Appendix 1. Chart Abstraction Form

Appendix 1. Chart Abstraction Form

Form Approved

CDC ID:_____

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Patient Name: ________________________________________________________

CDC ID#:____________________________________________________________

Hospital #1: _________________________________________________________

MRN#: ___________________________________________________

Hospital #2 (if transferred): _____________________________________________

MRN#: ___________________________________________________

Street Address: _______________________________________________________

City: ________________________ State: _______ Zip: ____________

Country:_________________

Telephone number: ______________________

Alt Telephone number:______________________

Public reporting burden of this collection of information is estimated to average XX 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-XXXX)

Name of person completing form:_______________________________________________

Demographic Information

Age: ________ DOB___ __/ __ __ / __ __ __ __

Sex:  Male  Female

What is your race? (Check all that apply.): American Indian or Alaska Native Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White

Are you Hispanic or Latino?:  Yes  No

Work (describe):

Timeline and Outcome

Date of prodrome (includes GI symptom) onset: ____/____/_________

 No prodrome

Date of neuro illness onset: ____/____/_________

Date of first hospital admission: ____/____/_________

Initial or admitting diagnosis:

Outcome of illness:  Died (Date (dd/mmm/yyyy):_________________)  Discharged to chronic care or rehabilitation facility  Discharged to home (Date:_________________)  Still hospitalized

(Date:_________________)

Prodrome Illness Symptoms

Diarrhea Yes No Unk Vomiting Yes No Unk Fever Yes No Unk Cough Yes No Unk Sore Throat Yes No Unk Joint pains/aches Yes No Unk

Bloody stool Yes No Unk Rash Yes No Unk Headache Yes No Unk Abdominal Pain Yes No Unk Other__________________________

Duration of prodromal symptoms: ___________ days

Location of patient in 7 days before prodromal symptoms:

Past Medical and Neurological History

Past Medical and Neurological History (include EtOH, tobacco, drug use):

Exposure History

Travel History (include all places visited in prior 30 days—include dates of travel):

Describe any agricultural or pesticide exposure in past 6 weeks:

Any upper respiratory infection in the last 6 weeks? Yes No Unk If yes,

What date of onset?: ____/____/_________

Any gastrointestinal infection in the last 6 weeks? Yes No Unk If yes,

What date of onset?: ____/____/_________

Any vaccinations received in the last 6 weeks? Yes No Unk

If yes, date of receipt: __ / __/ _____ If yes, vaccine(s)_administered________________________________

Ill household contacts in the past 6 weeks? Yes No Unk If yes,

Nature of illness: _____________________________________________________

Toxic/Chemical Exposures

1. Did patient recall taking any herbal or folk remedies during 2 weeks prior to illness onset?

 Yes

 No

 Unknown

If YES,

Remedy 1: __________________________________

Remedy 2: __________________________________

3. Did patient recall eating any wild picked plants (like. buckthorn or Karwinskia Humboldt pictured below) during 2 weeksprior to illness onset?

 Yes

 No

 Unknown

If YES,

Plant 1: __________________________________

Plant 2: __________________________________

Neuro Symptoms

Initial neurological signs and symptoms (describe):

Onset of weakness within first week of neuro illness?

 Yes

 No

 Unknown

Concurrent symptoms:

 Fever

 Headache

 Meningismus (nuchal rigidity, photo/phonophobia)

 Altered mental status

 Nausea/vomiting

 Muscle pain/myalgia

 Other

Specify if other: __________________________________________________________________________________________

Distribution of weakness at first onset (e.g. first noted weakness)

 Symmetric

 Asymmetric

 Unknown

Check all that apply:

 Right UE

 Left UE

 Right LE

 Left LE

 Prox

 Dist

 Prox

 Dist

 Prox

 Dist

 Prox

 Dist

 Neck Flexors/Extens.

 Respiratory muscles

 Quadriplegia/whole body paralysis

 Facial muscles

Describe weakness distribution: __________________________________________________________________________

Nature of weakness onset:

 Ascending

 Descending

 Acute/whole limb

 Unknown

Approximate time interval to maximal weakness: ________________________

Distribution of weakness at maximal weakness

 Symmetric

 Asymmetric

 Unknown

Check all that apply:

 Right UE

 Left UE

 Right LE

 Left LE

 Prox

 Dist

 Prox

 Dist

 Prox

 Dist

 Prox

 Dist

 Neck Flexors/Extens.

 Respiratory muscles

 Quadriplegia/whole body paralysis

 Facial muscles

Describe weakness distribution at maximum: ___________________________________________________________________

Approximate date of maximal weakness: ____/____/_______________

Reflexes in affected body parts at time of maximal weakness:

 Areflexic

 Hyporeflexic

 Reflexes normal

 Hyperreflexic/spastic

 Reflexes not tested

 Unknown

Tone in affected body parts at time of maximal weakness:

 Flaccid

 Hypotonic

 Tone normal

 Hypertonic/spastic

 Tone not tested

 Unknown

Sensory abnormalities present?

 Yes

 No

 Unknown

Date of sensory symptom onset: _____/_____/____________

Description of sensory abnormalities: __________________________________________________________________________ type _____________________________________

Pain present?

 Yes

 No

 Unknown

Date of pain onset: ____/____/_________________

Description/location of pain: _________________________________________________________________________

Prominent dyspnea/shortness of breath present?

 Yes

 No

 Unknown

Approximate date of dyspnnea onset: ____/____/__________

Patient ever intubated?

 Yes

 No

 Unknown

If yes, date of intubation:

Date of extubation:

Tracheostomy required?

 Yes

 No

 Unknown

Bowel/Bladder involvement present?

 Yes

 No

 Unknown

Description of bowel/bladder involvement: _______________________________________________________________

Date of bowel/bladder involvement: ____/____/__________________

Dysarthria and/or dysphagia present?		 Yes	 No		 Unknown
Date of dysarthria/dysphagia: ____/____/___________
Description of dysarthria/dysphagia: ______________________________________________________________________________
15. Any other cranial nerve abnormalities present?		 Yes		 No	 Unknown
If yes, specify cranial nerve abnormality, as specifically as possible:
Date of onset of CN abnormality: ____/____/____________	Date of resolution of CN abnormality: ____/____/____________
Ataxia present?  Yes  No  Unknown
If yes, date ataxia noted / recorded: ___/___/________
Does the Neurology Consult Note attribute neurologic symptoms to a definitive diagnosis other than Guillain-Barre Syndrome?  Yes  No If yes, what was the rendered diagnosis: ___________________________________________
Hospital Course
Please list nosocomial complications (if any):
Laboratory Testing
Serum Potassium ____________ on admission ____________ most abnormal Serum Calcium ____________ on admission ____________ most abnormal
Cerebrospinal fluid
Did the patient have any lumbar punctures (LP) performed within 30 days of onset of weakness?  Yes  No  Unknown
Date CSF 1: __/__/____ WBC _____/mm3 RBC_____/mm3 Protein_____ mg/dL Glucose_____ mg/dL
WBC differential: Neutrophils_____% Lymphocytes______% Monocytes______% Eosinophils_____%
Date CSF 2: __/__/____ WBC _____/mm3 RBC_____/mm3 Protein_____ mg/dL Glucose_____ mg/dL
WBC differential: Neutrophils_____% Lymphocytes______% Monocytes______% Eosinophils_____%
12. CSF Gram’s Stain:		Record result:__________________________________________
13. CSF VRDL:		14. CSF Cryptococcal Antigen:
18. CSF Oligoclonal Bands:		19. IgG Index:
20. IgG Synthesis Rate:		21. Myelin Basic Protein:

Neurodiagnostics: Please indicate whether the following tests were performed. Record all results on accompanying worksheet.
1.  Head computed tomography			2.  Spinal computed tomography
3.  Brain magnetic resonance imaging			4.  Spinal magnetic resonance imaging
5.  Electromyography/nerve conduction studies			6.  Pulmonary fluoroscopic studies
Please indicate whether any of the following treatments or procedures were rendered during the course of illness:
1.  Intravenous Immune Globulin (IVIG)		Date started: ____/____/_____				Date stopped: ____/____/_______
2.  Plasmapheresis/plasma exchange		Date started: ____/____/_____				Date stopped: ____/____/_______
3.  Alpha-interferon		Date started: ____/____/_____				Date stopped: ____/____/_______
4.  Corticosteroids		Date started: ____/____/_____				Date stopped: ____/____/_______
If yes, dosage used: __________________________________________________________________
5.  Other immunomodulating agent (Imuran, etc.)		Date started: ____/____/_____				Date stopped: ____/____/_______
If yes, specify: _________________________________________________
7.  Muscle biopsy	If yes, date obtained: ____/____/______________
If yes, specify site of biopsy: _______________________________________________________________________
If yes, narrative of result: ________________________________________________________________________________________
_______________________________________________________________________________________________________________

Lab results: Culture results

If any bacterial, viral or fungal culture results were obtained, please note the following results

Culture type

Result

Specimen type*

Date

(Check one)

(Check one)

If positive:

Bacterial

Viral

Fungal

No growth

Positive

Organism 1

Organism 2

Organism 3

*Specimen type: Blood, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate, pericardial fluid, peritoneal fluid, pleural fluid, sputum, synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine

Diagnostic Tests for Other Infectious Diseases (include Antibody tests/serology, antigen detection, PCR and special stains)

Specimen type*

Date

Test performed

Results

Interpretation

Laboratory

*Specimen type: Blood, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate, pericardial fluid, peritoneal fluid, pleural fluid, acute serum, convalescent serum, paired sera, sputum, synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine

Please attach results of all neurodiagnostics (include detailed EMG results if available):

FINAL BRIGHTON CASE DEFINITION CLASSIFICATION: (See Appendix

Guillain-Barre Syndrome

• Level I

• Level 2

• Level 3

• Level 4

• Level 5

Fisher Syndrome:

• Level I

• Level 2

• Level 3

• Level 4

• Level 5

APPENDIX I: BRIGHTON CASE DEFINITION CRITERIA

Guillain-Barré Syndrome

Level I (requires ALL criteria)

1. Bilateral AND flaccid weakness of the limbs

2. Decreased or absent deep tendon reflexes in weak limbs

3. Monophasic illness pattern AND interval between onset and nadir of illness between 12 hours and 28 days AND subsequent clinical plateau

4. Electrophysiologic findings consistent with GBS

5. Cytoalbuminologic dissociation (i.e., elevation of CSF protein level above laboratory normal value AND CSF total white cell count <50 cells / mm3

6. Absence of an identified alternative diagnosis for weakness

Level 2

1. Criteria 1, 2, and 3 for Level 1 fulfilled

AND

2. CSF 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, electrophysiologic studies consistent with GBS

3. Absence of identified alternative diagnosis for weakness

Level 3

1. Criteria 1, 2, and 3 for Level 1 fulfilled

2. Absence of identified alternative diagnosis for weakness

Level 4

1. Reported event of GBS, with insufficient evidence to meet case definition

Level 5

1. Not a case of GBS

Fisher Syndrome

Level 1 (Requires ALL Criteria)

1. Bilateral ophthalmoparesis AND bilateral reduced or absent tendon reflexes, AND ataxia

2. Absence of limb weakness

3. Monophasic illness pattern AND interval between onset and nadir of weakness between 12 hours and 28 days AND subsequent clinical plateau

4. Cytoalbuminologic dissociation (i.e., elevation of cerebrospinal protein above the laboratory normal AND total CSF white cell count <50 cells/mm3)

5. Nerve conduction studies are normal, OR indicate involvement of sensory nerves only

6. No alteration in consciousness or corticospinal tract signs

7. Absence of an identified alternative diagnosis

Level 2

1. Criteria 1, 2, and 3 for Level 1 fulfilled

AND

2. Cerebrospinal fluid (CSF) with a total white cell count <50 cells/mm3 (with or without CSF protein elevation above laboratory normal value)

OR

Nerve conduction studies are normal, OR indicate involvement of sensory nerves only

3. No alteration in consciousness or corticospinal tract signs

4. Absence of an identified alternative diagnosis

Level 3

1. Criteria 1, 2, 3, 6, and 7 for Level 1 fulfilled

Levels 4 and 5 as for GBS

3