Manitowoc County Health Department
Pertussis Case Report Form
Name of Patient (Last, First, Middle Initial)  1 Native American / Alaskan Native  5 White  2 Asian / Pacific Islander  8 Other Culture/PCR
Was patient tested for Bordetella pertussis? PCR? ____Yes ____No Date:
Culture? ____Yes ____No Date:
(Both a PCR and culture are recommended when testing for pertussis.) Attenti on Health Care Provider: The information on this form is to be completed and faxed to the
woc County Health Dept. (920-683-4156) within 24 hours on any patients meeting the following criteria –
 Any pat ient tested (PCR and/or culture) for Bordetella pertussis  Any patient exhibiting symptoms of pertussis and prescribed antibiotic treatment (if testing was not done, please fax copy of notes from patient’s visit as well)  Any patients needing antibiotic treatment due to an exposure to pertussis If you hav e questions or concerns, please contact our office at (920)683-4155. Thank you. rrhal (cold-like) symptoms started:________________ Date catarrhal (cold-like) cough started: ___________________ Paroxysmal cough:  Yes  No Whoop:  Yes  No Sleep disturbance:  Yes  No Apnea:  Yes  No Vomiting:  Yes  No Was patien t exposed to a known or suspect case of pertussis?  Yes  No If yes, please provide as much information as possible about source of exposure (if there was no exposure, feel free to utilize this extra space for additional comments):
me Isolation: If patient is symptomatic, did you instruct them that they must be on 5 day home isolation?  Yes  No
(Anyone sy mptomatic and on treatment, MUST be on home isolation for the first 5 days of appropriate treatment.)
t: Note – The antimicrobial agents and dosages used for chemoprophylaxis of contacts are the same as that
ded for treatment of a clinical case. Were antib iotics given?  Yes  No If yes, what date were antibiotics started? __________________
Number of days antibiotics are to be taken: _________ Check below as to which antibiotic was prescrib
 Azithrom ycin Infants <6 months: 10mg/kg per day for 5 days. Infants >6 months and children: 10 mg/kg (maximum 500 mg) day 1, followed by 5mg/kg per day (max. 250 mg) on days 2-5. Adults 500 mg day 1, followed by 250 mg per day on days 2-5.  Clarithro mycin Infants < 1 month: not recommended. Infants > 1 month and children: 15 mg/kg per day (maximum 1 g per day) in 2 divided doses each day for 7 days. Adults 1 g per day in 2 divided doses for 7 days.  Erythro mycin Infants < 1 month: not preferred. Infants > 1 month and older children: 40-50 mg/kg per day (maximum 2 g per day) in 4 divided doses for 14 days. Adults 2 g per day in 4 divided doses for 14 days.  Trimethoprin-Sulfamethoxazole (TMP-SMZ) Alternative treatment for patients who have contraindications to the use of macrolides. Infants < 2 months: contraindicated. Infants > 2 months and children: trimethoprim 8mg/kg per day, sulfamethoxazole 40 mg/kg per day in 2 divided doses for 14 days. Adults trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg per day in 2 divided doses for 14 days. Clinic Name and City:
Reporting Physician Name (please print legibly):
Name of CLINIC Contact Person and DIRECT Phone Number (if we have questions):



••• harmoniser au regard de leur Repères rapport bénéfices/risques équiva- Les inhibiteurs GÉNÉRIQUES : LE RAPPORT FINAL de la pompe DE LA COMMISSION EUROPÉENNE à protons (IPP) appartiennent à la classe des antiulcéreux. Cinq molécules sont faites dans des situations cli- commercialisées. L’ésoméprazole en question la qualité


„Rund um die Biene und alles Gesunde“ Ohne Gesundheit ist alles Nichts. B Shaw Wir nehmen nur das auf und ziehen nur das an, was im Einklang mit unserer eigenen Schwingungsfrequenz ist. Drum sei ehrlich mit dir und liebe die Wahrheit. Pflege Liebe und Harmonie. Aus der Natur kommt die Arznei. Ihr gehört die Kraft, die Gift und Medizin erschafft. Schon sind

Copyright © 2014 Articles Finder