospitalized Case Investigation

Form Approved OMB No. 0920-1011

Exp. Date 03/31/17

Hospitalized Case Investigation Form

Respiratory Illness

Public reporting burden of this collection of information is estimated to average 30 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)

I. Reporter Information
State/Territory State/Territory Epi Case ID State/Territory Lab ID
Date form completed: / / CDC Case ID
Person completing form: First Name:_ Last Name:_ Phone: Email:_
What are the source(s) of data for this report? (check all that apply) Medical chart Death certificate Case report form Other_
II. Patient Information and Medical Care
1. Patient Date of birth: / /_ (mm/dd/yyyy)
Did the patient have an outpatient or ER Yes, date: /_ / No Unknown medical care encounter during this illness? (if multiple, list most recent) Was the patient admitted to the hospital for this Yes, date: /_ / No Unknown illness? Time: : AM PM
4. Was patient hospitalized previously at another facility during this illness? Yes No Unknown Admission date: /_ / Discharge date: /_ / Was discharge from prior hospital a transfer? Yes No
Please note initial vital signs at hospital admission/ER presentation. Date taken: /_ /_ (mm/dd/yyyy)
5. Body Mass 6. Height Inches Height 7. Weight: Lbs. Weight Unknown Index: Cm Unknown Kg
8. Blood Pressure /_ 9. Respiratory Rate per min 10. Heart Rate beats/min Temperature: °C °F
11. O Sat % 12. Fraction of inspired oxygen % L 13. Using: O2 mask room air ventilator 2 Specify O2 mask type:
III. Illness Signs and Symptoms
14. Please mark all signs and symptoms experienced or listed in the admission note. Date of initial symptom onset: / /
Fever (measured) highest temp. °C °F Date of fever onset /_ /_ (mm/dd/yyyy) Feverishness (temperature not measured) Wheezing Altered mental status Cough Chills Red or draining eyes (conjunctivitis) With sputum (i.e., productive) Headache Abdominal pain Hemoptysis or bloody sputum Excessive crying/fussiness (< 5 years old) Vomiting Sore throat Fatigue/weakness Diarrhea Runny nose (rhinorrhea) Muscle pain/myalgia Rash, location Dyspnea/difficulty breathing Location Other_ Chest pain Seizure
IV. Patient Medical History
15. Does the patient have any of the following pre-existing medical conditions? Check all that apply.
15a. Asthma/Reactive Airway Disease		15h. Immunocompromising Condition
HIV infection
15b. Chronic Lung Disease		AIDS or CD4 count < 200
Emphysema/COPD		Stem cell transplant (e.g., bone marrow transplant)
Other:_		Organ transplant
Cancer diagnosis within last 12 months (excluding non- melanoma skin cancer) Type:_
15c. Chronic Metabolic Disease		Chemotherapy within last 12 months
Diabetes		Primary immune deficiency
Insulin dependent Yes No Unknown		Chronic steroid therapy (within 2 weeks of admission)
Other:_		Other:
15d. Blood disorders/Hemoglobinopathy		15i. Renal Disease
Sickle cell disease		Chronic kidney disease/chronic renal insufficiency
Splenectomy/Asplenia		End stage renal disease
Other:_		Dialysis
Nephrotic syndrome
Other:_

15e. Cardiovascular Disease (excluding hypertension) 15j. Other Atherosclerotic cardiovascular disease Liver disease Cerebral vascular incident/Stroke Scoliosis With disability Yes No Unknown Obese or BMI ≥ 30 Congenital heart disease Morbidly obese or BMI ≥ 40 Coronary artery disease (CAD) Down syndrome Heart failure/Congestive heart failure Pregnant, gestational age in weeks: Unknown Other:_ Post-partum (≤ 6 weeks) Current smoker 15f. Neuromuscular or Neurologic disorder Drug abuse Muscular dystrophy Alcohol abuse Multiple sclerosis Other:_ Mitochondrial disorder Myasthenia gravis Cerebral palsy Dementia PEDIATRIC CASES ONLY (<18 years old) Severe developmental delay Abnormality of upper airway Yes No Unknown Plegias/Paralysis History of febrile seizures Yes No Unknown Epilepsy/Seizure disorder Premature Yes No Unknown Other:_ (gestational age < 37 weeks at birth for patients < 2yrs) If yes, specify gestation age at birth in weeks: 15g. History of Guillain-Barré Syndrome Unknown gestational age at birth
V. Hematology and Serum Chemistries
16. Were any hematology or serum chemistries performed at hospital admission/presentation to care? Yes No (skip to Q. 35) Unknown (skip to Q. 35)
Please note initial values at admission/presentation to care. Date values were taken: /_ /_ (mm/dd/yyyy)
17. White blood cell count (WBC) cells/mm3	19. Hematocrit (Hct) %	24. Serum creatinine mg/dL
18. Differential: Neutrophils %	20. Platelets (Plt) 103/mm3	25. Serum glucose mg/dL
Bands %	21. Sodium (Na) U/L	26. SGPT/ALT U/L
Lymphocytes %	21. Potassium (K) U/L	27. SGOT/AST U/L
Eosinophils %	22. Bicarbonate (HCO3) U/L	28. Total bilirubin mg/dL
	23. Serum albumin g/dL	29. C-reactive protein (CRP) mg/dL
Please describe other significant lab findings (e.g., CSF, protein).
Type of test Specimen type Date (mm/dd/yyyy) Result
31. / /
32. / /
33. / /
34. / /
VI. Bacterial Pathogens – Sterile or respiratory site only
35. Was a pneumococcal urinary antigen test performed? Yes No Unknown If yes, result: Positive Negative Unknown
35. Was a Legionella urinary antigen test performed? Yes No Unknown If yes, result: Positive Negative Unknown
Were any bacterial culture tests performed (regardless of result)? Yes No (skip to Q.41) Unknown (skip to Q.41) . Indicate sites from which specimens Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) were collected (check all that apply): Sputum Pleural fluid Endotracheal aspirate Other:_ Was there culture confirmation of any bacterial infection? Yes No (skip to Q.41) Unknown (skip to Q.41)
38a. Positive Culture 1 collection date: 38b. Specimen type: Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) / / (mm/dd/yyyy) Sputum Pleural fluid Endotracheal aspirate Other:_ 38c. Pathogen(s) identified: S. aureus S. pyogenes S. pneumoniae H. influenzae Other: 38d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) Methicillin sensitive (MSSA) Sensitivity unknown
39a. Positive Culture 2 collection date: 39b. Specimen type: Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) / / (mm/dd/yyyy) Sputum Pleural fluid Endotracheal aspirate Other: 39c. Pathogen(s) identified: S. aureus S. pyogenes S. pneumoniae H. influenzae Other:_ 39d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) Methicillin sensitive (MSSA) Sensitivity unknown

40a. Positive Culture 3 collection date: 40b. Specimen type: Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) / / (mm/dd/yyyy) Sputum Pleural fluid Endotracheal aspirate Other:_ 40c. Pathogen(s) identified: S. aureus S. pyogenes S. pneumoniae H. influenzae Other:_ 40d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) Methicillin sensitive (MSSA) Sensitivity unknown
VII. Respiratory Viral Pathogens
41. Was the patient tested for any other viral pathogens? Yes No (skip to Q.42) Unknown (skip to Q.42) Positive Negative Not Tested/Unknown Collection Date Specimen Type Respiratory syncytial virus/RSV    / / Adenovirus    / / Parainfluenza 1    / / Parainfluenza 2    / / Parainfluenza 3    / / Human metapneumovirus    / / Rhinovirus    / / Coronavirus    / / Other, specify:    / / Other, specify:    / /
VIII. Medications
42. Did the patient receive influenza antiviral medications during illness? Yes No Unknown
Date started Date stopped Frequency Dose
Oseltamivir (Tamiflu) PO IV Inhaled / / / / QD BID TID
Zanamivir (Relenza) PO IV Inhaled / / / / QD BID TID
Peramivir PO IV Inhaled / / / / QD BID TID
Other influenza antiviral:_ PO IV Inhaled / / / / QD BID TID
Other influenza antiviral:_ PO IV Inhaled / / / / QD BID TID
43. Did the patient receive antibiotics during the illness? Yes No Unknown
If yes, name Date started Date stopped Dose
PO IV IM / / / /
PO IV IM / / / /
PO IV IM / / / /
PO IV IM / / / /
PO IV IM / / / /
44. Did the patient receive steroids (excluding inhaled steroids or one time injections) or other immune modulating treatment specifically for this illness? Yes No Unknown
If yes, name Date started Date stopped Dose
PO IV IM / / / /
PO IV IM / / / /
PO IV IM / / / /
45. Additional treatment comments:
IX. Chest Radiograph – Based on final impression/conclusion of the radiology report Please include a copy of the radiology report with the form.
46. Did the patient have a chest x-ray within 3 days of admission?	Yes, date /_ /_	No (skip to Q.52)	Unknown (skip to Q.52)
47. If yes, was the chest x-ray abnormal?	Yes, date /_ /_	No (skip to Q.52)	Unknown (skip to Q.52)
48. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Final impression/conclusion:

Consolidation: 	Single lobar infiltrate		Multi-lobar infiltrate (unilateral)		Multi-lobar infiltrate (bilateral)
	Lobar or segmental collapse		Cavitation/Abscess/Necrosis		Round pneumonia
Other Infiltrate: 	Alveolar (air space) disease		Interstitial disease		Mixed (airspace and interstitial) disease
Pleural Effusion: 	Unilateral		Bilateral
Bronchiolitis: 	Complicated		Uncomplicated
Other: 	Air leak/Pneumothorax		Lymphadenopathy		Chest wall invasion
	Specify:_
49. Did the patient have another chest x-ray within 3
days of admission? Yes, date /_ /_ No (skip to Q.52) Unknown (skip to Q.52)
50. If yes, was the chest x-ray abnormal? Yes, date /_ /_ No (skip to Q.52) Unknown (skip to Q.52)
51. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Final impression/conclusion:
Consolidation: 	Single lobar infiltrate		Multi-lobar infiltrate (unilateral)		Multi-lobar infiltrate (bilateral)
	Lobar or segmental collapse		Cavitation/Abscess/Necrosis		Round pneumonia
Other Infiltrate: 	Alveolar (air space) disease		Interstitial disease		Mixed (airspace and interstitial) disease
Pleural Effusion: 	Unilateral		Bilateral
Bronchiolitis: 	Complicated		Uncomplicated
Other: 	Air leak/Pneumothorax		Lymphadenopathy		Chest wall invasion
	Specify:_
X. Chest CT or MRI – Based on final impression/conclusion of the radiology report
please include a copy of the radiology report with the form.
52. Did the patient have a chest CT/MRI scan within
3 days of admission? Yes, date /_ /_ No (skip to Q.56) Unknown (skip to Q.56)
52. If yes, please select one: CT: contrast CT: non-contrast MRI
54. If yes, was the CT/MRI abnormal? Yes, date /_ /_ No (skip to Q.56) Unknown (skip to Q.56)
55. For abnormal chest CT/ MRI, please check all that apply and please transcribe the final impression/conclusion:
Final impression/conclusion:
Consolidation: 	Single lobar infiltrate		Multi-lobar infiltrate (unilateral)		Multi-lobar infiltrate (bilateral)
	Lobar or segmental collapse		Cavitation/Abscess/Necrosis		Round pneumonia
Other Infiltrate: 	Alveolar (air space) disease		Interstitial disease		Mixed (airspace and interstitial) disease
Pleural Effusion: 	Unilateral		Bilateral
Bronchiolitis: 	Complicated		Uncomplicated
Other: 	Air leak/Pneumothorax		Lymphadenopathy		Chest wall invasion
	Specify:_
XI. Clinical Course and Severity of Illness
56. At any time during the current illness, did the patient require or have the diagnosis of :
a. Admission to intensive care unit (ICU) Yes No Unknown Admission date: / / Discharge date: / / If multiple admissions, 2nd ICU admission date: / / 2nd ICU discharge date: / / If more than 2 ICU admissions, please provide dates in the comments section (Q.66)
b. Supplemental oxygen				Yes		No Unknown
Date started: /		/		Date stopped		/ /
c. Ventilatory support Check all that apply:	Intubation ECMO CPAP	Date started: / / Date started: / / Date started: / /		Yes Date stopped: Date stopped: Date stopped:		No Unknown / / / / / /

Alien Number

BiPAP Date started: / /	Date stopped: / /
d. Vasopressor medications (e.g. dopamine, epinephrine) Date started: / /	Yes No Unknown Date stopped / /
e. Dialysis (Acute) Date started: / /	Yes No Unknown Date stopped / /
Resuscitation, CPR Yes, date started: / / Acute respiratory distress syndrome (ARDS) Yes, date started: / /	stopped: /_ /			No	Unknown
	stopped:	/_	/	No	Unknown
h. Disseminated intravascular coagulopathy (DIC) Yes, date started: / /	stopped: /_ /			No	Unknown
Hemophagocytic syndrome Yes, date started: / / Bronchiolitis Yes, date started: / / Pneumonia Yes, date started: / / Stroke (Acute) Yes, date started: / / Sepsis Yes, date started: / / Shock Yes, date started: / / Type: hypovolemic cardiogenic septic toxic Acute myocarditis Yes, date started: / / Acute myocardial dysfunction Yes, date started: / / Acute myocardial infarction Yes, date started: / / Seizures Yes, date started: / / Reye’s syndrome Yes, date started: / / Acute encephalitis / encephalopathy Yes, date started: / / Guillain-Barre syndrome Yes, date started: / / Rhabdomyolysis Yes, date started: / / Acute liver impairment Yes, date started: / / Acute renal failure Yes, date started: / / Other, specify: Yes, date started: / / Other, specify: Yes, date started: / /	stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / No stopped: /_ / stopped: /_ /				Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

XII. Outcomes

57. Did the patient die during this illness? Yes, date /_ /_ No (skip to Q.62) Unknown (skip to Q.62)

58. What was the location of death? Home Hospital ER Hospice Other, specify

59. . Did the patient have a DNR (do not resuscitate) order? Yes No Unknown

60. Was an autopsy performed? Yes (please attach a copy of the autopsy form to this report if available) No Unknown

61. What were the causes of death (immediate and underlying) in order of appearance on the death certificate or medical record?

1. 4. 7.

2. 5. 8.

3. 6. 9.

62. Has the patient been discharged from the hospital? Yes, date /_ / No Unknown

63. If yes, please indicate to where: Home Other hospital Hospice Rehabilitation Facility

    • Other long-term care facility Other, specify: Unknown

63. If no, please indicate status: Hospitalized on ward Hospitalized in ICU Died

64. If patient was pregnant, please indicate pregnancy status at discharge or final update:

• Still Uncomplicated labor/delivery Complicated labor/delivery Fetal loss

pregnant Describe Date /_ /_

64. If pregnancy resulted in delivery, please indicate neonatal outcome: Birth date: /_ /

• Healthy newborn Ill newborn, describe: Newborn died: Date /_ /_ Unknown

65. Additional notes regarding discharge:

XIII. Additional Comments

66. Additional Comments: