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2019 lung injury response MEDICAL CHART ABSTRACTION FORM (CDC)September 11, 2019Case ID (de-identified): _______State or Territory: _________Age: ______SexMaleFemaleAdmitted to hospitalYesNo Date of Admission: ________Discharged from Hospital YesNoDischarge date: ____________Date of Symptom Onset: ___________Died:Yes (Y)No (N)Don’t Know (DK)Case Status:ConfirmedProbableCDC Case Definition UsedYesNo[IF NO or UNKNOWN] Please describe case definition used: _____________________________Date case reported to public health department: ______________In 3 months prior to symptom onset…Dabbing: Yes (Y)No (N)Don’t Know (DK)Vaping or e-cigarette use in 3 months: Yes (Y)No (N)Don’t Know (DK)Vaping related questions:The next section is about vaping or e-cigarette use. It may be referred as vapes, vaporizers, mods, e-cigs, e-hookahs, dab pens, rigs, vape-pens, or electronic nicotine delivery systems (ENDS).What substances did you use within the 3 months before symptoms started (select all that apply)?NicotineYes (Y)No (N)Don’t Know (DK)Marijuana, THC, THC Concentrates (e.g. dabs, dab wax, dab cards), hash oil, wax; includes Dank Vapes, Gorilla, and other THC brandsYes (Y)No (N)Don’t Know (DK)Synthetic cannabinoids (e.g., K2 or Spice)Yes (Y)No (N)Don’t Know (DK)CBD or CBD oilYes (Y)No (N)Don’t Know (DK)Flavor extracts or additives added by the userYes (Y)No (N)Don’t Know (DK)OtherYes (Y)No (N)Don’t Know (DK)Other specify: ______________Device(s) used in 3 months prior to symptoms onset:Disposable e-cigarette or vape (First Generation)Yes (Y)No (N)Don’t Know (DK)E-cigarette or vape with refillable cartridge (Second Generation)Yes (Y)No (N)Don’t Know (DK)E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems) (Third Generation)Yes (Y)No (N)Don’t Know (DK)E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)Yes (Y)No (N)Don’t Know (DK)Other (specify): ___________EthnicityNot Hispanic or LatinoHispanic or LatinoRace (Select all that apply)WhiteBlack or African AmericanAmerican Indian / Alaska Native AsianNative Hawaiian or Other Pacific IslanderPregnancy statusPregnantNot pregnantUnknownWorking diagnosis (if still hospitalized): ______Discharge diagnosis: ________PRODUCT SAMPLE ID NUMBERList unique ID numbers for all product samples submitted for laboratory testing.If you are sending any products to FDA or a state lab for testing, entire the same sample IDs you shared with FDA or the state lab so that product testing results can be linked to patient histories.Testing Lab TypeFDAState public health labOtherSpecify: _________FDA PRODUCT SAMPLE ID NUMBER(List unique ID numbers for all product samples submitted for laboratory testing)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________BIOLOGICAL SPECIMEN ID NUMBERList unique ID numbers for all biological specimens submitted for testing.For any patient clinical or autopsy specimens (blood, urine, BAL, etc.), enter the same sample IDs shared with the testing lab so that specimen test results can be linked to patient histories. Testing Lab TypeHospital or Clinical labState public health labFederal labOtherSpecify: _________BIOLOGICAL SPECIMEN ID NUMBER(List unique ID numbers for all biological specimens submitted for testing)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________History of Present Illness Symptoms at admission. If not admitted, symptoms at most recent evaluation. (“Don’t know” includes “Not Documented”.)Symptom at admission YesNo Don’t Know or Not DocumentedShortness of breathDifficulty breathingChest painChest pain, pleuriticCough (any) If yes to Cough), productive?WheezingHemoptysis (coughing blood)NauseaVomitingDiarrhea or loose stoolsAbdominal painUnexpected weight loss over past 3 months If yes, specify # of pounds lostSubjective (i.e. reported) feversChills/RigorsHeadacheStiff neckSore throatRunny noseSneezingNasal congestionMuscle Aches/myalgiaJoint painSweatsRashRed or draining eyesOther symptoms: ______________Past medical history:Check all that apply: Lung DiseasesAsthma Emphysema/bronchitis (COPD)BronchiectasisHypersensitivity pneumonitis Cystic FibrosisOther chronic lung disease [IF YES] specify: _____________Cardiac DiseasesHeart failureHistory of myocardial infarction (heart attack)Other cardiac diagnosis: __________[IF YES] specify: _____________HIV/AIDSCancerIf cancer, specify type: ____________Injection Drug UseDepressionCurrently on treatment for depression?AnxietyCurrently on treatment for anxiety? Other historyIf other history, specify: ___________Vital Signs Initial/first recorded temperature: _______(°F/°C) Initial/first recorded heart rate: _____Initial/first recorded respiratory rate: _____Initial/first recorded systolic blood pressure: ______Initial/first recorded diastolic blood pressure: ______Initial/first recorded SpO2 on room air (pulse oximetry, %): ______Substance Use HistoryCigarette Smoking Status Current smoker Former smokerNever smokerUnknownCombustible Marijuana Smoking status (does not include vaping or dabbing, see above; only include use of smoked marijuana (e.g., joint, pipe, bong; sometimes called cannabis, pot, weed, hashish, grass)) Current Former Never UnknownCombustible Synthetic Cannabinoids Smoking status (does not include vaping or dabbing, see above; only include use of synthetic cannabinoids (e.g. K2, Spice)) Current Former Never UnknownOther substances inhaledCocaine (crack)MethamphetamineHeroinHuffing (paint, glue, bath salts)Other, specify:_______________Selected laboratory testing:Admission sodium (Na): ___ mEq/LAdmission chloride (Cl): ___ mmol/LAdmission potassium (K): ___ mEq/LAdmission magnesium (Mg): ___ mg/dLAdmission blood urea nitrogen (BUN): ___ mg/dLAdmission creatinine: ___ mg/dLAdmission bicarbonate (CO2): ___ mmol/dLHighest ALT (U/L): ___ IU/LHighest AST (U/L): ___ IU/LAdmission total bilirubin: ___ mg/dLAdmission C-reactive protein (CRP): ___ mg/LAdmission Complete Blood Count:White blood cells (WBC): ___________ K/uLWBC differential % Neutrophils: ___ %% Lymphocytes: ___ %% Eosinophils: ___ %% Monocytes: ___ %% Basophils: ___ %Hemoglobin: ___ g/dLHematocrit: ___ %Platelets: ___ K/uLAdmission Blood Gas Prior to Mechanical Ventilation: ArterialVenouspH: _____pO2: _____ mmHgpCO2: _____ mmHgbicarbonate (HCO3): ______ mEq/Lpulse oximetry O2 saturation (at the time of the ABG draw): ______%Special laboratory testing:Indicate any positive laboratory tests for infectious, rheumatologic, hypersensitivity panel(See long form medical abstraction form for detailed examples of these tests)TestDate of collectionResults1.2.3.4.5.Toxicology testing:Indicate any relevant drug tests (e.g. urine or blood screening for presence of THC), positive or negative. TestSpecimen Type (e.g. blood, urine)Date of collectionResults (quantify if possible)1.2.3.4.5.Imaging, medical procedures, and treatment:Chest radiograph (x-ray) performed □ Yes□ No □ UnknownDate performed: ________Initial chest radiograph (x-ray) findings: __________Subsequent chest radiograph (x-ray) performed?□ Yes□ No □ UnknownDate performed: ________Subsequent chest radiograph (x-ray) findings: _____________Chest CT (computed tomography) performed □ Yes□ No □ UnknownDate performed: ________Initial chest CT findings: __________Bronchoscopy performed □ Yes□ No □ UnknownDate performed: ________Bronchoscopy findings: __________Lung biopsy performed□ Yes□ No □ UnknownDate performed: ________Lung biopsy findings: __________Antimicrobials administered:□ Yes□ No □ UnknownDocumented clinical response to antimicrobials:□ Improvement□ No change□ Worsening clinical status□ Unknown/not documentedAntimicrobials (e.g., antibiotics, antifungals, antivirals) administered. List all.Antimicrobial nameRouteDoseFrequencyDate startedSteroids administered:□ Yes□ No □ UnknownDocumented clinical response to steroids:□ Improvement□ No change□ Worsening clinical status□ Unknown/not documentedSteroid medication nameRouteDoseFrequencyDate startedRequired the following care:Intensive care unit (ICU) admission□ Yes□ No □ UnknownVentilatory support with CPAP or BiPAP□ Yes□ No □ UnknownMechanical ventilation via endotracheal or tracheal intubation□ Yes□ No □ UnknownDiagnosis of Acute Respiratory Distress Syndrome (ARDS)□ Yes□ No □ UnknownPlaced on extracorporeal membrane oxygenation (ECMO)□ Yes□ No □ UnknownOutcomesDied?□ Yes□ No □ UnknownDate of death (MM/DD/YYYY): _________Cause of death: ____________Autopsy performed? □ Yes□ No □ Unknown[IF YES] Report available? □ Yes□ No □ Unknown[IF YES] Autopsy findings: __________ How was this case first detected?Direct report by a clinician, hospital, or other medical providerReport by a non-clinician (patient, friend, relative, attorney, media, etc.)Syndromic surveillance query of emergency department dataSyndromic surveillance query of poison control dataOtherUnknown[IF OTHER] Specify other: ____________1517651877695For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).020000For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).*END OF MEDICAL CHART ABSTRACTION SHORT FORM (CDC)* ................
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