Document
Emergency Epidemic Investigations
ICR 201610-0920-005 · OMB 0920-1141 · Object 68716701.
Document Viewer [docx]
Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Emergency Epidemic Investigations |
| Author | CDC User |
| Last Modified By | Writer |
| File Modified | 2016-10-14 |
| File Created | 2026-10-10 |
| Conversion State | complete |
Extracted Text
Chart Abstraction Questionnaire for the Investigation of Severe Neurologic Illness
in Relation to Arboviral Infections
Chart Abstractor: ____________________________ Abstraction Date: __ __ /__ __ /________
MRN: ____________________________ MM DD YYYY
Hospital: ____________________________
1. First name: _______________________________ Middle name: ______________________________
2. Paternal name: ____________________________ Maternal name: _____________________________
3. Age (years): ______________________________ Date of birth: __ __ /__ __ /________
MM DD YYYY
4. Sex: □ Male □ Female
5. Patient address: ___________________________________________________________________________
6. Patient zip code: ____ ____ ____ ____ ____
7. Patient phone number: ______________________
8. Date of admission: __ __ /__ __ /________ Date first sought care: __ __ /__ __ /________
MM DD YYYY MM DD YYYY
Date of discharge/death: __ __ /__ __ /________
MM DD YYYY
9. Discharged to:
□ Home (with outpatient PT: Yes / No) □ Rehab/skilled nursing facility □ Hospice
□ Transferred (specify hospital) ________________ □ Died □ Other (specify) _______________
10. Health insurance: □ Reforma/SSS □ Private □ Veteran’s □ None □ Other (specify) _______________
11. How long from onset until hospital admission? __________minutes/hours/days/weeks
12. What were the initial neurologic symptoms within the three days prior to 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 □ Dysarthria □ Dysphagia □ Dysautonomia
□ Face weakness (circle: unilateral or bilateral)
13. 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 □ Dysarthria □ Dysphagia □ Dysautonomia
□ Face weakness (circle: unilateral or bilateral
14. Were motor deficits present? □ Yes □ No □ Unknown If so, describe:__________________________
15. Date of maximum/worst neuro symptoms: __ __ /__ __ /________
MM DD YYYY
16. At the worst point during this neuro illness, check all that apply for the patient:
□ Unable to walk without assistance □ Unable to walk at all □ Admitted to the hospital □ Admitted to the ICU/CCU □ Intubated □ Coma
17. Was there documented hyporeflexia/areflexia? □ Yes □ No □ Unknown
18. Was there documentation of upper motor neuron signs?
□ Hyperreflexia □ Increased tone/spasticity □ Babinski/Hoffman □ Sustained clonus
19. Was there any sensory level documented? □ Yes □ No □ Unknown
20. 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
Acyclovir □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY
Other □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY
21. Did the patient receive blood transfusion/blood products (other than IVIg)?
□ Yes □ No □ Unknown If so, which: ______________ Start date __ __ /__ __ /________
MM DD YYYY
22. 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 ___
23. 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___________
Opening pressure ___________________
Was an additional 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___________
Opening pressure ___________________
24. Were any of the following pathogens 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. Herpes simplex virus (HSV) □ Yes □ No Result: _____________________________________
j. Enterovirus / Rhinovirus □ Yes □ No Result: _____________________________________
k. Arboviruses □ Yes □ No Result: _____________________________________
l. Cryptococcus □ Yes □ No Result: _____________________________________
m. Toxoplasmosis □ Yes □ No Result: _____________________________________
n. Other: __________________________ □ Yes □ No Result: _____________________________________
o. Other: __________________________ □ Yes □ No Result: _____________________________________
p. Other: __________________________ □ Yes □ No Result: _____________________________________
q. Other: __________________________ □ Yes □ No Result: _____________________________________
r. Other: __________________________ □ Yes □ No Result: _____________________________________
s. Other: __________________________ □ Yes □ No Result: _____________________________________
25. Was neuro imaging done? If so, what was the result? (Transcribe the impression)
□ Yes □ No Result: _______________________________________________________________________
__________________________________________ Date __ __ /__ __ /________
MM DD YYYY
26. Were electro-diagnostics done (e.g. EMG)? If so, what were the results? (Transcribe the impression)
□ Yes □ No Result: _______________________________________________________________________
__________________________________________ Date __ __ /__ __ /________
MM DD YYYY
27. What was the GBS Brighton level? 1 2 3 4 5
28. a.) In the 2 months prior to neuro onset date, did the individual experience an acute illness?
□ Yes □No □ Unknown
How long from prior acute illness onset until admission for neuro illness? _________ minutes/hours/days/weeks
29. b.) 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
c.) 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 ___
d.) Were they hospitalized for this acute illness? □ Yes □ No □ Unknown
e.) Did they receive any blood products / IVIg for this illness? □ Yes □ No □ Unknown
What product? _____________________ Date? __ __ /__ __ /________
MM DD YYYY
g.) Did they receive plasmapheresis / plasma exchange for this illness? □ Yes □ No □ Unknown
If yes, date? __ __ /__ __ /________
MM DD YYYY
30. Is there a test result available for dengue from this medical visit? □ Yes □ No □ Unknown
31. Is there a test result available for chikungunya from this medical visit? □ Yes □ No □ Unknown
32. Is there a test result available for Zika from this medical visit? □ Yes □ No □ Unknown
33. What medical conditions are listed in the admission history and physical (H&P)?
□ Hypertension □ Diabetes □ HIV □ Syphilis □ Autoimmune disorder____________
□ B12 deficiency □ Hemoglobinopathy □ Prior GBS □ Cancer _______________________
34. What conditions are listed in family history of H&P?
□ Autoimmune disorder (specify): ___________________ □ Cancer (specify): _____________________
□ Hemoglobinopathy (specify): _____________________ □ Neuro (specify): ______________________
35. What social conditions are listed in admission H&P?
□ Alcohol use □ Drug use □ Tobacco □ Other ________________________
36. Did the patient receive a vaccine in the previous 6 months? □ Yes □ No □ Unknown
If yes, vaccine: _________________ Date of vaccination: __ __ /__ __ /________
MM DD YYYY
37. What other neurologic conditions were identified by the provider?
□ ADEM □ CIDP □ Encephalitis □ Encephalomyelitis □ Facial paralysis
□ Meningoencephalitis □ Myasthenia gravis □ Myelitis □ Myelopathy
□ Multiple sclerosis (MS) □ Neuropathy □ Optic neuritis □ Paresthesia
□ Papilledema □ Transverse myelitis □ Sensory motor peripheral neuropathy
□ Stroke □ Other: _________________________________________________________
38. Additional signs or symptoms not already noted:
□
Agitation
□
Altered lacrimal gland secretion
□
Altered mental status
□
Altered salivary gland secretion
□
Aphasia
□
Confusion
□
Drooping corner of mouth
□
Eye pain
□
Eyebrow sagging
□
Fatigable chewing
□
Fever
□
Headache
□
Inability to close eye
□
Irritability
□
Lethargy
□
Lower extremity dysthesesia
□
Loss of taste anterior 2/3 of tongue
□
Memory loss
□
Nausea
□
Nasolabial fold disappearance
□
Nuchal rigidity
□
Nystagmus
□
Oculomotor deficits
□
Personality changes
□
Ptosis
□
Seizures
□
Sensory deficits:
□
Somnolence
______________________
□
Transient visual obscuration
□
Tremors
□
Upper extremity dysthesesia
□
Urinary retention
□
Vision loss
□
Vomiting
□
Other: _________________
□
Other: ___________________