Form CDPH8583 "Psittacosis Case Report" - California

What Is Form CDPH8583?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2011;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CDPH8583 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8583 "Psittacosis Case Report" - California

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State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
Preliminary
Final
Sacramento, CA 95899-7377
PSITTACOSIS
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
Non-Hispanic/Non-Latino
Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 6)
Census Tract
County of Residence
Country of Residence
African-American/Black
American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
Asian (check all that apply)
Asian Indian
Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
Chinese
Laotian
Filipino
Thai
E-mail Address
Other Electronic Contact Information
Hmong
Vietnamese
Other:_____________________
Work/School Location
Work/School Contact
Pacific Islander (check all that apply)
Native Hawaiian
Samoan
Gender
Guamanian
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 6)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 6
CDPH 8583 (revised 11/11)
State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
Preliminary
Final
Sacramento, CA 95899-7377
PSITTACOSIS
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
Non-Hispanic/Non-Latino
Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 6)
Census Tract
County of Residence
Country of Residence
African-American/Black
American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
Asian (check all that apply)
Asian Indian
Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
Chinese
Laotian
Filipino
Thai
E-mail Address
Other Electronic Contact Information
Hmong
Vietnamese
Other:_____________________
Work/School Location
Work/School Contact
Pacific Islander (check all that apply)
Native Hawaiian
Samoan
Gender
Guamanian
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 6)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 6
CDPH 8583 (revised 11/11)
California Department of Public Health
PSITTACOSIS CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
Yes No Unk
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Highest temperature (specify °F/°C)
Fever
Chills
Headache
Photophobia
Cough
Myalgia
Other symptom (specify)
HOSPITALIZATION
Did patient visit emergency room for illness?
Was patient hospitalized?
If Yes, how many total hospital nights?
Yes No Unk
Yes No Unk
Was patient placed in respiratory isolation?
If there were any ER or hospital stays related to this illness, specify details below.
Yes No Unk
HOSPITALIZATION - DETAILS
Hospital Name 1
Street Address
Admission Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Hospital Name 2
Street Address
Admission Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
TREATMENT / MANAGEMENT
Received treatment?
If Yes, specify the treatments below.
Yes No Unk
TREATMENT / MANAGEMENT - DETAILS
Dose
Date Started (mm/dd/yyyy)
Days Prescribed
Antibiotic 1
Dose
Dase Started (mm/dd/yyyy)
Days Prescribed
Antibiotic 2
Dose
Dase Started (mm/dd/yyyy)
Days Prescribed
Antibiotic 3
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
Page 2 of 6
CDPH 8583 (revised 11/11)
California Department of Public Health
PSITTACOSIS CASE REPORT
First three letters of
patient’s last name:
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Type of Test
If Serum (acute) is submitted, then Serum (convalescent)
must also be submitted
Serum (acute)
MIF CF Culture Other:__________________
Serum (convalescent)
C. psittaci IgM Titer
C. psittaci IgG Titer
Other:__________________
Results
Interpretation
Positive Negative Equivocal
Laboratory Name
Telephone Number
Specimen Type 2
Type of Test
If Serum (acute) is submitted, then Serum (convalescent)
must also be submitted
Serum (acute)
MIF CF Culture Other:__________________
Serum (convalescent)
C. psittaci IgM Titer
C. psittaci IgG Titer
Other:__________________
Results
Interpretation
Positive Negative Equivocal
Laboratory Name
Telephone Number
IMAGING SUMMARY
Anatomic site
Date (mm/dd/yyyy)
Type of Imaging
X-Ray CT MRI Other:___________________________
Result
Interpretation
Laboratory Name
Telephone Number
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD IS 1 - 4 WEEKS PRIOR TO ILLNESS ONSET
EXPOSURES / RISK FACTORS
DID THE PATIENT HAVE CONTACT WITH ANY OF THE FOLLOWING DURING THE MONTH PRIOR TO ILLNESS ONSET?
Exposure
Yes
No
Unk
If Yes, Specify as Noted
Type of Bird
Psittacines
Pigeons
Poultry
Other:__________________________________
Type of Bird Exposure
Household pet
Pet store
Aviary
Other:_______________________________
Contact Dates (mm/dd/yyyy)
Bird(s)
From _______/_______/___________ to ______/_______/___________
Source of Birds
Date Birds Acquired (mm/dd/yyyy)
Any birds ill? Yes No Unk
Any birds die? Yes No Unk
Results
Any birds tested? Yes No Unk
Specify
Human psittacosis case
Specify
Other contact or exposure
Page 3 of 6
CDPH 8583 (revised 11/11)
California Department of Public Health
PSITTACOSIS CASE REPORT
First three letters of
patient’s last name:
CONTACTS / OTHER ILL PERSONS
Any contacts with similar illness?
If Yes, specify details below.
Yes No Unk
ILL CONTACTS - DETAILS
Name 1
Age
Gender
Telephone Number
Type of Contact / Relationship
Street Address
Date of Contact (mm/dd/yyyy)
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Date First Reported to Public Health (mm/dd/yyyy)
Name 2
Age
Gender
Telephone Number
Type of Contact / Relationship
Street Address
Date of Contact (mm/dd/yyyy)
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Date First Reported to Public Health (mm/dd/yyyy)
NOTES / REMARKS
REPORTING AGENCY
Investigator Name
Local Health Jurisdiction
Telephone Number
Date (mm/dd/yyyy)
First Reported By
Clinician Laboratory Other (specify):______________________
EPIDEMIOLOGICAL LINKAGE
Epi-linked to known case?
Contact Name / Case Number
Yes
No
Unk
DISEASE CASE CLASSIFICATION
Case Classification (see case definition page 5)
Confirmed
Probable
STATE USE ONLY
Case Classification
Confirmed Probable Not a case Need additional information
Page 4 of 6
CDPH 8583 (revised 11/11)
California Department of Public Health
PSITTACOSIS CASE REPORT
CASE DEFINITION
PSITTACOSIS (2010)
CLINICAL DESCRIPTION
An illness characterized by fever, chills, headache, myalgia, and a dry cough with pneumonia often evident on chest x-ray. Severe pneumonia requiring
intensive-care support, endocarditis, hepatitis, and neurologic complications occasionally occur.
LABORATORY CRITERIA FOR DIAGNOSIS
• Isolation of Chlamydophila psittaci from respiratory specimens (e.g., sputum, pleural fluid, or tissue), or blood, or
• Fourfold or greater increase in antibody (Immunoglobulin G [IgG]) against C. psittaci by complement fixation (CF) or microimmunofluorescence (MIF)
between paired acute- and convalescent-phase serum specimens obtained at least 2-4 weeks apart , or
• Supportive serology (e.g. C. psittaci antibody titer [Immunoglobulin M (IgM)] of greater than or equal to 32 in at least one serum specimen obtained
after onset of symptoms), or
• Detection of C. psittaci DNA in a respiratory specimen (e.g. sputum, pleural fluid or tissue) via amplification of a specific target by polymerase chain
reaction (PCR) assay.
CASE CLASSIFICATION
Probable: An illness characterized by fever, chills, headache, cough and myalgia that has either:
• Supportive serology (e.g. C. psittaci antibody titer [Immunoglobulin M, IgM] of greater than or equal to 32 in at least one serum specimen obtained
after onset of symptoms), or
• Detection of C. psittaci DNA in a respiratory specimen (e.g. sputum, pleural fluid or tissue) via amplification of a specific target by polymerase chain
reaction (PCR) assay.
Confirmed: An illness characterized by fever, chills, headache, cough and myalgia, and laboratory confirmed by either:
• Isolation of Chlamydophila psittaci from respiratory specimens (e.g., sputum, pleural fluid, or tissue), or blood, or
• Fourfold or greater increase in antibody (Immunoglobulin G [IgG]) against C. psittaci by complement fixation (CF) or microimmunofluorescence (MIF)
between paired acute- and convalescent-phase serum specimens obtained at least 2-4 weeks apart.
COMMENT
Although MIF has shown greater specificity to C. psittaci than CF, positive serologic findings by both techniques may occur as a result of infection with other
Chlamydia species and should be interpreted with caution. To increase the reliability of test results, acute- and convalescent-phase serum specimens should
be analyzed at the same time in the same laboratory. A realtime polymerase chain reaction (rtPCR) has been developed and validated in avian specimens but
has not yet been validated for use in humans (1).
REFERENCES
1. Mitchell, S.L., Wolff, B.J., Thacker, W.L., Ciembor, P.G., Gregory, C.R., Everett, K.D., Ritchie, B.W., & Winchell, J.M. (2009). Genotyping of
Chlamydophila psittaci by real-time PCR and high-resolution melt analysis. J Clin Microbiol, 47(1),175-181.
Page 5 of 6
CDPH 8583 (revised 11/11)