Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Botulism – Questionnaire For all cases please complete Sections 1
Transcript
Botulism – Questionnaire For all cases please complete Sections 1 and 2. If the patient is a drug user please complete Section 3. If food Botulism is suspected please complete Section 4. Please return completed questionnaire by post or fax to: Andrea Marongiu Unlinked Anonymous Surveys (Injecting Drug Use) Centre for Infections Health Protection Agency 61 Colindale Avenue Fax: 020 8200 7868 London Tel: 020 8327 7547 NW9 5EQ Email: [email protected] For queries regarding the Botulism questionnaire please contact: For CDSC use only: Number: Week of notification: Source of reporting: [email protected] [email protected] [email protected] Tel: 020 8327 7930 Tel: 020 8327 6423 Tel: 020 8327 7118 SECTION 1: DEMOGRAPHIC INFORMATION No. Please circle answers where appropriate Questions Answers Patient name Surname…………………………………………… Q.1 First name ………………………………………… Q.2 Q.3 Q.4 Sex Date of birth Male Female ………/………/…………. dd/mm/yyyy Age (years) Q.5 Address …………………………………………………………………… …………………………………………………………………… …………………………………………………………………… Q.6 Q.7 Ethnic group r White British r White Irish r White other r Other r Not known r Black-Caribbean r Black-African r Black-Other Occupation …………………………………………..……………… Q.8 Has the patient been involved in any activities that might expose wounds to soil e.g. gardening, carpentry, etc? Yes No DK Q.9 Has the patient travelled away from home or overseas in the last month? Yes No DK r Pakistani r Bangladeshi r Indian r Chinese r Asian other Specify place:………………………………………….. Specify dates: From…………………. To……………. SECTION 2: CLINICAL DETAILS No. Questions Answers Q.10 Hospital Name Q.11 Clinician in charge Q.12 Name Tel no. Name Address GP Please circle answers where appropriate ……………………………………………………………………… ……………………………………………………………………… Tel no. Q.13 Preliminary History: ……………………………………………………………………… Day Month Year A. Onset date of symptoms B. Date first seen by doctor C. Was patient hospitalised? Yes No DK Yes No DK Yes No DK If yes: date hospitalised D. Has the patient been admitted to intensive care? If yes: date admitted E. Has the patient been placed on a ventilator? If yes: date intubated: Q.14 Was the patient on any of the following medications in the month prior to onset? Q.15 Clinical History: Briefly describe history and general symptom progression: a. Phenothiazine b. Aminoglycoside c. Anticholinergic Yes Yes Yes No No No DK DK DK 2 SECTION 2: CLINICAL DETAILS (continued) No. Questions Q.16 Specific symptom history: Answers Abdominal pain YES NO DK Nausea YES NO DK Vomiting YES NO DK Diarrhoea YES NO DK Constipation YES NO DK Blurred vision YES NO DK Diplopia YES NO DK Dizziness YES NO DK Slurred speech YES NO DK “Thick tongue” YES NO DK Change in sound of voice YES NO DK Hoarseness YES NO DK Dry mouth YES NO DK Difficulty swallowing YES NO DK Shortness of breath YES NO DK Subjective weakness YES NO DK Fatigue YES NO DK Paraesthesia YES NO DK If yes, please describe site of paraesthesia: Does the patient have a wound, boil or abscesses, no matter how trivial? If yes, please describe site and nature: Q.17 Please circle answers where appropriate …………………………………………………………….. YES NO DK …………………………………………………………….. Vital signs on admission: Temperature (°C) ………….. Blood Pressure ………/…….. Heart Rate ………….. Respiratory Rate ………….. SECTION 2: CLINICAL DETAILS (continued) No. Questions Q.18 Physical Examination Findings: Altered mental state YES BILATERAL NO DK Extraocular palsy YES BILATERAL NO DK Ptosis YES BILATERAL NO DK Pupils Dilated YES BILATERAL NO DK Pupils constricted YES BILATERAL NO DK Pupils fixed YES BILATERAL NO DK Pupils reactive YES BILATERAL NO DK Facial paralysis YES BILATERAL NO DK Palatal weakness YES BILATERAL NO DK Impaired gag reflex YES BILATERAL NO DK Sensory deficit(s) YES BILATERAL NO DK If yes, please describe deficit: Q.19 Q.20 Please circle answers where appropriate Answers ……………. Deep tendon reflexes: Abnormal deep tendon reflexes BRISK NORMAL REDUCED ABSENT DK Biceps/Triceps BRISK NORMAL REDUCED ABSENT DK Brachial BRISK NORMAL REDUCED ABSENT DK Patellar BRISK NORMAL REDUCED ABSENT DK Ankle BRISK NORMAL REDUCED ABSENT DK Please indicate if weakness or paralysis was noted in the patient: a. Upper extremities YES If yes: Distal weakness/paralysis YES BILATERAL NO DK YES BILATERAL NO DK Proximal weakness/paralysis NO b. Lower extremities YES If yes: Distal weakness/paralysis YES BILATERAL NO DK YES BILATERAL NO DK i. Ascending (beginning in the lower extremities, moving to upper extremities and then cranial nerves) YES BILATERAL NO DK ii. Descending (beginning with cranial nerves, moving to upper then lower extremities) YES BILATERAL NO DK Proximal weakness/paralysis NO If yes to any of the above please describe weakness/paralysis: 4 SECTION 2: CLINICAL DETAILS (continued) No. Q.21 Questions Answers Please circle answers where appropriate YES NO Laboratory Results: a. Was a lumbar puncture done? DK If yes: i. ii. iii. iv. v. Date done: RBC WBC Protein Glucose b. Was a tensilon test (Edrophonium chloride) done? If yes: ………/………/…………. dd/mm/yyyy ...................... ....................... ....................... ....................... YES NO DK i. Date done: ………/………/………….dd/mm/yyyy ii. Results: ..................................................................…… ..................................................................…… c. Was electromyography (EMG) done? If yes: i. Date done: YES NO DK ………/………/………….dd/mm/yyyy ii. Muscle group ...................................................................…… iii. Nerve conduction results ..................................................................…… iv. Was rapid repetitive stimulation conducted? If yes: Hertz: Result: d. Was brain imaging done? If yes: Was a CT done? ...................................................................…… YES NO DK ....................... ...................................................................…… YES NO DK YES NO DK If yes: i. Date done: ii. Findings: ………/………/………….dd/mm/yyyy ...................................................................…… ...................................................................…… Was an MRI done? If yes: i. Date done: ii. Findings: YES NO DK ………/………/………….dd/mm/yyyy ...................................................................……… ...................................................................……… 5 SECTION 2: CLINICAL DETAILS (continued) No. Questions Answers Please circle answers where appropriate Q.22 Treatment Was surgical debridement performed? Yes No Yes No Was the patient treated with antimicrobial agents? DK If yes, please state which agents were used …………………………………………………………… Q.23 What samples have been sent to test for botulinum toxin? Serum r Pus r Wound tissue r Other r (please state) …………………………………………………….. Q.24 Botulinum antitoxin: Was the patient given Antitoxin? Yes No DK If yes, how many doses were given?: …………………….……… Dates given? ……………………………. Q.25 Differential Diagnosis by Clinician: Q.26 Patient outcome/status: Still ventilated Still in hospital Discharged Died Date of outcome …………………….. Q.27 Is the patient a known drug user? Yes No DK IF THE PATIENT IS A DRUG USER PLEASE COMPLETE SECTION 3. IF FOOD BOTULISM IS SUSPECTED PLEASE COMPLETE SECTION 4. 6 SECTION 3: QUESTIONS FOR DRUG USERS No. Questions Answers Please circle answers where appropriate Q.28 In the last month have you injected any of r Heroin the following drugs?: r Methadone (prescribed) Tick all that apply r Methadone (non-prescribed) r Cocaine r Heroin & Cocaine (together) r Crack r Heroin & crack (together) r Anything else? Specify…………………………….. Q.29 Q.30 For how many years/months have you been using these drugs? ……………….. Years ………………Months What methods have you used for taking these drugs in the last month? Injecting into a vein or mainlining Skin popping Muscle popping Smoking Snorting or sniffing Main method Methods also used r r r r r r r r r r Other, please specify……………………………….. Into which parts of the body do you inject? ……………………………………………………….… Q.31 Have you changed your dealer or supply of these drugs within the last month? Yes Q.32 In which areas have you bought drugs in the last month? Q.33 PLEASE SPECIFY THE NAME OF THE DISTRICT AND THE TOWN OR CITY FOR ALL PURCHASES IN THE LAST MONTH Have you noticed anything different about your drugs recently in terms of: Colour Consistency Effect Dissolving If yes to any of these please give details: No DK District or Area Town or City …………………… ………………………. …………………… ..……………………… …………………… ……………………….. Yes Yes Yes Yes No No No No DK DK DK DK ………………………………………………. SECTION 3: QUESTIONS FOR DRUG USERS (continued) No. Questions Q.34 Do you wash your hands before injecting? Q.35 Q.36 Q.37 Q.38 Q.39 Answers Please circle answers where appropriate Yes No DK Do you wipe the injection site with iodine, alcohol or a mediswab before injecting? Yes No DK Do you wet your skin with saliva before or after injecting? Yes No DK Yes No DK Do you lick the needle before injecting? During the last month have you used any of the following to dissolve your drugs? During the last month did you share any of the following with anyone? r Citric Acid r Vinegar r Lemon Juice (Jif) r Lemon Juice (fresh) r Descaler crystals r Vitamin C r Other If other, please specify r r r r r Water r Other If other, please specify Citric Acid Needles & syringes Filter Spoons ................................................ ………………………… If yes to sharing spoons, how often did you use a spoon already used by someone else (including your partner)? ……… times Q.40 During the last month have you reused your own needles/syringes? If yes: In the last month, what is the maximum number of times you have reused the same needle/syringe? Q.41 Yes No DK ……… times In the last month, where have you stored your used needles/syringes before reusing them? r In a closed container r Uncovered r Other, please specify………….……………..….. In the last month how many times have you visited a needle exchange (including pharmacy exchange)? ……… times 8 SECTION 3: QUESTIONS FOR DRUG USERS (continued) No. Questions Answers Q.42 In the last month, what kind of water have you used to inject? Tick all that apply Q.43 When you injected in the last month, what have you used to filter your heroin? Tick all that apply Q.44 r Boiled r Bottled r Sterile r Tap (KITCHEN) r Tap (BATHROOM) r Other r Cigarette filter r Filter tips r Cotton bud r Cotton wool r Clothing fibres r Nothing r Anything else When you injected in the last month, have you re-used the same filter? Yes If yes, How often? ………………times Where have you stored your used filters before reusing them? Q.45 Please circle answers where appropriate During the last month, have you had any area of skin with redness, swelling and tenderness in an area that you inject? No Specify….…………… ……………………….. Specify………………… …………………….…… DK r In a closed container r Uncovered r Other, please specify………….……………..….. Yes r r r r r No DK Q.46 Compared to a 1 pence coin, how large did it get? Q.47 Did you seek medical attention for this skin problem? Yes How many abscesses have you had during the past year? …………………………………..…. Is there anything else you that you think contributed to or caused this illness? ………………………………………………… Q.48 Q.49 Smaller Same size Larger Much larger Don’t Know No DK …………………………………………………. THANK YOU FOR COMPLETING THE QUESTIONNAIRE 9 SECTION 4: FOOD HISTORY No. Questions Answers During the week before the onset of symptoms, have you eaten?: Q.50 Q.51 Home made preserves (pickles, jam, bottled veg, bottled fruits) Yes r No r Don’t Know r Canned food Yes r No r Don’t Know r Casserole food eaten without re-heating Yes r No r Don’t Know r Any food from the freezer or refrigerator kept at room temperature and eaten without thorough reheating Yes r No r Don’t Know r Yes r No r Don’t Know r Vacuum packed or extended shelf life foods Meat or dish prepared with meat Beef Chopped beef Veal Pork Lamb Ham Dry sausage, e.g. salami Fresh sausages Pâté Other……..………………………………… Q.52 Home-made food RT Canned food Casserole food eaten without re-heating VPF CF r CF r CF r CF r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r Tick all that apply HM r HM r HM r HM r HM r HM r HM r CF r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r VPF r HM r CF r NRH r RT r VPF r Wild game or dish prepared with wild game Rabbit Hare Pheasant Partridge Pigeon Venison Wild Boar Other: …………………………………….. HM CF NRH HM r HM r HM r HM r HM r HM r HM r HM r HM r HM r Salted, cured, cold or hot smoked foods Beef Duck Chicken Lamb Venison Turkey Fish (eg smoked salmon, smoked mackerel) Other:………………………………………… Q.53 Tick all that apply Tick all that apply HM r HM r HM r HM r HM r HM r HM r HM r CF r CF r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r Any food from the freezer or refrigerator kept at room temperature and eaten without thorough reheating Vacuum packed or extended shelf life foods 10 SECTION 4: FOOD HISTORY (continued) No. Questions Answers During the week before the onset of symptoms, have you eaten?: Q.54 Poultry or dish prepared with poultry Chicken Turkey Duck Other:………………………………………. Q.55 Raw vegetable that have not been washed Which kind? Q.58 NRH r NRH r NRH r NRH r RT r RT r RT r RT r VPF r VPF r VPF r VPF r CF r CF r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r Tick all that apply HM r HM r HM r HM r HM r HM r HM r HM r HM r HM r HM r CF r CF r CF r CF r CF r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r VPF r ………………………………………………… Tick all that apply HM r HM r HM r HM r HM r Condiments Pickles Oil with fresh herbs or garlic Nut purée Olives Pesto sauce Other: …………………………………….. HM CF NRH HM r HM r HM r HM r HM r HM r HM r HM r Cheese and dairy products Mascarpone Plain Yoghurt Flavoured yoghurt Cheese sauce Other: ……………………………………. CF r CF r CF r CF r Tick all that apply Vegetables or dish prepared with vegetables Beans Green beans Carrots Eggplants Tomatoes Spinach Potatoes Vegetable juice Vegetable soup Salad Other: .……………………………………. Q.57 HM r HM r HM r HM r Fish or dish prepared with fish Salted or dried fish Roll mops herring Lump fish caviar Sea Food Tuna fish Other fish Fish soup Other: …………………………………….. Q.56 Tick all that apply CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r Tick all that apply HM r HM r HM r HM r HM r HM r CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r Home made food RT Any food from the freezer or refrigerator kept at room Canned food temperature and eaten without thorough reheating Casserole food eaten without re-heating VPF Vacuum packed or extended shelf life foods 11 SECTION 4: FOOD HISTORY (continued) . No. Questions Answers During the week before the onset of symptoms, have you eaten?: Q.59 Tick all that apply CF r NRH r RT r CF r NRH r RT r CF r NRH r RT r CF r NRH r RT r RT r CF r NRH r Fruits Jam Honey Fruit juice Other: ……………………………………… HM r HM r HM r HM r HM r Fresh fruits that have not been washed Which kind? ………………………………………………………… Q.60 Modified atmosphere, extended shelf life foods? Tick all that apply Pasta Crumpets or other confections Salad Beetroot or other vegetables Milk Other: ……………………………………….. Q.61 Have you eaten from a tin can that was blown, swollen or rusted? CF r CF r CF r CF r CF r CF r NRH r NRH r NRH r NRH r NRH r NRH r RT r RT r RT r RT r RT r RT r VPF r VPF r VPF r VPF r VPF r VPF r No r ………………………………………………………… ………………………………………………………… ………………………………………………………… Which brand? Q.62 Have you eaten from a vacuum pack that was blown? Yes r If yes, which kind of food? No r ………………………………………………………… ………………………………………………………… …………………………………………………….... Which brand? Q.63 Do you think there is a problem with the temperature of your fridge? During the week before the onset, was your fridge turned off? If yes, for how long? Yes r No r Yes r No r ……………………..Hours ……………………..Days Q.64 How often is your fridge cleaned? Home made food Canned food Casserole food eaten without re-heating HM r HM r HM r HM r HM r HM r Yes r If yes, which kind of food? HM CF NRH VPF r VPF r VPF r VPF r VPF r Less than once a month Once a month Once every 3 months Once every 6 months Once a year Never Don’ know r r r r r r r RT Any food from the freezer or refrigerator kept at room temperature and eaten without thorough reheating VPF Vacuum packed or extended shelf life foods 12 SECTION 4: FOOD HISTORY (continued) Questions Answers What have you eaten : Q.65 The day you became ill: Breakfast: ........................................................................................................... ............................................................................................................................ ............................................................................................................................ Lunch: ................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Dinner: ............................................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Sweets/Confectionery: ...................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Other: ............................................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ 13 SECTION 4: FOOD HISTORY (continued) No. Questions Answers What have you eaten : Q.66 The day before you became ill: Breakfast: .......................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Lunch: ............................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Dinner: ............................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Sweets/Confectionery: ...................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Other: .............................................................................................................. ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... 14 SECTION 4: FOOD HISTORY (continued) No. Questions Answers What have you eaten : Q.67 Two days before you became ill: Breakfast: ........................................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Lunch: ................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Dinner: ............................................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Sweets/Confectionery: ....................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Other: ............................................................................................................... ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ 15 SECTION 4: FOOD HISTORY (continued) No. Questions Answers What have you eaten : Q.68 Three days before you became ill: Breakfast: .......................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Lunch: ............................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Dinner: ............................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Sweets/Confectionery: ...................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Other: .............................................................................................................. ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... THANK YOU FOR COMPLETING THE QUESTIONNAIRE 16
