Veterinary Blastomycosis Case Report Form

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VETERINARY BLASTOMYCOSIS CASE REPORT FORM
A. DEMOGRAPHIC INFORMATION
Owner Name:
Breed:
Weight (lbs.):
Pet Name:
Species:
DOB: ____/____/____
Age:
M F
Spayed/Neutered: Y N
Address:
Gender:
Pet is primarily: Indoors Outdoors
Both
City/Zip:
County:
Phone (1):
(2):
Veterinarian:
Clinic Name:
Clinic Phone:
B. CLINICAL SIGNS
Y N
Y N
Illness onset date:____/____/____
Lethargy
Is the pet hospitalized?
Y N
Treatment:  Itraconazole
 Fluconazole
Recovery date:____/____/____
Seizures
Y
N
Y N
 Voriconazole
 Amphotericin B
Cough
Blindness
Y
N
 Ketoconazole  Other:_______
Coughing up blood
Lameness/limping
Y N
Y N
 None
Difficulty breathing
Non-healing skin sores Y
N
Did the pet die? Y N If yes, date:____/____/____
Other: ______________
Y
N
Y N
Poor appetite
Did the pet die as a result of blastomycosis?
Y
N
Weight loss
Previously treated for
If no, cause of death: _____________________
blastomycosis? Y N
Euthanized? Y N If yes, date:____/____/____
#lbs.______
Y N
If yes, when:__/__/__
 Poor prognosis
 Expense of treatment
Fever
Reason:
 Both
 Other: ______________
Lyme disease or
temp. ______F
anaplasmosis positive?
Y N
C. LABORATORY INFORMATION
Lab name: ___________________________
Urine Antigen
Serum Antigen
Culture:
Smear:
Collection date:____/____/____
Collection date:____/____/____
Collection date:____/____/____
Pos Neg DNA probe: Y N
Pos Neg
Result: Pos Neg
Specimen:
Specimen:
Value:
Radiology:
Histopathology:
Serology:
Xray
Collection date:____/____/____
Collection date: ____/____/____
Date:____/____/____
Result: Pos Neg
AGID Elisa Comp FX EIA
Location: Chest Extremity
Spine Other: ______________
Result: Pos Neg
Specimen:
Findings:
Titer:___________________________
D. CASE SUMMARY
Type of blastomycosis. Please check all locations that apply:
Pulmonary, disease present only in the lungs
Disseminated, both pulmonary and extra-pulmonary lesions
Extra-pulmonary, no disease in lungs
Bone
Skin
Eye
CNS
Other location:
Minnesota Department of Health
Minnesota Board of Animal Health
625 N. Robert Street
625 N. Robert Street
St. Paul, MN 55155-2538
St. Paul, MN 55155-2538
651-201-5414 Fax: 651-201-5743
651-296-2942 TTY:1-800-627-3529
Contact: Dr. Joni Scheftel
joni.scheftel@state.mn.us
Please fax completed form to Dr. Scheftel at 651-201-5743
Revised 11-13-13

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