Department Of Health And Human Services Plague Case Investigation Report

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U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Plague Case Investigation Report

CENTERS FOR DISEASE CONTROL

AND PREVENTION

ATLANTA, GA 30329-4027

OMB No. 0920-0728

Case ID #:

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Patient History

Age:

Sex:

Patient Ethnicity:

Patient race:

(select all that apply)

Female

Hispanic or Latino

American Indian/Alaska Native

Native Hawaiian or Pacific Islander

Male

Not Hispanic or Latino

Asian

White

years

Unknown

Black or African American

Unknown/other

Residence:

Concurrent conditions:

State:

Pregnant

Immunocompromised (please specify):

County:

Course of Current Illness

Date of initial symptom onset:

Was the patient hospitalized?

Yes

Unknown

mm/dd/yyyy

Date first seen by a medical person:

Admit date:

Discharge date:

mm/dd/yyyy

Symptoms at presentation:

Fever/sweats/chills

Yes

Unknown

Cough

Yes

Unknown

Yes

Unknown

Yes

Unknown

Confusion/delirium

Chest Pain

Vomiting/diarrhea/abdominal pain

Yes

Unknown

Shortness of breath

Yes

Unknown

Sore throat

Yes

Unknown

Other:

Localized signs:

Bubo

Yes

Unknown

If yes, specify:

Axillary

Cervical

Inguinal/Femoral

Other

Insect bites/skin ulcer

Yes

Unknown

Location/description:

Chest X-ray:

Not Done

Unknown

Infiltrates or nodules

Pleural effusion

Clear/normal

Treatment:

Illness outcome:

Receipt of effective antibiotics

(check all that were administered):

Recovered, no complications

start date:

Aminoglycosides

Recovered, complications (please specify):

mm/dd/yyyy

(e.g., streptomycin, gentamicin)

Tetracyclines

start date:

Recovered, unknown complications

mm/dd/yyyy

(e.g., doxycycline)

Died (please specify cause and date of death):

Fluoroquinolones

start date:

mm/dd/yyyy

(e.g., ciprofloxacin, levofloxacin)

Unknown

Primary clinical syndrome:

Secondary pneumonic plague:

Bubonic

Septicemic

Pneumonic

Unknown

Yes

Unknown

Pharyngeal

Meningitic

Gastrointestinal

CDC 56.37 (E), Revised May 2016, CDC Adobe Acrobat 10.1, S508 Electronic Version, May 2016

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not

conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to

CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329-4027; ATTN: PRA (0920-0728).

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