MAINE TUBERCULOSIS CONTROL PROGRAM PREVENTIVE …



MAINE CDC TB CONTROL: REPORT OF TB CASE/SUSPECT

PHONE: 800-821-5821 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 |Type:       |

|N Y U | |

|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 |Resident of Long Term Care Facility |

| |NY U |N Y U |

|Incomplete LTBI TX |Immunosuppressive Treatment |Immunosuppresssion (not HIV/AIDS) |

|N Y U |N Y U |N Y U |

| |If yes, specify:      | |

|Diabetes Mellitus |End Stage Renal Disease |Post Organ Transplant |

|N Y U |N Y U |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 |HIV Status: Negative Positive Unknown Pending Refused |

|If yes, specify:      |Not offered |

|Travel History:       |

| |

|Other Medical History |

|Underlying liver disease N Y U |LFTs: AST      ALT      |

|If yes, specify      |Date:      |

|Chronic Illnesses N Y U If yes, specify:       |

|Medication allergies:      |

|Pregnant N Y U |

|Treatment |

|Treatment Started |Date |Freq |Prescribing Physician |Reporter       |

|Y N |Ordered: | |      | |

| | | |Telephone       |Telephone       |

|Isoniazid: |     mg |      |      |Address:       |Address:      |

| | | | | | |

|Ethambutol: |     mg |      |      | | |

|Pyrazinamide: |     mg |      |      | | |

|Rifampin: |     mg |      |      |TB Consultant |Telephone: |

| | | | |      |      |

|Pyridoxine (vit B6): |     mg |      |      |Pharmacy: |Next f/u appt. if known: |

| | | | |      |      |

| | | | |Pharmacy ID #: | |

| | | | |      | |

| | | | |Telephone: | |

| | | | |      | |

|Additional Pertinent Patient History:       |

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