Case notification form - Strictly Confidential



Case notification form - Strictly Confidential

Surveillance of primary congenital hypothyroidism (CHT)

Reporting Instructions:

Please report any child up to and including 5 years of age who, during the past month, has

i. been referred for diagnostic confirmation following a newborn screening test result suggestive of primary congenital hypothyroidism,

OR

ii. been confirmed with a diagnosis of primary congenital hypothyroidism (known or considered likely to be present from birth), based on a serum TSH ≥10mU/l.

Excluding: Children with secondary CHT due to pituitary under-production of TSH; children with acquired hypothyroidism.

If there is doubt about whether the child fully meets the case definition, please complete this form.

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Appendix A[pic]

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Section A: Reporter Details

| |1.1 |Date of completion of questionnaire: |[pic] |

| |1.2 |Consultant responsible for case: | |

| |1.3 |Hospital name: | |

| |1.4 |Telephone number: | |Email: | |

| |1.5 |Which laboratory notified the screening result? | |

| | | | |

Section B: Case Details

| |2.1 |NHS No: |[pic] |(or equivalent Scottish CHI or Northern Irish Health & |

| | | | |Social Care number) |

| |2.2 |Hospital No: |[pic] | | |

| |2.3 |Postcode (first half): |[pic] | | |

| |2.4 |Sex: |M |[pic] |F |[pic] |Date of birth: |[pic] |

| |2.5 |Ethnicity*: |[pic] |Details of ethnicity (if relevant) | |

| |2.6 |Country of birth (if known): | | |

|*Please choose the correct ethnicity code from Appendix A overleaf |

Appendix A: Coding for Ethnic Group (ONS 2001 for UK wide data collection)

| | |Ethnicity Code | |

|A |White |1 |Any White background |

|B |Mixed |2 |White and Black Caribbean |

| | |3 |White and Black African |

| | |4 |White and Asian |

| | |5 |Any Other Mixed background, please specify in Details section |

|C |Asian or Asian British |6 |Indian |

| | |7 |Pakistani |

| | |8 |Bangladeshi |

| | |9 |Any Other Asian background, please write in Details section |

|D |Black or British Black |10 |Caribbean |

| | |11 |African |

| | |12 |Any Other African background, please write in Details section |

|E |Chinese or other ethnic group |13 |Chinese |

| | |14 |Any Other, please write in Details section |

|F |Unknown |15 |Ethnicity not known |

Section C: Presentation/Clinical features

|3.1 |How was the child first detected? | | | | |

| |Routine newborn screening |[pic] |Tested because of family history |[pic] |Clinical signs/symptoms |[pic] |

| |Other |[pic] |Please give details: | |

|If detection was by newborn screening, complete Q 3.2-3.3. If not, go straight to Q 3.4 |

|3.2 |Date screening test result was first reported to clinician (you or colleague): |[pic] |

|3.3 |Who informed parents of the screening result? | |Not Known |[pic] |

|3.4 |On what date was the child first examined (seen) by a clinician? |[pic] |

|3.5a |Which of the following signs/symptoms were present at this first examination/visit? | |

|Children aged d" 6 months |Yes |No |Not Known |Children aged > 6 months |Yes |No |Not Knownildren |

| | | | | | | |aged ≤ 6 months |

| |Poor feeding |[pic] |[pic] |[pic] |Short stature |[pic] |[pic] |[pic] |

| |Jaundice |[pic] |[pic] |[pic] |Constipation |[pic] |[pic] |[pic] |

| |Dry, mottled skin |[pic] |[pic] |[pic] |Abdominal distension |[pic] |[pic] |[pic] |

| |Abdominal distension |[pic] |[pic] |[pic] | | | | |

| |Umbilical hernia |[pic] |[pic] |[pic] | | | | |

|3.5b |Other signs/symptoms (details) | |

|3.6a |Does the child have any other health problems? |Yes |[pic] |No |[pic] |Not Known |[pic] |

|3.6b |If YES, please specify: | | | | | | |

|3.7 |Was testing done to confirm the diagnosis of CHT? |Yes |[pic] |No |[pic] |Not Known |[pic] |

|3.8a |Was the diagnosis of CHT confirmed by testing? |Yes |[pic] |No |[pic] |Results pending |[pic] |

|3.8b |If YES, on what date was the diagnosis confirmed? |[pic] |Not Known |[pic] |

|Even if diagnostic testing DID NOT confirm CHT, please continue to answer the following sections. |

| | | | | | | | |

Section D: Pregnancy/Birth Details

| |4.1 |Birth weight |[pic][pic][pic][pic] |grams |Not Known |[pic] |

| |4.2a |Was the child: |Term |[pic] |Preterm ( ................
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