Download DRAFT Novel Coronavirus CASE Form

DRAFT Novel Coronavirus CASE Form
CONFIDENTIAL
v0.5 April 2013
Page 1 of 4
Possible case: please complete page 1&2
Confirmed case: please complete pages 1-4
Outcome details: please complete page 4 ALL CASES
Date of Notification to Public Health Department:
PATIENT INFORMATION
Case ID
Sex: F
Surname
M
Unk
Forename
Date of Birth:
Age (years):
Address
HSE Area
CCA
Phone number
Country of birth
Email address
Occupation
GP Name
GP Address
GP email
GP Phone
GP Fax
CLINICAL DETAILS
Imported
Case type: Sporadic
Secondary
If imported, probable country of infection
Date of diagnosis:
Date of onset of 1st symptoms:
Symptoms
Cough
Runny nose
Headache
Shortness of breath
History of fever ≥ 380C (previous 14 days)
Sneezing
Sore throat
Fever ≥ 380C
Other symptom, please specify
Yes
No
Unknown
Chest x-ray evidence of pneumonia
Yes
No
Unknown
Suspicion parenchymal disease based on clinical evidence of pneumonia
Did the case develop ARDS?
Yes
No
Unknown
Hospitalised due to nCov infection Yes
Date of hospital admission
No
Unknown
ARDS onset date
Name of hospital
Date of hospital discharge
Was case mechanically ventilated? Yes
Date mechanical ventilation started
Duration of mechanically ventilation (days)
No
Was the case admitted to ICU
Date of admission to ICU
Yes
No
Did the case develop renal failure?
Yes
No
Unknown
Did case undergo ECMO?
ECMO abroad
ECMO country
Yes
No
Unknown
Yes
No
Unknown
Outcome:
Recovered
Unknown
Date mechanical ventilation finished
Unknown
Date of discharge from ICU
Recovering
Duration of ECMO (days)
Deceased
Unknown
LABORATORY DETAILS
Were specimens sent for respiratory viral screen? Yes
Influenza A
Results of respiratory viral screen result
(tick all positive result that apply)
Influenza B
If other respiratory viral screen result, please specify:
No
Unknown
Adenovirus
RSV
HMPV
PIV1
PIV2
PIV3
DRAFT Novel Coronovirus CASE Form
v0.5 April 2013
Page 2 of 4
Possible case: please complete page 1&2
Confirmed case: please complete pages 1-4
Outcome details: please complete page 4 ALL CASES
EXPOSURE DETAILS
Yes No Unk
Did this possible case have contact with a confirmed case of Novel Coronovirus 10 days prior to onset?
If yes, please give name of contact
Did this possible case travel outside Ireland 10 days prior to onset?
Yes
Country (visited by CASE)
Departure date
Airport of arrival
No
Did this possible case travel within Ireland 10 days prior to onset?
Town (visited by CASE)
No
Yes
Unknown
Arrival date
Flight number
Unknown
Departure date
Arrival date
Yes No Unk
Did this possible case have contact with someone who travelled to the Middle East (ME) 10 days prior to onset?
If yes, what is the case’s relationship with traveller returned from ME?
Country (visited by CONTACT)
Departure date
Arrival date
Flight number
Did the case have contact with any of the following during the 10 days prior to onset?
Yes No Unk
Yes No Unk
Cow
Goat
Camel
Sheep
If contact with other animal, please specify:
Location where animal contact occurred
Yes No Unk
Yes No Unk
Other animal
Bat
Civet
OCCUPATIONAL EXPOSURE DETAILS
Is the case a Health Care Worker (HCW)?
Yes
No
Unknown
HCW job title
No
Unknown
Direct patient contact? (e.g. hands on clinical contact) Yes
HCW caring for patients with SARI in ICU?
Yes
No
Unknown
Type of patients cared for i.e. ICU, outpatients etc
Does the case work in a laboratory handling specimens suspected to contain nCoV?
Name & address of Health
Care Facility/ laboratory
where employed
CLUSTER DETAILS
Part of cluster? Yes
CIDR outbreak ID
Details of cluster
location/setting
Comments
No
Unknown
Number symptomatic in cluster
Yes
No
Unknown
DRAFT Novel Coronovirus CASE Form
v0.5 April 2013
Page 3 of 4
Possible case: please complete page 1&2
Confirmed case: please complete pages 1-4
Outcome details: please complete page 4 ALL CASES
CLINICAL DETAILS - EXTENDED (Confirmed cases only)
Symptoms (continued):
Diarrhoea
Arthralgia
Vomiting
Myalgia
Altered consciousness
Other please specify
Anorexia
Nausea
Fatigue
Rash
Nose bleed
Headache
Seizures
Conjunctivitis
Maximum temp (oC)
Complications:
Cardiac arrest
Chest X-ray evidence of pneumonia
Hypotension requiring vasopressors
Underlying medical conditions: please tick all that apply
Chronic heart disease
Chronic neurological disease
Chronic kidney disease
Chronic liver disease
Diabetes
BMI
Chronic respiratory disease (excl. asthma requiring medication)
Other co-morbidity, please specify:
Was the case pregnant?
Yes
If yes, what is the current trimester? 1st
No
Unknown
2nd
3rd
Does the case currently smoke?
No
Unknown
Yes
Transplant recipient (organ/marrow)
HIV/ Other immunesuppressive illness
Malignancy
Asthma requiring medication
Pregnancy outcome
Estimated delivery date
Yes No Unk
Case vaccinated with pneumococcal vaccine?
Case vaccinated with current seasonal influenza vaccine?
Antiviral treatment prescribed?
Ribavarin Start date
Ribavarin finish date
Yes
Visited GP?
1st GP visit date
No
Visited ED?
Yes
1st ED visit date
No
Ribavirin only
Pneumococcal vaccine date
Influenza vaccine date
Other antiviral
Unknown
2nd GP visit date
Case admitted to hospital?
3rd GP visit date
Unknown
2nd ED visit date
Yes
Name of 1st admitting hospital
1st discharge diagnosis
1st Hospital admission source:
Name of 2nd admitting hospital
2nd discharge diagnosis
2nd Hospital admission source:
Name of 3rd admitting hospital
3rd discharge diagnosis
3rd Hospital admission source:
Antiviral combination
Other antivirals start date
Other antivirals finish date
No
3rd ED visit date
Unknown
Community
Date of 1st admission
Date of 1st discharge
Other ward in same hospital
Other hospital
Community
Date of 2nd admission
Date of 2nd discharge
Other ward in same hospital
Other hospital
Community
Date of 3rd admission
Date of 3rd discharge
Other ward in same hospital
Other hospital
DRAFT Novel Coronovirus CASE Form
v0.5 April 2013
Page 4 of 4
Possible case: please complete page 1&2
Confirmed case: please complete pages 1-4
Outcome details: please complete page 4 ALL CASES
LABORATORY RESULTS (Confirmed cases only)
Laboratory name
Specimen collected date
Laboratory result date
Specimen type
BAL
Specimen ID
NCoV test result
NPA
Pos
Neg
equivocal
Plasma
Nose swab
Sputum
Finger prick
Serum
Throat swab
Oral fluid
Tissue
Was baseline serology taken on case?
Date baseline serology taken
Yes
No
Faeces
Unknown
Date baseline serology sent to NVRL
OUTCOME DETAILS - All
Case classification:
Outcome
Confirmed
Still ill
Possible
Recovering
Denotified
Recovered
Deceased
Was a post-mortem examination performed?
Unknown
Underlying/primary
Contributary/secondary
Yes
No
No contribution to death
Awaiting Coroners report
Unknown
Cause of death as per
medical certificate of death
Result of coroners report
(where applicable)
SECONDARY BACTERIAL INFECTIONS
Did case have secondary bacterial infection
Yes
If yes, please specify positive result: H. influenzae
S. pneumoniae
Other organism, please specify:
No
Unknown
S. aureus
MRSA
E. coli
Other organism
POST-EXPOSURE SEROLOGY (21 days after 1st exposure)
Was post-exposure serology (21 days after exposure) taken on case?
Date post-exposure serology taken
Yes
No
Unknown
Date post-exposure serology sent to NVRL
REPORTER DETAILS
Reporter name
Reporter phone
Reporter HSE
Date of case interview
Unknown
If deceased, date of death:
Date of symptom resolution in the case
If deceased, was nCoV contributing factor:
Lost to follow up
Reporter position
Reporter email
Reporter fax
Date case notified to HPSC
Unknown
Pending