NICU TB Contact Follow up Form

NICU TB Contact Follow Up Form

Last Name: ______First Name: ______Date of Evaluation: ______

Parent Last Name: ______Parent First Name: ______

Gender (check one): Male__ Female__ Date of Birth: __ __ / __ __ / ______

Gestational Age at birth: __ __ , __ / __ weeks Current Age: ____ / __ weeks

Birth Weight: __ __ grams / __ __ pounds, __ __ ounces

Evaluator Name: ______

Tuberculosis History:

1.  Has this infant had a positive test for TB infection? Yes __ No ___

1. If yes, list type of test, test date (month and year), and result (in millimeters if TST)

Type of Test (e.g., TST, QFT, T-Sport®) / Test Date / Result in millimeters (if TST)

2.  Has this infant had BCG vaccination? Yes __ No ___

1. If yes, can you see a BCG scar? Yes __ No ___

3.  Has this infant been exposed to any person known to have been infected with tuberculosis?

1. If yes, please list name of person, location of exposure, and date

Name of person (first and last, if known) / Location (e.g., home, daycare) / Date of last contact with this person

4.  Has this infant been treated (or is the infant currently on treatment) for latent TB infection (LTBI) or TB disease?

1. If yes, please list, the dates of treatment

Dates of treatment (beginning and end date) / Name of medicine prescribed

Medical History:

1.  Has this infant ever been diagnosed any of the following conditions:

Conditions / Yes / No / Specific Diagnosis / therapy information (e.g., end stage renal disease on peritoneal dialysis)
Seizures or epilepsy
Vision problems (including retinopathy of prematurity)
Heart disease
Kidney disease
Short-gut syndrome
HIV exposed

Surgical History:

1.  Has this infant ever had surgery? Yes ___ No ___

1. If yes, please specify procedures and approximate dates:

Procedure (e.g., bowel resection) / Date (month and year)

Social History:

1.  Who else lives in the home with this infant?

Person / Check if adult 18 years of age or older / Check if age 5-17 / Check if child under age of 5

2.  Has child ever traveled outside of the United States?

If yes, provide place(s) and dates of return to the United States.

City / Country / Date of return to US

Allergies: ___ No known drug or food allergies

Drug or food / Reaction (i.e., hives, but no respiratory symptoms or hives with tongue swelling and difficulty breathing)

Current Medications

Drug, dose, and frequency
(i.e., Keppra 100 mg daily) / Purpose of medication (i.e., seizure management)

Review of Symptom:

Symptom / Yes / No / Additional information (for how long, description etc)
Fever
Poor feeding
Cough or increased work of breathing
Sweating with feedings
Vomiting
Abdominal pain
Diarrhea
Less than 6-8 wet diapers per day
Seizures
Lumps or bumps in neck, armpits or groin
Less active/Sleeping more than usual / difficult to arouse
Severe illness

Labs:

Test / Date / Result
Total Protein*
Total Bilirubin*
Direct Bilirubin*
ALT*
AST*
Alkaline Phosphatase*
Initial Tuberculin Skin Test/IGRA
CBC, creatinine

* if performed.

Radiographs:

Date / Location / Findings (check one) / Additional information
Normal / Suspicious for TB disease

Physical Examination:

Temperature: _____ Heart Rate: _____ Respiratory Rate: _____ Blood Pressure: _____

O2 Saturation: _____ in (circle one) Room air | ___ L oxygen

Weight: _____ kg ( ___%ile) length: _____ cm (____%ile) FOC: _____ cm (____%ile)

General: ___ Comfortable, no apparent distress | ______

HEENT: ___ Anterior fontanelle soft, flat

___ Symmetric red reflex | ______

___ No cervical, axillary, post-auricular lymphadenopathy | ______

___ No submandibular, supraclavicular lymphadenopathy | ______

___ Ororpharynx clear | ______

___ No scleral icterus | ______

___ Cranial nerves II – XII intact by exam | ______

Cardiovascular: ___ Normal S1 and S2, regular rate and rhythm | ______

Lungs: ___ Clear breath sounds bilaterally, no wheezes, no rales, no rhonchi

___ Decreased breath sounds

___ Rales, wheezes or rhonchi present

Abdomen: ___ Soft, not tender, not distended | ______

___ No hepatomegaly, No splenomegaly | ______

GU: ___ Normal external genitalia | ______

Skin: ___ No cutaneous lesions | ______

___ No jaundice

Neuro: ___ Moves all extremities | ______

___ Normal deep tendon reflexes | ______

Back: ___ Normal appearance, normal to palpation| ______

Impression:

____ Contact to Case of Active TB disease

____ Tuberculosis infection (i.e., positive laboratory test for TB infection AND absence of ANY signs / symptoms of TB disease).

____ Suspect active TB disease

____ Other: ______

Plan:

____ Notified Local Health Department of TB Infection/TB Disease/TB Suspect of Disease.

Directly observed therapy (DOT) for TB disease through Local Health Department. Seek specific treatment regimen through consultation with the Local Health Department/State Health Department in consultation with the Heartland National TB Center.

____ Monitor liver panel (T. bilirubin / D. bilirubin / ALT / AST / Alkaline Phosphatase), CBC and BUN/creatinine -- Consider at least at baseline in children with a history of hepatic disease or on medication for chronic disease

____ Monitor drug absorption and toxicity level. Seek specific monitoring and access to testing through consultation with the Local Health Department/State Health Department in consultation with the Heartland National TB Center.

____ Review signs and symptoms of toxicity. Child should stop taking these medicines immediately if she/he has vomiting, not feeding, jaundice (yellow skin color), light colored stools, unexplained bruising, bleeding and then contact a physician. These will also be reviewed and assessed at each DOT visit by the health department nurse case manager.

____ Follow-up in 1 month

____ Other plan ______