Site brasileiro onde você pode comprar qualidade e entrega viagra preço cialis barato em todo o mundo.

Pertussis case track record

Immunization Division, Texas Department of Health
1100 West 49th St., Austin, TX 78756
(800) 252-9152 (512) 458-7544 fax
Pertussis Case Track Record
FINAL STATUS : NETSS CASE #:
Patient’s Name: ______________________________________________________ Reported By: ___________________________________________ Address: ___________________________________________________________ Agency: _______________________________________________ Phone:( )___________________________________________ City: ________________________ County: _______________ Zip: ____________ Region: _________ Phone:( ) ______________________________________ Parent/Guardian: _____________________________________________________ Report Given to: _______________________________________ Organization: ___________________________________________ Physician: _______________________________Phone:( ) _______________ Physician’s Address: __________________________________________________ Phone: ( ) __________________________________________ ___________________________________________________________________ DEMOGRAPHICS:
DATE OF BIRTH: _____/_____/_____ AGE: ______ SEX: o Male o Female o Unknown RACE: o White o Black o Asian/Pacific Islander o Native American o Unknown o Other: _________________________ CLINICAL DATA:
TREATMENT:
o Cough - Onset Date: ____/____/____ Final Cough Duration:______ # of Days Were antibiotics given? o Yes o No o Paroxysmal Cough - Onset Date: _______/________/_______ o Erythromycin: Date Started:_____/_____/_____for _____ Days o Cotrimoxazole: Date Started:_____/____/_____for ______ Days o Apnea (Exclude Cyanotic Episode) o Cyanosis after Paroxysm o Azithromycin: Date Started:_____/_____/_____for _____ Days o Pneumonia: Chest X-Ray o + o - o Seizures (Focal or Generalized) o Tetracycline: Date Started:_____/_____/_____for _____ Days Date Started:_____/_____/_____for _____ Days Is patient still coughing at final interview? o Yes o No Date: ___/_____/____
o Other:_________ Date Started:____/____/____for ______ Days o Hospitalized at: __________________________________________________ o Other:_________ Date Started:____/____/____for ______ Days Admitted: _____/_____/_____ Discharged: _____/_____/_____ # Days_______ OUTCOME: o Survived o Died o Unknown
Physician Diagnosis:_________________________________________________
If Deceased, Date of Death: ____/_____/_____ Note: A Pertussis
Death Worksheet must also be submitted to TDH.
INFECTION TIMELINE: Enter onset of cough. Count backwards and forwards to enter dates for probable exposure and communicable periods.
P e r i o d o f C o m m u n i c a b i l i t y VACCINATION HISTORY:
VACCINATED: o Yes o No o Unknown
o 1 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 2 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 3 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 4 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ o 5 DTP: ____/____/____ Type: o DTP o DTaP o DTP-Hib o DT Manufacturer: __________________ Lot #:_____________ If no, indicate reason: o Religious exemption o Medical Contraindication o Evidence of immunity o Previous Disease - Lab Confirmed
o Previous Disease - MD Diagnosed o Under Age o Parental Refusal o Unknown o Other: ____________________________ Name: ________________________________________ LABORATORY DATA: Was laboratory testing done? o Yes o No o Unknown
LABORATORY: o TDH o Other: ________________________________________________ Phone:( ) ________________________ o Culture: Date specimen collected: _____/_____/_____ Result: ________________ o PCR: Date specimen collected: _____/_____/_____ Result: ________________ o DFA: Date specimen collected: _____/_____/_____ Result: ________________ o IgA o IgG: Date of acute specimen: _____/_____/_____ Result: ________________ Date of convalescent specimen: _____/_____/_____ Result: ________________ Note: A four-fold rise in titer level from acute specimen to convalescent sample may be considered positive serology for pertussis. Results from a
single specimen are not accepted as laboratory confirmation of a suspected pertussis case
.
Results called to local investigator: o Yes o No o Unknown Person Contacted: Date Called: _____/_____/_____ Initials: _________ SOURCE OF INFECTION: o No exposure Identified o Close contact with a known or suspected case.
____________________________ ( )____________________ __________ o Is case epidemiologically linked to a culture-confirmed case? o Yes o No o Unknown o Where did this case acquire pertussis?: o Day-care o School o College o Work o Home o Dr Office o Hospital ER o Hospital Inpatient o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: _____________ Name(s) of Setting:__________________________________________________________________________________________________ o Has any travel occurred within the exposure period? o Yes o No o Unknown If yes, list location: __________________________ o Importation Class: o Indigenous o International o Out-of-state o Unknown If imported, from what country/state:________________ o Is case traceable within 2 generations to international import? o Yes o No o Unknown o Is case part of an outbreak?: o Yes o No o Unknown If yes, list outbreak name: _________________________________________ Total number of contacts in any settings recommended antibiotics: _________________
HOUSEHOLD CONTACTS: Were control activities initiated?: o Yes o No o Unknown If no, explain: __________________________
*Symptoms/Date of Onset
______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ *Investigations must be completed on all contacts with symptoms
POSSIBLE SPREAD CONTACT:
Setting: o No Spread o Day -care o School o College o Work o Home o Dr. Office o Hospital ER o Hospital Inpatient
o Hospital Outpatient o Military o Jail o Church o International Travel o Unknown o Other: ___________________________
Name (s) of Settings: __________________________________________________________________________________________________
Name
*Symptoms/Date of Onset
______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ ______________________ _______________ _____ ______________ ______________________ ___________________________ *Investigations must be completed on all contacts with symptoms
Investigator's Name: _____________________________________________ Agency name: _________________________________________ Phone:( ) ______________________ Date Investigation Initiated: _____/_____/_____ Date Investigation Completed: ____/_____/____ COMMENTS:

Source: http://acchd.us/PDFs/diseasereporting/PERTUSSIS.pdf

jcaai.readyportal.net

Current reviews of allergy and clinical immunology (Supported by a grant from Astra Pharmaceuticals, Westborough, Mass) Series editor: Harold S. Nelson, MD Health economics of asthma and rhinitis. II. Assessing the value of interventions Sean D. Sullivan, PhD,a and Kevin B. Weiss, MDb Seattle, Wash, and Chicago, Ill Health care providers and payers are being asked to weigh data on t

Ley 33 de 1985

LEY 33 DE 1985 Por la cual se dictan algunas medidas en relación con las Cajas de Previsión y con las prestaciones sociales para el sector público. DECRETA: Artículo 1. El empleado oficial que sirva o haya servido veinte (20) años continuos o discontinuos y llegue a la edad de cincuenta y cinco (55) tendrá derecho a que por la respectiva Caja de Previsión se le pague una pen

Copyright © 2014 Articles Finder