Invasive Group a Streptococcal Disease Investigation Form

Invasive Group A Streptococcal Disease Investigation Form

Shaded areas are mandatory for reporting to Saskatchewan Ministry of Health [Indicates field in iPHIS]

Please use YYYY/MM/DD for all dates

CDC Report
Diagnosis:
Source of Referral: / Interview Date: ______
Onset Date: ______
Specimen Date: ______
Specimen Site: ______
Patient Information [Demographics module]: Data entry completed o
Name: ______Phone (Home): ______Phone (Work): ______

Address: ______DOB: ______

Sex: ¨ M o F HSN: ______Parent’s Name (if applicable): ______

Next of Kin: ______Contact phone number: ______

Ethnicity: o White o Black o Latin-American o North American Indian o Métis o Inuit

o Asian o South Asian o Arab/West Asian o Unknown o Other: ______

Occupation/School/Daycare: ______Date last attended: ______
(if student, name school, grade)
Reside in LTC: o Yes o No Name of Facility: ______
Yes / No / Symptom [S&S screen] / Onset Date / Comments (enter value, site, description, etc., as needed)
Bacteremia
Cellulitis
Fever
Puerperal fever
Meningitis
Necrotizing fasciitis/myositis/gangrene/soft tissue necrosis
Pneumonia
Redness/swelling
Septic Arthritis
Septicaemia
Severe pain
Sore throat
Toxic shock Syndrome:
·  adult respiratory distress syndrome
·  coagulopathy – platelet count 100 x109 or disseminated intravascular coagulation (DIC)
·  hypotension – systolic BP<90 mmHg in adults or <5th percentile for age in children
·  liver function abnormality – AST, ALT, or total bilirubin levels 2 x upper limit of normal
·  rash
·  renal impairment – creatinine 177umol/L for adults
Other, specify:

(please turn over)

Hospitalization: [Outcome screen]

Hospitalized: o Yes o No Date of admission: ______Date of death: ______
ICU: o Yes o No Date of discharge: ______Cause of death: o primary (underlying)
o contributing
o incidental
Name of hospital: ______Attending physician: ______
Admission to Hospital in previous 30 days: o Yes o No
Long term sequelae: o Yes o No Details (if available): ______
[Notes screen]

Laboratory Information:

Specimen source: o Blood o CSF o Joint Fluid o Tissue
[Lab module] o Other, specify
Serotyping: Emm type: T type: Serum opacity factor (SOF):
[CD module – Case Details screen – Further Differentiation]

Treatment:

1)  Antibiotics: / Name / Dose / Dates
2)  Surgery: / Date / Procedure

Underlying conditions / Risk factor: [Exposure screen]

o Aboriginal / o Heart failure/Chronic Heart Failure / o Postpartum Date of delivery: ______
o Alcohol Abuse / o History of injury / o Trauma or burn
o Chronic lung disease / o Homelessness / o Skin infection or dermatological condition
o Chronic Renal insufficiency / o Immunodeficiency disease (including HIV/AIDS) / o Surgery/Surgical wound
o Contact to person with iGAS / o Immunosuppressive therapy / o Varicella
o Crowded living conditions / o Liver disease / o No risk
o Diabetes / o Injection Drug Use

History of Travel (when/where): ______

Additional Notes: ___________

____________

______

Final Diagnosis: ______

Contact follow-up and prophylaxis: o Yes o No If yes, complete “Contact Follow-up Form”
Comments: ______
______
______
______

Signature: ______Title: ______Date: ______