Hemolytic Uremic Syndrome (HUS)

CASE ID__ __ __ __ --__ __ -- __ __ __

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

Hemolytic Uremic Syndrome Surveillance

State Department of Health

Case Report Form

Instructions: Complete the following by interviewing the attending physician and/or reviewing patient's medical record.

I. PATIENT IDENTIFICATION

1

A. Patient name _______________________________ ___________________ 2A. Date of birth _____/_____/____

^{last first mo / day / yr}

3A. Parent/guardian __________________________ ___________________ 4A. Medical Rec # ____________________

^{last first}

5A. Address__________________________________________________________________________________________

^{number/street city state zip}

6A. Phone home (____) _________ 7A. Phone work (____) _________ 8A. County of residence________________

9A. Sex  Female  Male

10A. Ethnicity  Hispanic  Non-Hispanic Unknown

11A. Race  White  Asian / Pacific Islander  Black  American Indian / Alaska Native

 Other___________________________________  Unknown

12A. How was patient's illness first identified by public health (state or local health department or EIP)?

Report of HUS case by a physician or service participating in the FoodNet HUS active

surveillance network

Date Entered (MM/DD/YY): __________________

Report of HUS case by a non-participating physician or service

Routine STEC infection surveillance

Other, describe_______________________________

13A. Was this case captured through Hospital Discharge Data?

Yes Date Entered (MM/DD/YY): __________________

 No

II. HOSPITAL INFORMATION

14A. Person reporting case ____________________________________________ 15A. Phone (_____)______________

16A. Attending physician _____________________________________________ 17A. Phone (_____)_____________

18A. Hospital ________________________________________________________ 19A. Phone (_____)____________

^{Name City/State}

20A. Date of admission or transfer to this facility ____/____/____

21A. Date of discharge or transfer from this facility ____/____/____  Still hospitalized

22A. Institution transferred to (if applicable) ____________________________________________________

^{Name City/State}

23A. Institution where first hospitalized (if different) _____________________________________________________

^{Name City/State}

24A. Date of initial hospitalization (if different) ____/____/____

25A. Physician, initial hospitalization (if different) ___________________________ 26A. Phone (_____)_________

Public reporting burden of this collection of information is estimated to average 1 hour 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

III. CLINICAL INFORMATION

27A. Date of HUS diagnosis ____/____/____

28A. Is this case outbreak related?........................ yes  no  unsure

29A. Did patient have diarrhea during the 3 weeks before HUS diagnosis?..............  yes  no  unsure

if yes 30A. Date of diarrhea onset _____/_____/_____

31A. Did stools contain visible blood at any time .......................... yes  no  unsure

32A. Was diarrhea treated with antimicrobial medications............ yes  no  unsure

if yes 33A. Type of antimicrobial ________________________________________

If no to diarrhea 34A. Did the patient have contact with another person with diarrhea or HUS during the 3 weeks before HUS diagnosis (include daycare, household, etc)?  yes  no  unsure

35A. Was patient treated with an antimicrobial medication for any other reason

than diarrhea during the 3 weeks before HUS diagnosis? ………………........... yes  no  unsure

if yes 36A. Type of antimicrobial _____________________________________________________

37A. Reason(s)_______________________________________________________________

Other medical conditions present during 3 weeks before HUS diagnosis:

38A. Other gastrointestinal illness………………………………………………. yes  no  unsure

39A. Urinary tract infection ............................................................................. yes  no  unsure

40A. Respiratory tract infection ...................................................................... yes  no  unsure

41A. Other acute illness....................................…………................................. yes  no  unsure

if yes 42A. Describe ___________________________________________________________

43A. Pregnancy ................................................................................................ yes  no  unsure

44A. Kidney Disease ....................................................................................... yes  no  unsure

45A. Immune compromising condition or medication ……………………… yes  no  unsure

if yes 46A. Malignancy......................................................................... yes  no  unsure

47A. Transplanted organ or bone marrow............................... yes  no  unsure

48A. HIV infection....................................................................... yes  no  unsure

49A. Steroid Use (parenteral or oral)........................................ yes  no  unsure

50A. Other, describe ______________________________________________________

Laboratory values within 7 days before and 3 days after HUS diagnosis:

51A. Highest serum creatinine.......................................………………….........______ mg/dL

52A. Highest serum BUN ....................................................…………………....______ mg/dL

53A. Highest WBC ...............................................................…………………....______K/mm³

54A. Lowest hemoglobin .....................................................…………………..______ g/dL

55A. Lowest hematocrit ............................................……………….…….......______ %

56A. Lowest platelet count ..................................................…………………..______ K/mm³

57A. Microangiopathic changes (i.e., schistocytes, helmet cells or red cell fragments) at any time within 7 days before HUS diagnosis to hospital discharge (if patient was not hospitalized or discharged within 3 days of HUS diagnosis, then outpatient lab results from 7 days before to 3 days after diagnosis should be used, if available).……………………………………………………………………………. yes  no  unsure  not tested

Other laboratory findings within 7 days before and 3 days after HUS diagnosis:

58A. Blood (or heme) in urine......................................................… yes  no  unsure  not tested

59A. Protein in urine...................................................................….. yes  no  unsure  not tested

60A. RBC in urine by microscopy..................................................… yes  no  unsure  not tested

61A. Status of report _______Initial ________Update ________Complete

62A. Date ____/____/____ 63A. Completed by (initials)________________

Hemolytic Uremic Syndrome Surveillance

State Department of Health

Microbiology Report Form

Instructions: Complete by contacting microbiology laboratory at each institution where patient’s specimen was tested. Complete one composite form for all laboratories (includes hospital laboratories, outpatient laboratories, state public health laboratories and CDC).

1B. Was stool specimen obtained from this patient ...........................................  yes  no  unsure

if no Skip to question 20B

2B. Laboratories where stool(s) tested

_____________________________________________________ Phone (____) _________

^{Name City/State}

_____________________________________________________ Phone (____) ________

^{Name City/State}

_____________________________________________________ Phone (____) _________

^{Name City/State}

_____________________________________________________ Phone (____) _________

^{Name City/State}

3B. Was stool tested for Shiga toxin at any CLINICAL laboratory.................................................... yes  no  unsure

if yes

4B. Result............................................... positive  negative  unsure

5B. Collection date of first specimen tested ____/____/____

6B. Collection date of 1st positive specimen: ____/____/____

7B. Was stool cultured for E. coli O157 (on selective or differential media e.g. SMAC, CHROMagar O157, CTSMAC) at any CLINICAL laboratory?  yes  no  unsure

if yes 8B. Collection date 1st specimen culture for O157: ____/____/____

9B. Was E. coli O157 isolated?................................................................ yes  no  unsure

if yes 10B. Collection date 1st positive specimen culture for O157: ____/____/____

11B. Result of H antigen testing (check one):

 H7 positive  other H, specify:_____

 H7 negative 

 unsure or not tested

 non-motile

12B. Was a stool sample, or any type of specimen or isolate originating from stool sent to a public health laboratory (state or CDC)? ............................................................ yes  no  unsure

If yes 13B. Date of specimen collection: ____/____/____

14B. Was E. coli O157 or non-O157 STEC identified?  yes  no  unsure

If yes Strain 1: O antigen:_________ H antigen:_______

 Rough  non-motile

 undetermined  not tested

 not tested

Strain 2: O antigen:_________ H antigen:_______

 Rough  non-motile

 undetermined  not tested

 not tested

15B. Was immunomagnetic separation (IMS) used to identify common STEC serogroups?  yes  no unsure

If yes 16B. What serogroup(s) did the IMS procedure target? 1____, 2____, 3____, 4____, 5____,

6_____, 7______

17B. Other pathogen isolated from stool (at PHL or clinical lab)...................................................... yes  no  unsure

if yes 18B. Pathogen #1____________________ Specimen collection date ____/____/____

19B. Pathogen #2____________________ Specimen collection date ____/____/____

20B. Pathogen isolated from source other than stool (at PHL or clinical lab)…………..…………. yes  no  unsure

if no Skip to 26B

if yes 21B. Pathogen ________________________________________________________

22B. Specimen Source _________________________________________________

23B. First date of isolation ____/____/____

If O157 or other STEC was isolated, complete the following based on health department records:

24B. Disposition of isolate  Sent to state laboratory (state laboratory ID # ________________________)

(check all that apply)  Sent to CDC (ID, if different than SLABID, _____________________________)

 Sent to other reference laboratory (specify ___________________)

 Discarded

25B. Is the patient a resident of the FoodNet catchment area?  yes  no

if yes 26B. FoodNet PersonID ________________________________

27B. Has patient serum or plasma been sent to CDC for testing for antibodies to O157 or other STEC?......... yes  no  unsure

if no Skip to 29B

if yes

28B. State laboratory ID for serum _____________________________________

Other laboratory ID numbers for serum sent to CDC__________________________________

LPS type	Titer IgG	Interpretation of IgG			Titer IgM	Interpretation of IgM			Not tested
		Positive	Negative	Borderline		Positive	Negative	Borderline

29B. Status of report _________initial _________ update __________ complete

30B. Date ____/____/____ 31B. Completed by (initials) __________

Hemolytic Uremic Syndrome Surveillance

State Department of Health

Chart Review Form

Instructions: Complete after patient has been discharged; use hospital discharge summary, consultation notes and DRG coding sheet. Complete one composite form for all institution where hospitalized.

1C. Hospitals admitted __________________________________________________ Phone (____) ____________

Date admitted above:____/____/___ Date discharged above:____/____/___

__________________________________________________ Phone (____) ____________

Date admitted above:____/____/___ Date discharged above:____/____/___

__________________________________________________ Phone (____) ____________

Date admitted above:____/____/___ Date discharged above:____/____/___

__________________________________________________ Phone (____) ____________

Date admitted above:____/____/___ Date discharged above:____/____/___

2C. Date of first admission:____/____/___ 3C. Date of last discharge:____/____/___

Did any of the following complications occur during this admission:

Date of onset

4C. Pneumonia.......................................................... yes  no  unsure if yes 5C. ___/___/___

6C. Seizure................................................................  yes  no  unsure if yes 7C. ___/___/___

8C. Paralysis or hemiparesis................................... yes  no  unsure if yes 9C. ___/___/___

10C. Blindness............................................................  yes  no  unsure if yes 11C. ___/___/___

12C. Other major neurologic sequelae ..................  yes  no  unsure if yes 13C. ___/___/___

if yes, Describe: _____________________________________________

Were any of the following procedures performed during this admission:

14C. Peritoneal dialysis..........................................................  yes  no  unsure

15C. Hemodialysis..................................................................  yes  no  unsure

Transfusion with:

16C. packed RBC or whole blood...........................  yes  no  unsure

17C. platelets............................................................  yes  no  unsure

18C. fresh frozen plasma.........................................  yes  no  unsure

19C. Plasmapheresis ..............................................................  yes  no  unsure

20C. Laparotomy or other abdominal surgery*.....................  yes  no  unsure

(*other than insertion of dialysis catheter)

if yes 21C. Describe:_________________________________________________________

22C. Condition at discharge..................................................................  dead  alive

if dead, 23C. Date deceased:____/____/____

if alive, 24C. Requiring dialysis...........................................  yes  no  unsure

25C. With neurologic deficits.................................  yes  no  unsure

26C. Status of report _____initial _____update ______complete

27C. Date ___/___/___ 28C. Completed by (intials)________