Form assigned Tularemia

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OMB No. 0920-0009

DRAFT

Tularemia Case Investigation Report
Date of report:

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?
Yes
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
Pulmonary Disease
Cardiovascular Disease
Immunocompromised
Renal Disease
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
Headache
Cough
Myalgias
Chest pain
Shortness of breath

Yes

dd

yyyy

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

Urgent Care Center
Unknown
Other:____________________

No Unknown

Yes

No

Unknown

Skin lesions (e.g. papules, ulcer)
Swollen/tender lymph nodes
Conjunctival irratition/discharge
Sore throat
Weakness/lethargy/malaise
Nausea, vomiting, and/or diarrhea
Abdominal pain

Other(s): __________________________________________________________________________________________
CDC 0.56.50 (E), CDC Adobe Acrobat 5.0 Electronic Version, 1/2006
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 bur den 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).

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

)

Date: _____/_____/______
mm

Temperature: _______

Blood pressure: ______/______

Physical findings: Yes No Unk

Heart rate: _______

dd

yyyy

Respiratory rate: _______

Description (e.g. location, size, tenderness, erythema, etc…):

Skin ulcer

____________________________________________________________________

Adenopathy

____________________________________________________________________

Pharyngitis/tonsillitis

____________________________________________________________________

Conjunctivitis

____________________________________________________________________

Other:________________________

____________________________________________________________________
Radiographic and Laboratory Findings

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

Results:
Clear/normal
Hilar adenopathy
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): _______

Tularemia testing:

Yes No Unk

Segs: _______

BUN (U/dl): ________

Date specimen collected
(mm /

Bands: _______

dd / yyyy)

Lymphs: ________

Creatinine (mg/dl): ________

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

Blood culture (1)

____/____/______

_____________________________________________

Blood culture (2)

____/____/______

_____________________________________________

Ulcer/wound swab

____/____/______

_____________________________________________

Lymph node aspirate

____/____/______

_____________________________________________

Sputum sample

____/____/______

_____________________________________________

_______________

____/____/______

_____________________________________________

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

dd

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

yyyy

Francisella tularensis subspecies identified:

mm

dd

yyyy

Type A (i.e. tularensis)
Type B (i.e. holartica)
Other (specify: ____________)
Unknown

Clinical Course and Treatment
Was the patient hospitalized?

Yes

No

Unknown Admit date: _____/______

Discharge date: ______/______

mm / (dd)

Was the patient isolated?

No

Unknown

mm / dd

Respiratory

Contact

Date isolated: _____/______

Did the patient receive antibiotics?
If yes, please list all antibiotics:

Yes
No
Date started

Unknown
Date stopped

Dosage and schedule

1. ____________________________

____/_____

_____/_____

___________________________________

2. ____________________________

____/_____

_____/_____

___________________________________

3. ____________________________

____/_____

_____/_____

___________________________________

mm / dd

mm / dd

mm / dd

CDC 0.56.50 (E), CDC Adobe Acrobat 5.0 Electronic Version, 1/2006

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

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
Hunting, including contact with wild animals
Lawnmowing or landscaping
Tick, deerfly, or other biting fly bite
Laboratory worker
Contact or ingestion of uncooked meat
Contact or ingestion of soil or untreated water
Other (specify): ______________________________
Pets:

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

No

Pocket pet(s) (e.g. hamster)
Yes
Unknown
Yes
Unknown

Is this patient’s illness associated with any other human tularemia cases?

No

Unknown

Other (specify below)

Yes (specify below)

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; and/or explanations from above):
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
CDC 0.56.50 (E), CDC Adobe Acrobat 5.0 Electronic Version, 1/2006
_____________________________________________________________________________________________________

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