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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