Medical Chart Abstraction Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Undetermined source for Salmonella Infantis infections among detention center inmates — South Carolina, 2016

Chart abstraction form to be used by federal employees

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

1. Patient’s Name:

2. Unit:

3. DOB: //

4. When was the first documented episode of diarrhea: //

5. Admission date: //

6. Discharge date: //

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

Part 1. Demographic Information

1. Gender: M F

Unknown

2. Race (check all that apply)

American Indian or Alaska Native Asian

Black or African American White

Native Hawaiian/other Pacific Islander Unknown

Other race

2. Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Unknown

2. Unit of residence: ____________ Unknown

2. Underlying conditions (check all that apply) None Unknown

Asplenia Autoimmune disease Cancer, any (incl. leukemia/lymphoma) Chronic kidney disease (with or without dialysis) Chronic liver disease (incl. cirrhosis) Chronic pulmonary disease (incl. COPD/emphysema, asthma) Congestive heart failure Connective tissue disease Diabetes mellitus Gastroesophageal reflux disease (GERD) HIV/AIDS

Ischemic heart disease/Myocardial infarction/Peripheral vascular dz IVDU in past year Peptic ulcer disease Pregnancy (current) Prosthetic device or vascular graft Recurrent cystitis or urinary tract infection Sickle cell disease Smoking in past year Transplant (incl. solid organ, hematopoietic stem cell, bone marrow) Other _________________________

2. How long did the patient remain in the medical unit?

_________ Hours Days Did not go to medical unit Unknown

2. In the 30 days prior to illness onset, did the patient receive any form of antacid?: (check all that apply)

   Y	N	Unk
   			a. Calcium carbonate (may be taken for heartburn/indigestion)? [Common medication names include Tums, Maalox, Mylanta, Rolaids]	Name(s): _________
   			b. H2 receptor blocker (may be taken for peptic ulcer disease)? [Common medication names include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)]	Name(s): _________
   			c. Proton pump inhibitor (may be taken for peptic ulcer disease or gastroesophageal reflux disease [GERD])? [Common medication names include omeprazole (Prilosec), pantoprazole (Protonix), lansoprazole (Prevacid), esomeprazole (Nexium)] d.Other	Name(s): _________ Name(s): _________

3. In the 30 days prior to illness onset, did the patient receive any of the following?: (check all that apply)

			a. Any form of radiation therapy?
			b. Abdominal surgery (e.g. removal of appendix, removal of gallbladder, any surgery of the stomach, small intestine or large intestine)	Notes: ___________
			c. Any oral or intravenous (IV) steroid? [Common steroids include prednisone, prednisolone, methylprednisolone, hydrocortisone, dexamethasone]	Name(s): _________
			d. Any other oral, intravenous (IV), or injectable immune-suppressing medication? [Common medication names include azathioprine, cyclosporine, methotrexate, tacrolimus (FK 506), sirolimus, rituximab, infliximab, etanercept, or other chemotherapy]	Name(s): _________
			e. Probiotics	Name(s): _________

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

2. In the 30 days prior to illness onset, did the patient receive any antimicrobial medication(s)?

No antimicrobial medication was given

Yes antimicrobial medication was given (please list them below)

Drug no.	Drug name	Route	Start date (mm/dd/yy)	End date (mm/dd/yy)	Other Comments
1		IV IM PO INH	___/___/___	___/___/___
2		IV IM PO INH	___/___/___	___/___/___
3		IV IM PO INH	___/___/___	___/___/___
4		IV IM PO INH	___/___/___	___/___/___
5		IV IM PO INH	___/___/___	___/___/___
6		IV IM PO INH	___/___/___	___/___/___
7		IV IM PO INH	___/___/___	___/___/___

CDC ID: Date: // Data collector initials: _____

Part 2. Medical unit Information

2. When was the first documented episode of diarrhea? //

3. When was the patient first seen in the medical unit: //

2. What was the highest documented temperature at the time of medical unit visit?
   ______°C ­­­_______°F Unknown

2. What were the documented clinical signs and symptoms?

Symptom	Yes/No/Don’t Know	Onset Date	Resolution Date (only applicable for highlighted symptoms, V/D/F)	Notes
Nausea	Yes No Unk	___/____/_______
Vomiting	Yes No Unk	___/____/_______	___/____/_______
Diarrhea	Yes No Unk	___/____/_______	___/____/_______
Bloody diarrhea	Yes No Unk	___/____/_______
Abdominal pain/cramping	Yes No Unk	___/____/_______
Fever	Yes No Unk	___/____/_______	___/____/_______
Chills	Yes No Unk	___/____/_______
Headache	Yes No Unk	___/____/_______
Body aches	Yes No Unk	___/____/_______
Fatigue/Tiredness	Yes No Unk	___/____/_______
Dizziness	Yes No Unk	___/____/_______
Other:________________	Yes	___/____/_______

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

2. Was any treatment given to the patient in the medical unit? Yes No Unknown

1. If yes, please select all that apply:

Probiotics (specify: ________________________________)

Analgesic/antipyretic medication (specify: ­___________________)

Antidiarrheal medication (specify: ­__________________________)

Antiemetic medication (specify: ­____________________________)

Antimicrobial medication (specify: ­__________________________)

Oral fluids for rehydration (specify: ­_________________________)

Intravenous fluids for rehydration (specify: ­___________________)

Other: __________________________________

Other: __________________________________

2. If any antimicrobial medication(s) were given to treat the gastrointestinal illness, please list them below. If none were given, please mark that none were given.

No antimicrobial medication was ever given

Drug no.	Drug name	Route	First date (mm/dd/yy)	Last date (mm/dd/yy)	Other Comments
1		IV IM PO INH	___/___/___	___/___/___
2		IV IM PO INH	___/___/___	___/___/___
3		IV IM PO INH	___/___/___	___/___/___
4		IV IM PO INH	___/___/___	___/___/___
5		IV IM PO INH	___/___/___	___/___/___
6		IV IM PO INH	___/___/___	___/___/___
7		IV IM PO INH	___/___/___	___/___/___

2. What diagnoses were given to the patient in the medical unit?

No.	Diagnoses
1
2
3
4
5
6
7

2. Was this patient ever hospitalized? Yes No Unknown

2. If yes, on what day was he/she admitted? //

3. When was he/she discharged? //

4. What were the discharge diagnoses?

No.	Discharge diagnoses
1
2
3
4
5
6
7

2. Were any specimens collected for laboratory testing at the medical unit? Yes No Unknown

5. If yes, please proceed to Part 3 of this form.

6. If no, end of survey.

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

Part 3. Laboratory testing – Positive Culture Data

19. Were cultures done? Yes No Unknown

If “Yes,” complete the table below.

Positive Cultures

Culture No.	Specimen ID -------------------- Alternate ID	Specimen	Collect date (mm/dd/yy)	Positive for any pathogen?	Pathogens identified	AST data recorded in AST Table?
1		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
2		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
3		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
4		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
5		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
6		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
7		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N
8		Stool Blood Other _______________________	____ / ___ / ___	Y N Unk	Path1 ________ Path2 ________ Path3 ________	Path1: Y N Path2: Y N Path3: Y N

MEDICAL RECORD ABSTRACTION FORM

CDC ID: Date: // Data collector initials: _____

19. Table 4: Antimicrobial Sensitivity

Complete the AST table below by filling in the culture no. from the positive culture table, checking the appropriate pathogen, and circling the corresponding AST results.

Culture No. _______ Pathogen No. _______		Culture No. _______ Pathogen No. _______		Culture No. _______ Pathogen No. _______			Culture No. _______ Pathogen No. _______
Amoxicillin-clavulanic acid	S I R N	Amoxicillin-clavulanic acid	S I R N		Amoxicillin-clavulanic acid	S I R N	Amoxicillin-clavulanic acid	S I R N
Ampicillin	S I R N	Ampicillin	S I R N		Ampicillin	S I R N	Ampicillin	S I R N
Azithromycin	S I R N	Azithromycin	S I R N		Azithromycin	S I R N	Azithromycin	S I R N
Cefoxitin	S I R N	Cefoxitin	S I R N		Cefoxitin	S I R N	Cefoxitin	S I R N
Ceftiofur	S I R N	Ceftiofur	S I R N		Ceftiofur	S I R N	Ceftiofur	S I R N
Ceftriaxone	S I R N	Ceftriaxone	S I R N		Ceftriaxone	S I R N	Ceftriaxone	S I R N
Chloramphenicol	S I R N	Chloramphenicol	S I R N		Chloramphenicol	S I R N	Chloramphenicol	S I R N
Ciprofloxacin	S I R N	Ciprofloxacin	S I R N		Ciprofloxacin	S I R N	Ciprofloxacin	S I R N
Gentamicin	S I R N	Gentamicin	S I R N		Gentamicin	S I R N	Gentamicin	S I R N
Kanamycin	S I R N	Kanamycin	S I R N		Kanamycin	S I R N	Kanamycin	S I R N
Streptomycin	S I R N	Streptomycin	S I R N		Streptomycin	S I R N	Streptomycin	S I R N
Sulfamethoxazole	S I R N	Sulfamethoxazole	S I R N		Sulfamethoxazole	S I R N	Sulfamethoxazole	S I R N
Tetracycline	S I R N	Tetracycline	S I R N		Tetracycline	S I R N	Tetracycline	S I R N
	S I R N		S I R N			S I R N		S I R N
	S I R N		S I R N			S I R N		S I R N
	S I R N		S I R N			S I R N		S I R N

19. Culture-Independent Diagnostic Tests:

Test	Results & Notes

END OF ABSTRACTION

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