Form assigned Plague

Plague Case Investigation Report
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First Name:

Phone No:

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Plague Case Investigation Report
Date of report:

Form Approved
OMB No. 0920-0009

Case ID #:
Reporting and Basic Contact Information

Person reporting the case:

Person taking the report:

_______________________________________________

__________________________________________________

Agency/affiliation:

Agency/affiliation:

_______________________________________________

_______________________________________________

Phone number/Email:

Phone number/Email:

(_____)_________________________________________

(_____)_________________________________________

Has the local health department
been notified?
o Yes
o No

If yes, provide name, phone number and/or email of contact person:
________________________________________________________________

Treating Physician(s)

Phone number and/or email of contact person:

_____________________________________________
_____________________________________________
Hospital:
City/State:
_________________________

Phone:

______________________________

(____ _)_______________________

Patient Demographics
Age:

Sex:
Patient Ethnicity:
Patient race: (select all that apply)
Female
Hispanic or Latino
American Indian/Alaska Native
Native Hawaiian or Pacific Islander
Male
Not Hispanic or Latino
Asian
White
______
Black or African American
Unknown
Unknown
Unknown
Residence:
State: _________ County:________________________________ Zip: _________________________
Occupation: ______________________________________ Works primarily:

Indoors

Outdoors

Both

Unknown

Medical History and Current Illness
Any underlying medical
conditions?
Yes
No
Unknown

If yes, please indicate all conditions that apply:
Cancer
Diabetes Mellitus
Cardiovascular Disease
Immunocompromised
For females - pregnant
Other (specify):

Date of initial symptom onset:

_____/_____/______
mm

dd

yyyy

Date first seen by medical person: _____/_____/______
mm

Symptoms at initial presentation:
Fever
Sweats/chills/rigors
Weakness/lethargy/malaise
Shortness of breath
Chest pain
Cough
Bloody sputum

Yes

dd

yyyy

Location where first seen:
Emergency Department
Hospital
Outpatient clinic/office

Pulmonary Disease
Renal Disease

Urgent Care Center
Unknown
Other:____________________

No Unknown

Yes

No

Unknown

Swollen tender glands
Sore throat
Headache
Confusion/delirium
Muscle/joint pains
Nausea, vomiting, and/or diarrhea
Abdominal pain

Other(s): __________________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 20 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 (0920-0009).
CDC 56.37 (E), 2/2006, CDC Adobe Acrobat 5.0 Electronic Version, 2/2006

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2
Medical History and Current Illness (continued)
If known, vital signs at initial presentation: (if unknown, check here

)

Date: _____/_____/______
mm

Temperature: _______
Bubo:
Yes
No
Unknown

Blood pressure: ______/______

Heart rate: _______

Location (please circle right or left):
Axillary (Right or Left)
Inguinal (Right or Left)
Cervical (Right or Left)
Other:
Femoral (Right or Left)
__________________

Insect bites or Skin ulcer:

dd

yyyy

Respiratory rate: _______

Description (size, tenderness, erythema, etc..):
_______________________________________
_______________________________________

Description of bite and/or ulcer (including location and date of onset):

(please circle bite, ulcer, or both)

Yes

No

Unknown

________________________________________________________________________
Radiographic and Laboratory Findings

Chest X-ray:
Yes (date: ____/____/______)
No
mm
dd
yyyy
Unknown

Results:
o Clear/normal
o Hilar adenopathy
o Infiltrates, unilateral

Infiltrates, bilateral
Interstitial changes
Pleural effusion

Pulmonary abscess
Pulmonary nodules
Unknown

Initial blood tests: (date: ____/____/______)
mm

dd

yyyy

WBC (x 103): __________

Differential (indicate %)

Hgb (mg/dl) or Hct: ______

Platelets (x 103): _______
o Yes

Bacteria seen on blood smear?
Plague testing:

Yes

No Unk

o No

Segs: _______

BUN (U/dl): ________

Lymphs: ________

Creatinine (mg/dl): ________

o Unknown (date of blood smear: ____/____/______)

Date specimen collected
(mm /

Bands: _______

dd / yyyy)

Test(s) performed - Results
(e.g. culture - positive, DFA - positive, PCR - negative)

Blood culture (1)

____/____/______

_____________________________________________

Blood culture (2)

____/____/______

_____________________________________________

Bubo aspirate

____/____/______

_____________________________________________

Sputum sample

____/____/______

_____________________________________________

CSF sample

____/____/______

_____________________________________________

_______________

____/____/______

_____________________________________________

Serology: S1: Date drawn _____/_____/______ Titer: _______
mm

dd

S2: Date drawn _____/_____/______ Titer:____________

yyyy

mm

dd

yyyy

Clinical Course and Treatment
Was the patient hospitalized? o Yes

o No o Unknown Admit date: _____/______

Discharge date: ______/______

mm / (dd)

Was the patient isolated?

o No

o Respiratory

o Contact

o Unknown

mm / dd

Date isolated: _____/______
mm / dd

If hospitalized, what was the maximum temperature noted within first 72 hours of hospitalization: _________
How many days elapsed from symptom onset until symptoms improved (i.e. afebrile for 24 hours): ___________
Did the patient receive antibiotics?
If yes, please list all antibiotics:

o Yes o No
Date started

o Unknown
Date stopped

Dosage and schedule

1. ____________________________

____/_____

_____/_____

___________________________________

2. ____________________________

____/_____

_____/_____

___________________________________

3. ____________________________

____/_____

_____/_____

___________________________________

mm / dd

mm / dd

CDC 56.37 (E), 2/2006, CDC Adobe Acrobat 5.0 Electronic Version, 2/2006

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Clinical Course and Treatment (continued)
Complications :
Yes
No Unknown
Yes
No
Unknown
Amputation/limb ischemia
Multisystem (i.e. > 2) organ failure
Bleeding/DIC
Renal failure (Cr >2.0 mg/dl)
Cardiac arrest
Secondary pneumonia
Intubation
Shock (SBP <90 mmHg)
Other(s): __________________________________________________________________________________________
Initial diagnosis given: ________________________________________________________________________________
Number of days from initial diagnosis until plague diagnosis given:___________________________________________
Classification of clinical syndrome: (please check here if unknown
Bubonic
Pneumonic Septicemic
Primary (select one)
Secondary (select all that apply)
Outcome:

)
Pharyngeal

Meningitic

Ocular Gastrointestinal

Recovered, no complications
Recovered, complications (please specify): _________________________________________________
Recovered, unknown complications
Died (please specify cause and date of death): ______________________________________________
Unknown
Epidemiologic and Environmental Investigation

Possible exposure source and location: (please check all that apply)
Yes specify location below)
Contact with sick or dead animals
Exposure to abandoned burrows
Hunting, including contact with wild animals
Flea or insect bites
Contact with someone ill or who has died in last week
Contact with known plague patient
Other (specify): ______________________________
Pets:

Are there pets in the home?
No
If have pets, are any ill or have any died?
If have pets, have they brought home dead animals?

Dogs (#_____)
No
Yes
No
Yes

Is this patient’s illness associated with any other human plague cases?
Did this patient’s illness result in any secondary human plague cases?

No

Cats (#______)
Unknown
Unknown
No
No

Unknown

Other (specify below)

Yes (specify below)
Yes (specify below)

Unknown
Unknown

Comments regarding the environmental and epidemiologic investigation (including exposures during 10 days
preceeding illness onset; any travel within or outside of the United States; contact tracing of household, school/work,
and community close contacts for pneumonic cases; and/or explanations from above):
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
CDC 56.37 (E), 2/2006, CDC Adobe Acrobat 5.0 Electronic Version, 2/2006

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