2014013-XXX_Resp Illness UAC_Multi

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Respiratory Disease Cluster

Medical Record Form

This form is intended to be used as a supplement to the Novel Influenza A Case Report Form for patients with severe outcomes (hospitalization or death). Please complete all sections of this form for each patient with a severe outcome in addition to the Novel Influenza A Case Report Form. Once this form is complete, please submit it as an email attachment to [email protected] or fax the completed form to 404-471-8119.

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)

2. Did the patient have an outpatient or ER medical care encounter during this illness?

 Yes, date: ____/____/______

(if multiple, list most recent)

 No

 Unknown

3. Was the patient admitted to the hospital for this illness?

 Yes, date: ____/____/______

Time: ____:____  AM  PM

 No

 Unknown

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

Index:

________

6. Height

________

 Inches

 Cm

 Height Unknown

7. Weight:

_________

 Lbs.

 Kg

 Weight Unknown

8. Blood Pressure ____ /_____

9. Respiratory Rate ______ per min

10. Heart Rate ___________ beats/min

Temperature: ______ °C °F

11. O₂ Sat ______%

12. Fraction of inspired oxygen ______  %  L

13. Using:  O₂ mask  room air  ventilator

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

35. Were any bacterial culture tests performed (regardless of result)?

 Yes

 No (skip to Q.41)

 Unknown (skip to Q.41)

36. Indicate sites from which specimens were collected (check all that apply):

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 Sputum

 Pleural fluid

 Endotracheal aspirate

 Other:_____________________

37. 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: _____/_____/________ (mm/dd/yyyy)

38b. Specimen type:

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 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: _____/_____/________ (mm/dd/yyyy)

39b. Specimen type:

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 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: _____/_____/________ (mm/dd/yyyy)

40b. Specimen type:

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 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

a. Respiratory syncytial virus/RSV







____/____/______

___________________________

b. Adenovirus







____/____/______

___________________________

c. Parainfluenza 1







____/____/______

___________________________

d. Parainfluenza 2







____/____/______

___________________________

e. Parainfluenza 3







____/____/______

___________________________

f. Human metapneumovirus







____/____/______

___________________________

g. Rhinovirus







____/____/______

___________________________

h. Coronavirus







____/____/______

___________________________

i. Other, specify: ________________







____/____/______

___________________________

j. 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

 Yes

 No

 Unknown

Check all that apply:

 Intubation

Date started:

____/____/______

Date stopped:

____/____/_______

 ECMO

Date started:

____/____/______

Date stopped:

____/____/_______

 CPAP

Date started:

____/____/______

Date stopped:

____/____/_______

 BiPAP

Date started:

____/____/______

Date stopped:

____/____/_______

d. Vasopressor medications (e.g. dopamine, epinephrine)

 Yes

 No

 Unknown

Date started:

____/____/_______

Date stopped

____/____/_______

e. Dialysis (Acute)

 Yes

 No

 Unknown

Date started:

____/____/_______

Date stopped

____/____/_______

f. Resuscitation, CPR

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

g. Acute respiratory distress syndrome (ARDS)

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

h. Disseminated intravascular coagulopathy (DIC)

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

i. Hemophagocytic syndrome

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

j. Bronchiolitis

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

k. Pneumonia

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

l. Stroke (Acute)

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

m. Sepsis

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

n. Shock

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

Type:

 hypovolemic

 cardiogenic

 septic

 toxic

o. Acute myocarditis

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

p. Acute myocardial dysfunction

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

q. Acute myocardial infarction

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

r. Seizures

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

s. Reye’s syndrome

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

t. Acute encephalitis / encephalopathy

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

u. Guillain-Barre syndrome

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

v. Rhabdomyolysis

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

w. Acute liver impairment

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

x. Acute renal failure

 Yes, date started:___/___/_____

stopped: ___/___/_____

 No

 Unknown

y. Other, specify: ____________________________

 Yes, date started:___/___/_____

stopped: ___/___/_____

z. Other, specify: ____________________________

 Yes, date started:___/___/_____

stopped: ___/___/_____

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 pregnant

 Uncomplicated labor/delivery

 Complicated labor/delivery Describe ______________________________________________

 Fetal loss 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:

1

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