AFM Patient Summary Form track changes

AFM-patient-summary-form-update abridged 7.27.2017_edits_20180122_tracked.docx

National Disease Surveillance Program

AFM Patient Summary Form track changes

OMB: 0920-0009

Document [docx]
Download: docx | pdf


Acute Flaccid Myelitis: Patient Summary Form

FOR LOCAL USE ONLY

Name of person completing form: ______________________________________________________ State assigned patient ID: ____________________________

Affiliation__________________________________________ Phone: ____________________________Email: __________________________________________

Name of physician who can provide additional clinical/lab information, if needed ___________________________________________________________________

Affiliation_____________________________________________ Phone: ___________________________ Email: ________________________________________

Name of main hospital that provided patient’s care: ________________________________________________ State: _____ County: ______________________

-------------------------------------------------------------DETACH and transmit only lower portion to [email protected] if sending to CDC-------------------------------------------------------------

Shape1

Form Approved

OMB No. 0920-0009

Exp Date: 06/30/2019



Acute Flaccid Myelitis: Patient Summary Form

Shape2

Please send the following information along with the patient summary form (check information included):

History and physical (H&P) MRI report MRI images Neurology consult notes EMG report (if done)

Infectious disease consult notes (if available) Vaccination record Diagnostic laboratory reports


1. Today’s date__ __/__ __/__ __ __ __ (mm/dd/yyyy) 2. State assigned patient ID: ______________________________

3. Sex: M F 4. Date of birth __ __/ __ __/ __ __ __ __ Residence: 5. State_______ 6. County______________________

7. Race: American Indian or Alaska Native Asian Black or African American 8. Ethnicity: Hispanic or Latino

Native Hawaiian or Other Pacific Islander White (check all that apply) Not Hispanic or Latino

9. Date of onset of limb weakness __ __/__ __/__ __ __ __ (mm/dd/yyyy)

10. Was patient admitted to a hospital? yes no unknown 11.Date of admission to first hospital__ __/__ __/__ __ __ __

12.Date of discharge from last hospital__ __/__ __/__ __ __ __(or still hospitalized at time of form submission)

13. Did the patient die from this illness? yes no unknown 14. If yes, date of death__ __/__ __/__ __ __

SIGNS/SYMPTOMS/CONDITION:


Right Arm

Left Arm

Right Leg

Left Leg

15. Weakness? [indicate yes(y), no (n), unknown (u) for each limb]

Y N U

Y N U

Y N U

Y N U

15a. Tone in affected limb(s) [flaccid, spastic, normal for each limb]

flaccid

spastic

normal

unknown

flaccid

spastic

normal

unknown

flaccid

spastic

normal

unknown

flaccid

spastic

normal

unknown


Yes

No

Unk


16. Was patient admitted to ICU?




17. If yes, admit date: __ __/__ __/__ __ __ __

In the 4-weeks BEFORE onset of limb weakness, did patient:

Yes

No

Unk


18. Have a respiratory illness?




19. If yes, onset date __ __/__ __/__ __ __ __

20. Have a gastrointestinal illness (e.g., diarrhea or vomiting)?




21. If yes, onset date __ __/__ __/ __ __ __ __

22. Have a fever, measured by parent or provider 38.0°C/100.4°F?




23. If yes, onset date __ __/__ __/__ __ __ __

24. Travel outside the US?




25. If yes, list country:


26. At onset of limb weakness, does patient have any underlying illnesses?




27. If yes, list:



Other patient information:

28. Was MRI of spinal cord performed? yes no unknown 29. If yes, date of spine MRI: __ __/__ __/__ __ __ __

30. Was MRI of brain performed? yes no unknown 31. If yes, date of brain MRI: __ __/__ __/__ __ __ __



CSF examination: 32. Was a lumbar puncture performed? yes no unknown

If yes, complete 32 (a,b) (If more than 2 CSF examinations, list the first 2 performed)


Date of lumbar puncture

WBC/mm3

% neutrophils

% lymphocytes

% monocytes

% eosinophils

RBC/mm3

Glucose mg/dl

Protein mg/dl

32a. CSF from LP1









32b. CSF from LP2














Shape3

Acute Flaccid Myelitis Outcome – follow-up (completed at least 60 days after onset of limb weakness)

33. Date of follow-up: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

34. Impairment:

None Minor (any minor involvement) Significant (impacts daily life and independence ≤2 extremities, major involvement)

Severe (≥3 extremities and respiratory involvement) Death (Date: __ __/__ __/__ __ __ __ (mm/dd/yyyy) Unknown



35. Physical condition (includes cardiovascular, gastrointestinal, urologic, endocrine as well as neurologic disorders):

  1. Medical problems sufficiently stable that medical or nursing monitoring is not required more often than 3-month intervals

  2. Medical or nurse monitoring is needed more often than 3-month intervals but not each week.

  3. Medical problems are sufficiently unstable as to require medical and/or nursing attention at least weekly.

  4. Medical problems require intensive medical and/or nursing attention at least daily (excluding personal care assistance)



36. Upper limb functions: Self-care activities (drink/feed, dress upper/lower, groom, wash) dependent mainly upon upper limb function:

  1. Age-appropriate independence in self-care without impairment of upper limbs

  2. Age-appropriate independence in self-care with some impairment of upper limbs

  3. Dependent upon assistance in self-care with or without impairment of upper limbs.

  4. Dependent totally in self-care with marked impairment of upper limbs.



37. Lower limb functions: Mobility (walk, stairs, wheelchair, transfer to chair/toilet/tub or shower) dependent mainly upon lower limb function:

  1. Independent in mobility without impairment of lower limbs

  2. Independent of mobility with some impairment of lower limbs, such as needing ambulatory aids such as a brace or prosthesis.

  3. Dependent upon assistance or supervision in mobility with or without impairment of lower limbs.

  4. Dependant totally in mobility with marked impairment of lower limbs.



38. Sensory components: Relating to communication (speech and hearing) and vision:

  1. Age-appropriate independence in communication and vision without impairment

  2. Age-appropriate independence in communication and vision with some impairment such as mild slurred speech, delayed speech or need for eyeglasses or hearing aid.

  3. Dependent upon assistance, an interpreter, or supervision in communication or vision

  4. Dependent totally in communication or vision



39. Excretory functions (bladder and bowel control, age-appropriate):

  1. Complete voluntary control of bladder and bowel sphincters (at least as well as prior to AFM diagnosis)

  2. Control of sphincters allows normal social activities despite urgency or need for catheter, appliance, suppositories, etc.

  3. Dependent upon assistance in bowel and bladder sphincter management

  4. Frequent wetting or soiling from bowel or bladder incontinence



40. Support factors:

  1. Able to fulfil usual age-appropriate roles and perform customary tasks (at least as well as prior to AFM diagnosis)

  2. Must make some modifications in usual age-appropriate roles and performance of customary tasks

  3. Dependent upon assistance, supervision, and encouragement from an adult due to any residual limb weakness or impairment?

  4. Dependent upon long-term institutional care (chronic hospitalization, residential rehabilitation)



Shape4

Acute Flaccid Myelitis case definition (http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2015PS/2015PSFinal/15-ID-01.pdf)

Criteria

An illness with onset of acute focal limb weakness AND

a magnetic resonance image (MRI) showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments, OR

cerebrospinal fluid (CSF) with pleocytosis (white blood cell count >5 cells/mm3)


Case Classification

Confirmed:

An illness with onset of acute focal limb weakness AND

MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments

Probable:

An illness with onset of acute focal limb weakness AND

CSF showing pleocytosis (white blood cell count >5 cells/mm3).



Acute Flaccid Myelitis specimen collection information

(https://www.cdc.gov/acute-flaccid-myelitis/hcp/instructions.html)


Acute Flaccid Myelitis job aid

(https://www.cdc.gov/acute-flaccid-myelitis/downloads/job-aid-for-clinicians.pdf)

Public reporting burden of this collection of information is estimated to average 30 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.

Page 1 of 2 Version 5.0 March 27, 2017

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy