"Confidential Case Report - Babesiosis" - Rhode Island

Confidential Case Report - Babesiosis is a legal document that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island.

Form Details:

  • Released on October 6, 2014;
  • The latest edition currently provided by the Rhode Island Department of Health;
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Rhode Island Department of Health
Use this form to report
Babesiosis
CONFIDENTIAL CASE REPORT
RHODE ISLAND DEPARTMENT OF HEALTH
Confirmed
Probable
Suspect
3 CAPITOL HILL, PROVIDENCE RI 02908 Fax: 401-222-2488
Epi-link to: _______________________
Last Name
____________________________________
First Name
___________________________
MI_____
Address
_________________________________________________________
Phone (____ _) ______-__________
City
___________________________________
State ___________
Zip _____________
Race
Hispanic
Gender
American Indian / Alaskan
White
Yes
Male
Birthdate: _____ /____ /____
Asian / Pacific Islander
Other
No
Female
Black / African American
Unknown
Unknown
Unknown
Age
_____________
CLINICAL and TREATMENT INFORMATION
_____/_____/_____
Date of Illness Onset:
Y
N
U
Y
N
U
Y
N
U
Arthralgia
Myalgia
Anemia
Objective
Subjective
Chills
o
Fever
Sweats
(Highest Temp: ___
F)
Symptoms
Symptoms
Thrombocytopenia
Headache
Additional Signs and Symptoms
Complications on Infection
(check all that apply)
(check all that apply)
Dark Urine
Splenomegaly
Acute Respiratory Distress
Fatigue
Weakness
Altered Mental Status
Hemolytic Anemia
Other: _____________
Disseminated Intravascular Coagulation
Hepatomegaly
Other: _____________
Hepatic Compromise
History of Splenectomy
Other: _____________
Myocardial Infarction
Jaundice
Renal Distress
Malaise
Other: ____________/_____________/______________
Clinical Information
Y
N
U
Is/was the patient pregnant during illness?
Weeks Pregnant: ______
Due Date: ____/_____/_____
Underlying immunosuppressive condition exist?
/
/
Conditions:
Prescribed Treatment
Azithromycin
Atovaquone
Chloroquine
Clindamycin
Quinine
Quinidine
Did patient die due to illness?
Date of Death: _____/_____/_____
Other: _____________________________
Provider and Hospitalization Information
Physician:
________________________
Phone (____) ______-__________
Hospitalized:
Y
N
Hospital:
________________________
Admission Dt:
____/_____/____
Discharge Dt:
____/_____/____
Reporting Information
Date of Report:
Reporting Provider: _____________
Reporting Organization: ___________________
____/____/_____
TRAVEL and EXPOSURE HISTORY
Y
N
U
History of tick bite(s) in the 8 Weeks Prior to Illness Onset Date?
Approximate Date of Bite: ___/____/____
Location of Bite:
City: ________________
State:
____________
Has Patient Traveled in the 8 Weeks Prior to Illness Onset Date?
Location: __________
Date: __/___/___
Location: _________
Date: __/___/___
Location: _________
Date: __/___/___
BLOOD TRANSFUSION INFORMATION
(up to 12 months prior to onset)
Y
N
U
Did the Patient Donate Blood?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Receive Blood?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Donate an Organ?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Receive an Organ?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Rhode Island Department of Health
Use this form to report
Babesiosis
CONFIDENTIAL CASE REPORT
RHODE ISLAND DEPARTMENT OF HEALTH
Confirmed
Probable
Suspect
3 CAPITOL HILL, PROVIDENCE RI 02908 Fax: 401-222-2488
Epi-link to: _______________________
Last Name
____________________________________
First Name
___________________________
MI_____
Address
_________________________________________________________
Phone (____ _) ______-__________
City
___________________________________
State ___________
Zip _____________
Race
Hispanic
Gender
American Indian / Alaskan
White
Yes
Male
Birthdate: _____ /____ /____
Asian / Pacific Islander
Other
No
Female
Black / African American
Unknown
Unknown
Unknown
Age
_____________
CLINICAL and TREATMENT INFORMATION
_____/_____/_____
Date of Illness Onset:
Y
N
U
Y
N
U
Y
N
U
Arthralgia
Myalgia
Anemia
Objective
Subjective
Chills
o
Fever
Sweats
(Highest Temp: ___
F)
Symptoms
Symptoms
Thrombocytopenia
Headache
Additional Signs and Symptoms
Complications on Infection
(check all that apply)
(check all that apply)
Dark Urine
Splenomegaly
Acute Respiratory Distress
Fatigue
Weakness
Altered Mental Status
Hemolytic Anemia
Other: _____________
Disseminated Intravascular Coagulation
Hepatomegaly
Other: _____________
Hepatic Compromise
History of Splenectomy
Other: _____________
Myocardial Infarction
Jaundice
Renal Distress
Malaise
Other: ____________/_____________/______________
Clinical Information
Y
N
U
Is/was the patient pregnant during illness?
Weeks Pregnant: ______
Due Date: ____/_____/_____
Underlying immunosuppressive condition exist?
/
/
Conditions:
Prescribed Treatment
Azithromycin
Atovaquone
Chloroquine
Clindamycin
Quinine
Quinidine
Did patient die due to illness?
Date of Death: _____/_____/_____
Other: _____________________________
Provider and Hospitalization Information
Physician:
________________________
Phone (____) ______-__________
Hospitalized:
Y
N
Hospital:
________________________
Admission Dt:
____/_____/____
Discharge Dt:
____/_____/____
Reporting Information
Date of Report:
Reporting Provider: _____________
Reporting Organization: ___________________
____/____/_____
TRAVEL and EXPOSURE HISTORY
Y
N
U
History of tick bite(s) in the 8 Weeks Prior to Illness Onset Date?
Approximate Date of Bite: ___/____/____
Location of Bite:
City: ________________
State:
____________
Has Patient Traveled in the 8 Weeks Prior to Illness Onset Date?
Location: __________
Date: __/___/___
Location: _________
Date: __/___/___
Location: _________
Date: __/___/___
BLOOD TRANSFUSION INFORMATION
(up to 12 months prior to onset)
Y
N
U
Did the Patient Donate Blood?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Receive Blood?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Donate an Organ?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Receive an Organ?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Babesiosis Case Report Form - This page for Department of Health Use Only
Last Name
____________________________________
First Name
___________________________
BLOOD TRANSFUSION INFORMATION (up to 12 months prior to onset)
Y
N
U
Y
N
U
Did the Patient Receive Blood?
Did the Patient Donate Blood?
Blood Product
Blood Product
Date
Bag/Unit #:
Date
Bag/Unit #:
Type
Type
1
____/_____/____
_____________
_______________
1
____/_____/____
_____________
_______________
2
____/_____/____
_____________
_______________
2
____/_____/____
_____________
_______________
3
____/_____/____
_____________
_______________
3
____/_____/____
_____________
_______________
4
____/_____/____
_____________
_______________
4
____/_____/____
_____________
_______________
5
____/_____/____
_____________
_______________
5
____/_____/____
_____________
_______________
For Blood Product Type use only the following: Whole Blood, RBC (or packed RBC), Platelet (or platelet concentrate), Plasma
(or FFP), Cryoprecipitate, WBC (or granulocyte), Ig, Unknown, Other (specify)
Y
N
U
Did the Patient Receive an Organ?
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Date: ___/___/____
Did the Patient Donate an Organ?
LABORATORY DATA
Name of Laboratory: _________________________________________________________
Laboratory Confirmed Criteria
Isolation of Babesia Organisms by light Microscopy in a Stained Blood Smear
Detection of Babesia microti DNA in a whole blood specimen by PCR
Detection of Babesia genomic sequences in a whole blood specimen by nucleic acid amplification
Isolation of Babesia organism from whole blood specimen
Laboratory Supportive Criteria
Babesia microti IFA-total Ig or IFA-IgG titer ≥ 1:256 (or ≥ 1:64 in linked blood donor or
Date of Test Result: ___/____/____
recipient)
Date of Test Result: ___/____/____
Positive Immunoblot IgG result for Babesia microti
Babesia divergens IFA-total Ig or IFA-IgG titer ≥ 1:256
Date of Test Result: ___/____/____
Babesia duncani IFA-total Ig or IFA-IgG titer ≥ 1:512
Date of Test Result: ___/____/____
INVESTIGATOR NOTES
CASE CLASSIFICATION
Confirmed (if all of the following apply)
Lab results match at least one criterion for 'Lab Confirmed'
At least one Objective or Subjective symptoms are present
Probable (must meet one of the following)
At least one criterion for 'Lab Supportive' is present with at least one Objective symptom
Blood donor or recipient is epidemiologically linked to a confirmed or probable case and
a) is 'Lab Confirmed' but no Objective or Subjective symptoms are present
OR
b) is 'Lab Supportive' with or without Subjective symptoms but no Objective symptoms
Suspect: Only 'Lab Confirmed' or 'Lab Supportive' results are present (only lab report was provided)
Not a Case
ADMINISTRATIVE INFORMATION
Investigator’s Name: _________________________________
In
Date: ___/____/____
Babesiosis Case Report Form
10/6/2014
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