Diphtheria Case Investigation Worksheet
|Diphtheria Case Investigation Worksheet |
Shaded areas are mandatory for reporting to Saskatchewan Ministry of Health [Indicates field in iPHIS]
Please use YYYY/MM/DD for all dates
|PATI|Date Reported |Name (Last, First) |HSN |
|ENT | | | |
|INFO| | | |
|RMAT| | | |
|ION | | | |
| |Birth Date |
| | |
| |Date Symptom Onset |Date First Diagnosis (clinical or lab |Date Hospitalized |
| | |diagnosis) | |
| |Symptoms |Signs |Complications |
| | | | |
| |Fever | |Airway obstruction |
| |Sore throat | |Date of onset: |
| |Difficulty swallowing | |___________ |
| |Change in voice | |Intubation/traech required |
| |Shortness of breath | |Myocarditis |
| |Weakness | |Date of onset: |
| |Fatigue | |___________ |
| |Other | |(Poly)neuritis |
| | | |Date of onset: |
| | | |___________ |
| | | |Other |
| | | |Describe: |
| | | Fever | Soft tissue swelling |
| | |If yes Temp ____ F/C |(around membrane) |
| | | |Neck edema? |
| | | |If yes Bilateral |
| | |Membrane present |Left side only |
| | |Yes No |Right side only |
| | |If yes, Sites |If yes, Extent |
| | |Tonsils |Submandibular only |
| | |Soft palate |Midway to clavicle |
| | |Hard palate |To clavicle |
| | |Larynx |Below clavicle |
| | |Nares |Stridor |
| | |Nasopharynx |Wheezing |
| | |Conjunctive |Palatal weakness |
| | |Skin |Tachycardia |
| | | |EKG abnormalities |
| |If culture positive, results of toxigenicity testing? |Type of specimen? |PCR result? |
| |Positive |(check all that apply) |Positive |
| |Negative |Clinical swab |Negative |
| |Unknown |Piece of membrane |Unknown |
| |Not done |C. diphtheriae isolate |Not done |
(please turn over)
|ANTI|Treated with Antibiotics? Yes No Unknown |
|BIOT| |
|ICS | |
| |As an Outpatient? |
| |If yes, Date Initiated: |
| |_________________ |
|ANTI|To access Diphtheria Antitoxin, Special Access Program Form A* must be completed and |Amount of DAT administered: |
|TOXI|returned to Saskatchewan Ministry of Health. | |
|N | |_________________________ units |
|INFO|Date Requested: _________________________________ | |
| | | |
| |Date Administered: _______________________________ | |
|EXPO|Country of Residence |If Other, Country Name: |Date of Arrival to Canada |
|SURE|Canada |_____________________________________________ |_____________________ or Unknown |
| |Other | | |
| |History of International |Country(s) Visited: |Dates |
| |Travel? | | |
| |(2 weeks Prior to Onset) | | |
| |Yes | | |
| |No | | |
| |Unknown | | |
| | |_________________________________________ |To: _______________ |
| | |_________________________________________ |To: _________________ |
|CONF|Has this Suspected Case been reported to the Saskatchewan Ministry of Health? |If Yes, Date Reported: __________________ |
|IRMA|Yes | |
|TION|No | |
|& |Unknown | |
|REPO| | |
|RTIN| | |
|G | | |
| |Person Informed: |Phone: |Fax: |
| |Reporting Physician: |Phone: |Fax: |
| |Final Diagnosis |How was the Final Diagnosis Confirmed? |Final Case Status or Classification: |
| | | |Confirmed |
| | | |Probable |
| | | |Not a case |
*
Signature: ________________________________ Title: _____________________________ Date: ______________
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