Appendix 1. Chart Abstraction Form

App 1_Chart Abstract Form.docx

Emergency Epidemic Investigation Data Collections

Appendix 1. Chart Abstraction Form

OMB: 0920-1011

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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

  1. 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

  1. 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

  1. 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

  1. No alteration in consciousness or corticospinal tract signs

  2. 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


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AuthorCenters for Disease Control & Prevention
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File Created2022-10-10

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