Medical Case Review Form

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Medical Case Review
___________________________________
Date of Birth ___________ age ___ race ___ sex ___ HIV _____  US born  Foreign-born
.
 Contact to known case? _________________________________  If case is < 18, source identified ______________________________
Physician or Health Department _________________________________________________________________________________________
Occupation _____________________________________________ Last date worked _________________ Return to work date _____________
DIAGNOSTIC INFORMATION
Major site of disease:
Skin Test
Diagnosed at  Hospital  Physican’s Office  Health Dept.
Date ___________________
Status at Diagnosis: Alive Dead (date) ____________
Additional site:
Results _________________
Reason ________________
Date(s)
Fluid specimens
Smear
Culture
Biopsy specimens for hisopathology & culture
Collected
Pos / Neg / Pend/Not done
Pos / Neg / Pend / Not done
Date
AFB
Necrotizing
Culture
Result
Collected
granuloma
Initial Sputum
_________
 ___  
  
Lymph node________ ________
________ _________
Pleura
________ ________
________ _________
  
_________
 ___  
Bone
________ ________
________ _________
  
_________
 ___  
Other
________ ________
________ _________
  
__________
 ___  
Bronchial Wash
__________
  
 ___  
Gastric Aspirate
Not performed
__________
  
Pleural Fluid
 ___  
__________
  
CSF
 ___  
__________
Not applicable
Urine
  
 ___  
__________
Other _______________
  
 ___  
DRUG SUSCEPTIBILITY RESULTS:  No
 INH
 RIF
 Other _______________________
resistance
resistance
resistance
SPUTUM CULTURE CONVERSION: Date ____________________ Occurred within 2 months of treatment?
 Yes  No
BACTERIOLOGY SUMMARY: Smear:
________
________ Culture:
________
___________
Last Positive
1
Negative
Last Positive
1
Negative
st
st
CHEST RADIOGRAPHY
INITIAL
FOLLOW-UP
Interpretation
Date _________________
Date _____________________
 Normal
 Not done
 Unknown
Status
 Abnormal →  Cavitary
 Stable
Remarks:
 Non-cavitary →
 Consistent with TB
 Worsening
 Inconsistent with TB
 Improving
 Pleural Effusion
 Unknown
CO-MORBID MEDICAL
 Diabetes Mellitus
Cancer (site) ______________________________
HIV Test Offered  Yes  No
 Silicosis
Chronic Liver disease
Initial weight ____________
Refused Testing
 Yes  No
 End Stage Renal Disease
Hepatitis B
 Hepatitis C
Current weight __________
Test done, results unknown
 Tumor necrosis factor alpha (TNF) antagonists
 Other ____________________________________________________________________
ALLERGIES:
Status Negative
Recent hospitalization, specify details:
Status Positive 
CD4 _________
On Antiretrovirals  Yes  No
If Yes, List:
Medical Complications:
PCP Prophylaxis  Yes  No
INITIAL DRUG REGIMEN
Date RX Started:___________________ Daily Twice Weekly Other ________________________________
 DOT
Non-DOT
 Isoniazid ____________________
 Rifampin ____________________  Pyrazinamide _________________  Ethambutol __________________
 Other ___________________________________  Other ___________________________________  Other __________________________________
CURRENT DRUG REGIMEN
Date RX Started:___________________ Daily Twice Weekly Other ________________________________  DOT
Non-DOT
 Isoniazid ____________________
 Rifampin ____________________  Pyrazinamide _________________  Ethambutol __________________
 Other ___________________________________  Other ___________________________________  Other __________________________________
# Months on Therapy ___________# Doses to Date ____________ Est. length of treatment _____________ Anticipated completion date ________________
Describe clinical improvement __________________________________________________________________________________

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