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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