Free TB Suspect Case Data, DPH 42001 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 42001 (04/01)

TB SUSPECT CASE DATA
Client information is confidential under Wis. Stat. 146.82(1)

STATE OF WISCONSIN Bureau of Communicable Diseases ss. 252.05, Wis. Stats.

FOR INTERNAL USE ONLY: Date Local Health Department Contacted (mm/dd/yyyy) Name Of Patient Address Local Health Department Telephone No. of PHN ( ) Name of Primary Physician Name of Other Physician (Pulmonary Specialist, etc.) CHEST X-RAY Date(s) taken (mm/dd/yyyy) Normal Location Apex LUL RUL RLL BACTERIOLOGY Laboratory where specimen was sent Specimen Information Date Collected Source POS Referral Source Referral Telephone No. ( ) Date Of Birth (mm/dd/yyyy) Patient Telephone No. ( ) Public Health Nurse (PHN)

IN TIMS

Reported To LHD Within 24 Hrs Yes No Race Gender Female Male Patient occupation last 2 years

Date Reported to State TB Program (mm/dd/yyyy) Telephone No. ( ) Telephone No. ( ) Results of X-ray Cavitation Infiltrate Comments: LL RL

Abnormal LLL

Opacity

Granulomas

Nodule

Smear Results

NEG

POS

MTD / PCR NEG Comment

POS

Culture NEG Date Identified

Drug Sensitivities INH RIF PZA SENS SENS SENS RES RES RES Patient's weight INH RIF PZA EMB OTHER(S) SENS SENS SENS DOT Yes If yes, where? RES RES RES No

TREATMENT Date Started (mm/dd/yyyy) Drugs Dose(s) and Frequency PATIENT HISTORY Date of PPD (mm/dd/yyyy) Date of Previous PPD (mm/dd/yyyy)

Regimen Duration EMB OTHER

Results (induration) mm Results (induration) mm

Homeless in the past year?

Yes

No

Unk

Non-injection drug use within the past year? Yes No Unk Yes No Unk Injection drug use within the past year? Alcohol use within the past year? How much and how often? Smoker? Yes No No Regular Excess

If previously tested, list city and state If previous PPD was positive, was treatment for TB infection taken? Yes No If yes, was treatment completed? Yes No Patient history of TB disease? Yes Year (yyyy) No Yes No Family history of TB disease? If yes, who and when (yyyy) Signs and Symptoms cough fever hemoptysis night sweats weight loss loss of appetite Duration/ dates (mm/dd/yyyy) _______________________________ _______________________________________________________ HIV Status positive negative not tested Date tested (mm/dd/yyyy) not offered refused other If not tested, Why? Other risk factors? diabetes kidney disease liver disease immunosuppressed cancer List type___________________ corticosteroid use How much and how long?________________ other risk factors_______________________________________

If yes, how much and how long?

Foreign born? Yes No If yes, country of origin____________ Month and year arrived in USA_______________________________ Type of VISA Visitor / Tourist Other Explain_________________________________________ _______________________________________________________ Recent foreign travel? Yes No If yes, where and when (mm/yyyy) Resident of long-term care or correctional facility? Yes No If yes, which one and how long? Disposition pulmonary extrapulmonary not a case If extrapulmonary, site_____________________________________ laboratory clinical improvement Case verified by Immigrant / Refugee Student Work

Instructions for completing TB SUSPECT CASE DATA
This form is used to gather data on tuberculosis (TB) suspect and confirmed cases. The Department of Health and Family Services requires some of the information in accordance with Wis. Stats. s. 252.05(4) and other data elements are incorporated to assist with TB elimination efforts. Please fill out the form completely and submit it to the Wisconsin TB Program by fax (608) 266-0049 or by mail to: TB Program ­ Division of Public Health, PO Box 2659, Madison WI 53701-2659. Local Health Department Contacted (mm/dd/yyyy), Referral Source, Reported to LHD Within 24 Hrs Date the LHD is notified of the suspect (or case) by whom and was the suspect (or case) reported to the LHD within 24 hours of the patient being considered a suspect. Referral source is the person/agency who refers the suspect (or confirmed case) to the LHD. Wisconsin Administrative Code HFS 145, Appendix A, includes Tuberculosis with Category I diseases of "urgent public health importance" that shall be reported IMMEDIATELY to the patient's local health officer upon identification of a case or suspected case. Once reported to the local health officer, the local health officer is required to notify the State Epidemiologist immediately [HFS 145.04 (4)] Name of Patient, Date of Birth, Gender, Race, Patient Address and Telephone Number Name of Local Health Department (LHD), Public Health Nurse, Telephone Number of PHN Put the name of the primary PHN contact and whichever phone number is better for contacting the PHN (LHD or PHN's direct number). Date Reported to the State TB Program These fields assist in tracking whether reporting time frames are consistent with statutory reporting criteria (see above). Name of Primary Physician, Telephone Number, Name of Other Physician (Pulmonary Specialist, etc.), Telephone Number CHEST X-RAY: Record date(s), Results of X-ray, Location Date(s) and specific result(s). Use comment section for results that are not addressed by the boxes. BACTERIOLOGY: Laboratory where specimen was sent Indicate all laboratories where the specimens were sent for smear, Mycobacterium Tuberculosis Direct (MTD) / polymerase chain reaction (PCR) and culture results. There is often more than one laboratory involved. Specimen information - Date Collected, Source, Smear (POS, NEG, Results), MTD/PCR and Culture For smear results, indicate the amount of AFB seen on positive specimens (e.g. 1-9/field). MTD/PCR note any comments (such as inhibitors, specimen too old, etc.). On the culture, indicate the date the specimen was identified (either as TB or not TB). Drug Sensitivities For each medication, indicate if the TB isolate is sensitive or resistant to the drug TREATMENT: Date started (mm/dd/yyyy), DOT, regimen duration, Drugs, Dose(s) and Frequency Indicate the date the patient began appropriate TB disease treatment, whether or not it was given as directly observed therapy (DOT), and if given via DOT, where DOT occurred (workplace, LHD, home, etc.). Record the initial medication regimen prescribed. PATIENT HISTORY: Date of PPD, Results Document current TB skin test (PPD) information in millimeters Date of Previous PPD, Results Document last known (and documented) previous test date and results If previously tested, list city and state Document where previous test was given. If previous PPD was positive, was treatment for latent TB infection (LTBI) taken? If yes, was treatment completed? Determine if patient with a previous positive skin test took treatment for LTBI and if LTBI treatment was completed. Signs and Symptoms Indicate which symptoms the patient currently has or has had in relation to their TB suspect case status. Note the duration of the symptoms. Patient history of TB disease?, Family history of TB disease? Fill in as indicated. Note: history of TB disease, not infection. HIV status HIV information is requested under the authority of Wis. Stats. s. 250.04 (1). All client information is confidential under Wis. Stat.146.82 (1). Per Centers for Disease Control and Prevention (CDC) protocol all individuals with TB disease should be tested for HIV infection. Other risk factors? Note other risk factors. If a patient is infected with TB, the risk of TB disease increases with corticosteroid use at high dose for long duration (e.g. >15 mg/day of prednisone (or equivalent) for 1 month or more). Homeless in the past year? Non-injection drug use within the past year?, Injection drug use within the past year? Alcohol use within the past year? Regular, Excess, Smoker? Fill in per patient and medical history. Re. alcohol use: subjective assessment to guide DOT decision and the recommendations given to physician. Regular alcohol use indicates baseline and follow-up liver function tests (LFTs) may be indicated [2/day ­ men, 1/day ­ women]. Excess alcohol use is an indicator for DOT and LFTs are indicated to supplement frequent liver symptom monitoring. [Reports intake that exceeds regular; diagnosis, hospitalization or treatment for excess alcohol, etc.] Foreign born?, Month and Year arrived in USA, Type of VISA Document the patient's country of origin and both the month and year of their arrival in the USA. Indicate which type of VISA they came on. Recent foreign travel?, Resident of long-term care or correctional facility? Disposition Fill in as indicated.