Enterovirus D68 (ev-d68) Patient Summary Form




Дата канвертавання19.04.2016
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Enterovirus D68 (EV-D68) Patient Summary Form
To be completed for all patients for whom specimens are being submitted to CDC for EV-D68 typing. As soon as possible, please 1) notify and send completed form to your local/state health department, and 2) include a hard copy of the form along with the 50.34 form for specimen shipment.


Today’s Date:      

Name of person filling in form:      


Phone:      
Email:      


Hospital / Health Care Facility Name:      
STATE:      
COUNTY:      


Hospital ID:      
State ID:      


Specimen ID (as submitted on 50.34 form for specimen shipment):      

If multiple specimens are submitted per patient, please include additional specimen IDs in table below
Patient Sex:  M F Age:        Days Months  Years Patients State of Residence      
Race:  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  American Indian or Alaska Native

 White (More than one box can be checked) Ethnicity:  Hispanic  Non-Hispanic


Date of symptom onset:      
Symptoms (mark all that apply):  Fever / Highest recorded temperature       (°F / °C )  Chills  Cough  Wheezing  Sore throat
 Runny nose  Shortness of breath / difficulty breathing  Tachypnea  Retractions  Cyanosis  Vomiting  Diarrhea  Rash
 Lethargy  Seizure  Other (describe):      
Does the patient have any comorbid conditions? (mark all that apply):  None  Unknown  Asthma  Reactive airway disease
 Bronchopulmonary dysplasia  Cardiac disease  Immunocompromised  Prematurity, if yes gestational age      
 Other (describe):      
Abnormal Chest radiograph  Yes  No  Unknown Abnormal Chest CT  Yes  No  Unknown





Yes

No

Unknown

Is/Was the patient: Hypoxic (sat <93%) on room air?







Treated with supplemental oxygen?







Treated with bronchodilators?







Treated with antibiotics?







Hospitalized? If Yes, admission date:      







If Yes, was the patient admitted to the Intensive Care Unit (ICU)?







If Yes was the patient placed on non-invasive ventilation (BiPAP/CPAP)







If Yes, was the patient intubated?







If Yes, was the patient placed on ECMO?







Did the patient die? If Yes, date of death:      










General Pathogen Laboratory Testing (mark all that apply)

Pathogen

Pos

Neg

Pending

Not Done

Pathogen

Pos

Neg

Pending

Not Done

Influenza A PCR









Rhinovirus and/or Enterovirus









Influenza B PCR









Coronavirus (not MERS-CoV)









Influenza Rapid Test









Chlamydophila pneumoniae









RSV









Mycoplasma pneumoniae









Human metapneumovirus









Legionella pneumophila









Parainfluenzavirus









Streptococcus pneumoniae









Adenovirus









Blood culture  Yes  No If positive, which bacteria:      

Other:      









CSF culture  Yes  No If positive, which bacteria:      

Other:      









Sputum culture  Yes  No If positive, which bacteria:      




Enterovirus Typing - Specimen Type

Date Collected

Specimen ID

Enterovirus Typing - Specimen Type

Date Collected

Specimen ID

 NP  OP  NP/OP (check one)

     

     

Bronchoalvelolar lavage (BAL)

     

     

Nasal wash / aspirate

     

     

Tracheal Aspirate

     

     

Sputum

     

     

Stool/Rectal swab

     

     

Other:      

     

     

Other:      

     

     

To be completed by CDC: Patient ID:      

CSID:      

CSID:      

CSID:      

CSID:      

CSID:      


Version 1.0 (fillable), September 12, 2014


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