MAINE CDC TB CONTROL: REPORT OF TB CASE/SUSPECT

PHONE: 207-287-5194 FAX: 207-287-6865 Date of Report:

Patient Name: / DOB: / SEX: / M / F
ADDRESS: / PHONE:
COUNTRY OF BIRTH:
LANGUAGE SPOKEN:
< 18 Guardian NAME :
Race: / White / Black / American Indian/Alaskan / Asian Pacific Islander Unknown
Ethnicity: / Hispanic Non-Hispanic Unknown
Clinical History
Pulmonary X-pulmonary Site: / Airborne Precautions Y N
Hospitalized / N / Y / Hospital:
Alive at report N Y
Primary Reason Evaluated:
Symptoms: Cough Hemoptysis Fever Night Sweats Chills Wt loss SOB Chest pain
Other Specify Date Symptom Onset:
Patient current weight: kg
Diagnostics
Mantoux TST / N / Y / U / Date: / Result: mm
Previous TST / N / Y / U / Date: / Result: mm
IGRA / N / Y / U / Date: / Pos Neg Indeterminate ND Unknown
Specify Test:
Chest X-ray / N / Y / U / Date: / Normal ND Unknown
Abnormal (consistent with TB)
If abnormal: Cavity Miliary
CT Scan (Chest) / N / Y / U / Date: / Normal ND Unknown
Abnormal (consistent with TB)
If abnormal: Cavity Miliary
Specimens Collected
N Y U / Type: / Date: / AFB / Pos / Neg / Pending / ND
PCR / Pos / Neg / Pending / ND
Culture / Pos / Neg / Pending / ND
Type: / Date: / AFB / Pos / Neg / Pending / ND
PCR / Pos / Neg / Pending / ND
Culture / Pos / Neg / Pending / ND
Type: / Date: / AFB / Pos / Neg / Pending / ND
PCR / Pos / Neg / Pending / ND
Culture / Pos / Neg / Pending / ND
Specimen Location: / Specimen Sent to HETL? N Y U PCR Authorized? N Y
Risk Factors Associated with TB
Non-IV Drug Use N Y U / IV Drug Use: N Y U / Excess EtOH N Y U
Homelessness N Y U / Resident of Correctional Facility
NY U / Resident of Long Term Care Facility
N Y U
Incomplete LTBI TX
N Y U / Immunosuppressive Treatment
N Y U
If yes, specify: / Immunosuppresssion (not HIV/AIDS)
N Y U
Diabetes Mellitus
N Y U / End Stage Renal Disease
N Y U / Post Organ Transplant
N Y U
Previous TB Disease Diagnosis N Y U If yes, specify date:
If yes specify treatment regimen:
Previous Latent TB Infection Diagnosis N Y U If yes, specify date:
If yes specify treatment regimen:
Contact to known case: N Y U
If yes, specify: / HIV Status: Negative Positive Unknown Pending Refused
Not offered
Travel History:
Other Medical History
Underlying liver disease N Y U
If yes, specify / LFTs: AST ALT
Date:
Chronic Illnesses N Y U If yes, specify:
Medication allergies:
Pregnant N Y U
Treatment
Treatment Started
Y N / Date
Ordered: / Freq / Prescribing Physician
Telephone / Reporter
Telephone
Isoniazid: / mg / Address: / Address:
Ethambutol: / mg
Pyrazinamide: / mg
Rifampin: / mg / TB Consultant / Telephone:
Pyridoxine (vit B6): / mg / Pharmacy:
Pharmacy ID #: / Next f/u appt. if known:
Telephone:
Additional Pertinent Patient History: