Blastomycosis Case Worksheet - Wisconsin



DepartmenT of Health ServicesDivision of Public HealthF-01758 (07/2016)STATE OF WISCONSINPage PAGE \* MERGEFORMAT 1 of NUMPAGES \* MERGEFORMAT 4BLASTOMYCOSIS CASE WORKSHEETINSTRUCTIONS: Enter responses in WEDSS or fax completed worksheet to the Bureau of Communicable Diseases at (608) 261-4976 or submit with Wisconsin Division of Public Health, Acute & Communicable Disease Case Report, F-44151.*All information in red is essential for case classification. DEMOGRAPHIC INFORMATIONPatient Name (last, first, middle initial) FORMTEXT ?????Parent Name (if patient is a minor) FORMTEXT ?????Date of BirthSexPregnant at diagnosis? FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Yes FORMCHECKBOX No Due Date: Street Address FORMTEXT ?????CityZip CodeCounty FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Telephone: HomeWorkCell FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OccupationEmployer Location FORMTEXT ????? FORMTEXT ?????Race FORMCHECKBOX White FORMCHECKBOX Black FORMCHECKBOX Native American/Native Alaskan FORMCHECKBOX Asian (specify): FORMTEXT ????? FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX Other: FORMTEXT ?????Ethnicity FORMCHECKBOX Hispanic FORMCHECKBOX Non-HispanicSYMPTOM AND SIGNS HISTORYHistory from: FORMCHECKBOX Physician or chart/medical record FORMCHECKBOX Patient or relative FORMCHECKBOX BothOnset date of first symptoms: FORMTEXT ????? or FORMCHECKBOX AsymptomaticSymptoms or signs (check all that apply) FORMCHECKBOX Cough FORMCHECKBOX Headache FORMCHECKBOX Fever FORMCHECKBOX Shortness of breath FORMCHECKBOX Coughing up blood FORMCHECKBOX Back pain FORMCHECKBOX Chills FORMCHECKBOX Joint pain FORMCHECKBOX Single skin lesion FORMCHECKBOX Chest pain FORMCHECKBOX Night sweats FORMCHECKBOX Muscle pain/aches FORMCHECKBOX Multiple skin lesions FORMCHECKBOX Poor appetite FORMCHECKBOX Weight loss FORMCHECKBOX Bone pain FORMCHECKBOX Fatigue FORMCHECKBOX Other Was the patient ever diagnosed with pneumonia or other respiratory disease within one year prior to developing current symptoms? FORMCHECKBOX Yes FORMCHECKBOX NoDid the patient’s illness progress to ARDS (acute respiratory distress syndrome)? FORMCHECKBOX Yes FORMCHECKBOX NoDuration of disease (check one) FORMCHECKBOX Acute Infection (symptoms present for less than a month before being tested for blastomycosis) FORMCHECKBOX Chronic Infection (symptoms present for more than a month before being tested for blastomycosis)Site of disease (check one) FORMCHECKBOX Pulmonary (disease present only in lungs) FORMCHECKBOX Extra-pulmonary (no current or undiagnosed past disease in lungs) FORMCHECKBOX Disseminated (both pulmonary and extra-pulmonary locations)If disseminated or extra-pulmonary, which sites besides the lungs were affected (check all that apply) FORMCHECKBOX Skin FORMCHECKBOX Bone FORMCHECKBOX CNS FORMCHECKBOX Eye FORMCHECKBOX Other: FORMTEXT ?????CLINICAL INFORMATIONWhat type of medical care was sought? (check all that apply)OutpatientInpatient FORMCHECKBOX Clinic #1 FORMCHECKBOX Hospital #1Date(s) FORMTEXT ?????Date(s) FORMTEXT ?????Doctor FORMTEXT ?????Doctor FORMTEXT ?????Phone FORMTEXT ?????Phone FORMTEXT ?????Clinic name FORMTEXT ?????Hospital name FORMTEXT ?????Was the patient ever on a ventilator? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Clinic #2 FORMCHECKBOX Hospital #2Date(s) FORMTEXT ?????Date(s) FORMTEXT ?????Doctor FORMTEXT ?????Doctor FORMTEXT ?????Phone FORMTEXT ?????Phone FORMTEXT ?????Clinic name FORMTEXT ?????Hospital name FORMTEXT ?????Was the patient ever on a ventilator? FORMCHECKBOX Yes FORMCHECKBOX No*If patient was seen at more than two hospitals or clinics please provide the name of the other hospitals or clinics and the dates seen in comments sections at the end of this form.Which medication(s) was the patient prescribed to treat the blastomycosis: (check all that apply) FORMCHECKBOX Itraconazole (Sporanox?) FORMCHECKBOX Amphotericin B FORMCHECKBOX Fluconazole (Diflucan?) FORMCHECKBOX Other: FORMTEXT ?????What was the duration prescribed? FORMTEXT ?????Outcome FORMCHECKBOX Alive, include recovery date if symptoms have resolved: FORMTEXT ????? FORMCHECKBOX Deceased due to blastomycosis on: FORMTEXT ????? FORMCHECKBOX Deceased due to other cause on: FORMTEXT ????? Cause: FORMTEXT ?????DIAGNOSTIC INFORMATIONMicroscopy (smear or wet prep) FORMCHECKBOX Yes FORMCHECKBOX NoSerology FORMCHECKBOX Yes FORMCHECKBOX NoDate collected: FORMTEXT ?? ? ?Date collected: FORMTEXT ? ????Specimen(s): FORMTEXT ??? ? ?Lab: FORMTEXT ? ????Lab: FORMTEXT ?? ?? ? FORMCHECKBOX AGID FORMCHECKBOX ELISA FORMCHECKBOX CFResult for Blastomyces: FORMCHECKBOX Positive FORMCHECKBOX NegativeResult: FORMCHECKBOX Positive FORMCHECKBOX Negative Titer: FORMTEXT ?????Culture FORMCHECKBOX Yes FORMCHECKBOX NoUrine Antigen FORMCHECKBOX Yes FORMCHECKBOX NoDate collected: FORMTEXT ?? ?? ?Date collected: FORMTEXT ?? ???Specimen(s): FORMTEXT ???? ?Specimen: FORMTEXT ??? ? ?Lab: FORMTEXT ? ?? ?Lab: FORMTEXT ? ????Result for Blastomyces: FORMCHECKBOX Positive FORMCHECKBOX NegativeResult for Blastomyces antigen: FORMCHECKBOX Positive FORMCHECKBOX NegativeDNA Probe/PCR: FORMCHECKBOX Positive FORMCHECKBOX Negative FORMCHECKBOX Not performedAntigen level: FORMTEXT ?????Histopathology FORMCHECKBOX Yes FORMCHECKBOX NoAdditional tests to rule out other fungal infectionsDate collected: FORMTEXT ?????Date of collection: FORMTEXT ?????Specimen(s): FORMTEXT ?????Specimen: FORMTEXT ?????Lab: FORMTEXT ?????Lab: FORMTEXT ?????Result for Blastomyces: FORMCHECKBOX Positive FORMCHECKBOX NegativeTest: FORMTEXT ? ????Comments: FORMTEXT ?????Result: FORMTEXT ?????Radiology (check all that apply) FORMCHECKBOX X-rayDate: FORMTEXT ???? ? FORMCHECKBOX MRI Date: FORMTEXT ?? ???Imaged area: FORMCHECKBOX Chest FORMCHECKBOX Extremity FORMCHECKBOX Spine FORMCHECKBOX OtherImaged area: FORMCHECKBOX Chest FORMCHECKBOX Extremity FORMCHECKBOX Spine FORMCHECKBOX OtherComments: FORMTEXT ?? ???Comments: FORMTEXT ???? ? FORMCHECKBOX CTDate: FORMTEXT ???? ? FORMCHECKBOX Other: FORMTEXT ?????Date: FORMTEXT ???? ?Imaged area: FORMCHECKBOX Chest FORMCHECKBOX Extremity FORMCHECKBOX Spine FORMCHECKBOX OtherImaged area: FORMCHECKBOX Chest FORMCHECKBOX Extremity FORMCHECKBOX Spine FORMCHECKBOX OtherComments: FORMTEXT ?? ???Comments: FORMTEXT ???? ?RISK FACTORSDid patient have any of the following chronic/immunosuppressive medical conditions? (check all that apply) FORMCHECKBOX COPD FORMCHECKBOX Diabetes FORMCHECKBOX Cancer FORMCHECKBOX Rheumatoid arthritis FORMCHECKBOX Organ transplant FORMCHECKBOX Steroid treatment FORMCHECKBOX Asthma FORMCHECKBOX Asplenia FORMCHECKBOX Other: FORMTEXT ?????Is the patient a smoker or has the patient ever smoked (including but not limited to cigarettes, cigars, pipe)? (check one) FORMCHECKBOX Smoker at time of diagnosis FORMCHECKBOX Smoked prior to diagnosis FORMCHECKBOX Never smokedFor how many years? FORMTEXT ?????Quantity smoked per day (i.e. number of packs or cigars)? FORMTEXT ?????Has anyone else in the patient’s household been diagnosed with blastomycosis? FORMCHECKBOX Yes FORMCHECKBOX NoWho/When: FORMTEXT ?????Has anyone else that patient knows been recently diagnosed with blastomycosis? FORMCHECKBOX Yes FORMCHECKBOX NoWho/When: FORMTEXT ?????Has patient owned a dog that was diagnosed with blastomycosis? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Does not own a dogWhen was the diagnosis made? (Date, or season and year): FORMTEXT ?????Veterinarian’s name: FORMTEXT ?????Telephone: FORMTEXT ?????EXPOSURE HISTORY – Outdoor activities Did the patient participate in any of the following recreational outdoor activities during the past 3 months (90 days) before onset of illness? Provide date and specific location information for all yes responses. Y=Yes N=No U=UnknownYNU FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX HuntingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fishing from shoreWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Visiting a cabinWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CampingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hiking/cross country runningWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Trail bikingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ATV usageWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Visiting parksWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Kayaking, canoeing, tubingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????When/Where: FORMTEXT ?????EXPOSURE HISTORY – Disrupted earthWas the patient exposed to disturbed earth from any of the following activities during the 3 months (90 days) before onset of illness? Provide date and specific location information for all yes responses. Y=Yes N=No U=UnknownYNU FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wood/brush cuttingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ExcavationWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gardening/landscapingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mulch exposureWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Occupational exposuresWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Construction (road/structural)When/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lawn care (raking, mowing)When/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CompostingWhen/Where: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????When/Where: FORMTEXT ?????Did patient travel in-state or out-of-state during the 3 months before the onset of illness? FORMCHECKBOX Yes FORMCHECKBOX NoWhen/Where FORMTEXT ?????When/Where FORMTEXT ?????Does patient live on or near a lake, river, stream, or wetland? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what is the name of the body of water? FORMTEXT ?????If yes, how far away? FORMCHECKBOX Less than 100 feet FORMCHECKBOX Less than ? mile FORMCHECKBOX Less than 1 mile FORMCHECKBOX Greater than 1 mileNotes/Remarks: FORMTEXT ????? ................
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