Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission— Colombia, 2016
The ID number begins with the 2 digit case number (for example COL-01). Information as documented by attending physician.
The following pages are to be abstracted from the medical records / exam:
Chart Abstractor: ____________________________ Abstraction Date: __ __ /__ __ /________
MRN: ____________________________ MM DD YYYY
First name: _______________________________ Middle name: ______________________________
Paternal name: ____________________________ Maternal name: _____________________________
Age
(years): ______________________________ Date of birth: __ __ /__
__ /________
MM DD YYYY
Sex: □ Male □Female
Patient address: ___________________________________________________________________________
Patient zip code: ____ ____ ____ ____ ____
Patient phone number: ______________________
Date
of neuro symptom onset: __ __ /__ __ /________ Date first sought
care: __ __ /__ __ /________
MM DD YYYY
MM DD YYYY
Date
of admission: __ __ /__ __ /________ Date of discharge/death: __ __
/__ __ /________
MM DD YYYY MM DD
YYYY
Discharged to:
□ Home □ Rehab/skilled nursing facility □ Transferred □ Died □ Other (specify) _____________
CURRENT ILLNESS |
How
long from onset until hospital admission?
__________minutes/hours/days/weeks
What were the initial neurologic symptoms (i.e. within the three days of illness onset)? (check all that apply, signs from PE, symptoms from HPI)
□ Leg weakness □ Arm weakness □ Diplopia/Ophthalmoplegia
□ Leg numbness/paresthesias □ Arm numbness/paresthesias □ Face numbness/paresthesias
□
SOB
/ respiratory distress □
Gait
imbalance (not weakness)/ataxia □
Hand
clumsiness/ataxia
□ Hyporeflexia/areflexia □
Face
weakness □
Dysarthria □
Dysphagia
□
Dysautonomia
What neurologic symptoms occurred AT ANY TIME during the neuro illness? (check all that apply, signs from PE, symptoms from HPI)
□ Leg weakness □ Arm weakness □ Diplopia/Ophthalmoplegia
□ Leg numbness/paresthesias □ Arm numbness/paresthesias □ Face numbness/paresthesias
□
SOB
/ respiratory distress □
Gait
imbalance (not weakness)/ataxia □
Hand
clumsiness/ataxia
□ Hyporeflexia/areflexia □
Face
weakness □
Dysarthria
□
Dysphagia
□
Dysautonomia
How long from onset until maximum/worst neuro symptoms? ____________ minutes/hours/days/weeks
At the worst point during this neuro illness, check all that apply for the patient:
□ Unable to walk without assistance (e.g. cane, walker) □ Unable to walk at all
□ Admitted to the hospital □ Admitted to the ICU/CCU □ Intubated
If any blood was taken for this neurologic illness, please fill out the following for the INITIAL blood draw:
Date
__ __ /__ __ /_______ WBC ____ HgB____ Plts _____ Na ____ K____
MM DD YYYY
BUN ____ Cr ______ Glucose____ TBili____ AST ____ ALT____ AlkPhos ___
Was there documented hyporeflexia/areflexia? □ Yes □ No □ Unknown
Was there documentation of upper motor neuron signs?
□ Hyperreflexia □ Increased tone/spasticity □ Babinski/Hoffman □ Sustained clonus
Was
there any sensory level documented?
□ Yes □
No □
Unknown
LABORATORY, IMAGING, AND ELECTROPHYSIOLOGIC STUDIES |
Was a lumbar puncture (LP) done? □ Yes □ No □ Unknown
LP
date ___/____/____ RBCS _______ WBCS ______ Protein
(mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY
Differential________________________IgG index______ Oligoclonal bands______ IgG synthesis___________
LP
date ___/____/____ RBCS _______ WBCS ______ Protein
(mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY
Differential________________________IgG
index______ Oligoclonal bands______ IgG synthesis___________
Did they receive any targeted treatment (IVIG/steroids/plasma exchange) for this neuro illness?
IVIG
□
Yes □
No
□
Unknown Start
date __ __ /__ __ /________
MM DD YYYY
Plasma exchange □
Yes □
No
□
Unknown Start
date __ __ /__ __ /________
MM DD YYYY
Steroids
□
Yes □
No
□
Unknown Start
date __ __ /__ __ /________
MM DD YYYY
Mechanical ventilation □
Yes □
No
□
Unknown Start
date __ __ /__ __ /________
MM DD YYYY
Other
□
Yes □
No
□
Unknown Start
date __ __ /__ __ /________
MM DD YYYY
Did the patient receive blood transfusion/blood products? (other than IVIG)
□ Yes □
No □
Unknown which one________________ Start date __ __ /__ __
/________
MM DD
YYYY
Were any of the following diseases tested for? If so, what was the result? (including specimen and type of test)
a. Campylobacter jejuni □ Yes □ No Result:___________________________
b. Mycoplasma pneumoniae □ Yes □ No Result:___________________________
c. Haemophilus influenzae □ Yes □ No Result:___________________________
d. Salmonella spp. □ Yes □ No Result:___________________________
e. Cytomegalovirus (CMV) □ Yes □ No Result:___________________________
f. Epstein-Barr virus (EBV) □ Yes □ No Result:___________________________
g. Varicella-zoster virus (VZV) □ Yes □ No Result:___________________________
h. Human immunodeficiency virus (HIV) □ Yes □ No Result:___________________________
i.
Enterovirus / Rhinovirus □
Yes □
No Result:___________________________
j. Arboviruses □
Yes
□ No
Result:___________________________
k. Other □ Yes □ No Result:___________________________
Was neuro imaging done? If so, what was the result? (Transcribe the impression)
□ Yes □ No Result:_______________________________________________________________________
__________________________________________ Date __ __ /__ __ /________
MM DD YYYY
Were electro-diagnostics done (e.g. EMG)? If so, what were the results? (Transcribe the impression)
□ Yes □ No Result:_______________________________________________________________________
__________________________________________ Date __ __ /__ __ /________
MM DD YYYY
What was the GBS Brighton level? 1 2 3 4 5
Levels of Diagnostic Certainty
Level 1 |
Level 2 |
Level 3 |
Level 4* |
Level 5 |
Absence of an alternative diagnosis for weakness |
NOT a case |
|||
Acute onset of bilateral and relatively symmetric flaccid weakness of the limbs |
* Lacking documentation to fulfill minimal case criteria |
|||
Decreased or absent deep tendon reflexes in affected limbs |
||||
Monophasic illness pattern with weakness nadir between 12 hours and 28 days, followed by clinical plateau |
||||
Albuminocytologic dissociation (elevation of CSF protein level above laboratory normal value and CSF total white cell count < 50 cells/mm3) |
CSF with a total white cell count < 50 cells/mm3 (with or without CSF protein elevation above laboratory normal value) or if CSF not collected or results not available, and electrodiagnostic studies consistent with GBS |
|
||
Electrophysiologic findings consistent with GBS |
|
|
ANTECEDENT ILLNESS |
a.) In the 2 months prior to neuro onset date, did the individual experience an acute illness? (other than their neuro illness)? □ Yes □No □ Unknown
b.) How long from prior acute illness onset until admission for neuro illness? _________ minutes/hours/days/weeks
a.) What symptoms did they report having or what signs were noticed? (check all that apply)
□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Conjunctivitis
□ Headache □ Pain behind eyes □ Stiff neck □ Confusion
□ Back pain □ Abdominal pain □ Coughing □ Runny nose
□ Sore throat □ Calf pain □ Pruritis
b.) If any blood was taken for this acute illness, please fill out the following for the INITIAL blood draw:
Date
__ __ /__ __ /________ WBC ____ HgB____ Plts _____ Na
____ K____
DD MM YYYY
BUN ____ Cr ______ Glucose____ TBili____ AST ____ ALT____ AlkPhos ___
c.) Were they hospitalized for this acute illness? □ Yes □ No □ Unknown
d.) Did they receive any blood products / IVIG for this illness? □ Yes □ No □ Unknown
What
product? _____________________ Date? __ __ /__ __ /________
MM DD YYYY
e.) Did they receive plasmapheresis / plasma exchange for this illness? □ Yes □ No □ Unknown
If
yes, date? __ __ /__ __ /________
MM DD YYYY
Is there a test result available for dengue from this medical visit? □ Yes □ No □ Unknown
If yes, please specify:_______________________________________
Is there a test result available for chikungunya from this medical visit? □ Yes □ No □ Unknown
If yes, please specify:_______________________________________
Is there a test result available for Zika from this medical visit? □ Yes □ No □ Unknown
If yes, please specify:_______________________________________
PAST MEDICAL, SOCIAL AND FAMILY HISTORY |
What medical conditions are listed in the admission history and physical (H&P)?
□ Hypertension □ Diabetes □ HIV □ Autoimmune disorder____________
□ Prior GBS □ Hemoglobinopathy □ B12 deficiency □ Cancer _______________________
What social conditions are listed in admission H&P?
□ Alcohol use □ Drug use □ Tobacco □ Other ________________________
What conditions are listed in family history of H&P?
□ Autoimmune disorder (specify)___________________ □ Cancer (specify) ____________________
□ Hemoglobinopathy (specify) _____________________ □ Neuro (specify) ____________________
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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |