Tuberculosis Case/suspect Review Form
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TUBERCULOSIS CASE /SUSPECT REVIEW
Conference Date: ___/___/___
Nurse Case Manager: _________________________________
Two Month: ____ or Eight Month: ____
PHN phone # (______)____________________
Patient Name (last, first): _______________________________ DOB: ___/___/___
Male ___ Female ___
Race: Black White Asian/Pacific Islander Native Am Hispanic: N Y
Country of Origin: __________________________
Mo/Yr Arrived in US: ___/___ Primary Language: _________________________
Date LHD Received Report: ___/___/___
Reported by: ___________________________________
Patient Alive at Time of Report: N Y
Primary Disease Site: ____________________________
Secondary Disease Site: ____________________________
Health Provider: PMD LHD BOTH
Hospitalized Due to TB: N Y
# of Days Hospitalized: _______
HIV Test Result: _____ or Denies Risks: _____
TST Results in mm: ______
Date TST Done: ___/___/___
Hx of Previous TB Infection: N Y
Completed Treatment for LTBI: N Y
Year: ____
Hx of Previous TB Disease: N Y
Year: ______
Probable Reason for Relapse: _________________________
Initial CXR Date: ___/___/___ Reading: Normal Abnormal
Cavitary: N Y (specify) ________________________
Is this Person a Contact to Another Case? Name Case: _________________________________ Year of Contact: ______
Is this Person Homeless: N Y
Substance Abuse: N Y
Type of SA: Injection: ____ Alcohol: ____ Other: ____________
Occupation Within the Past Two Years: ________________________ Presently Incarcerated: N Y (specify) _______________
Presently in Long Term Care: N Y (specify) _________________________________________________
Initial Sputum Date: ___/___/___
Smear Result: _______ Culture Result: (specify) ___________________________________
Sputum Smear Conversion Date: ___/___/___
Smear Conversion Occurred in _______ Weeks.
Sputum Culture Conversion Date: ___/___/___
Culture Conversion Occurred in _______ Weeks.
Current Sputum Collection Frequency:
WEEKLY
BI-MONTHLY
MONTHLY
Lab Used: DCLS or (specify) __________________________________________ ph # ______________________________
Other Bacteriology: Type of Specimen (specify): _______________________________ Date: ___/___/___
Smear Result: ____ Culture Result: (specify) _____________________________________________
Chemotherapy:
Drug:
Dose/Freq
Start
Stop
DOT Start Date: ___/___/___
INH
__________
___/___/___
___/___/___
Number of DOT Doses Delivered to Date: ______
RIF
__________
___/___/___
___/___/___
If Not on DOT, Reason: _____________________________
PZA
__________
___/___/___
___/___/___
EMB
__________
___/___/___
___/___/___
Pt’s admission weight ________
Drug Susceptibility Testing: Specimen Collection Date: ___/___/___
(Use “S” for Susceptible and “R” for Resistant)
INH ______ RIF ______ EMB ______ PZA ______ SM ______ Other ________
Follow Up Subjective/Objective Information:
:
Initial Subjective/Objective Information
Symptoms: IMPROVED WORSENING UNCHANGED
Symptoms: FEVER COUGH ANOREXIA FATIGUE
CXR: IMPROVED WORSENING UNCHANGED ND
NIGHT SWEATS WT. LOSS HEMOPTYSIS
Sputum Collection: WEEKLY BI-MONTHLY MONTHLY
CXR: CAVITARY ABNORMAL (NON-CAVITARY)
Change in treatment plan? N Y (specify)
(specify) __________________ NORMAL
_________________________________________________
Treatment Plan: Regimen __________________;
Infection Control Issues: REMAINS INFECTIOUS? N Y
# ____ Doses for # ____ Months
If Not, Were 3 Consecutive Sputa Smear Negative? N
Y
Infection Control Issues: INFECTIOUS? N Y
MANAGEMENT PLAN: (central office use)
Number of Contacts Identified: ________
# Appropriate for Testing: _______ Date First Contacts Tested: ___/___/___
# Newly Infected Contacts: _____ # Contacts Started on Therapy: _______ # Contacts Completed Therapy: _______
Date of Case Closure: ___/___/___
Disposition Reason: COMPLETED TX
MOVED
DIED
LOST TO FOLLOW UP
If Moved, State Where if Known: ___________________________________ Date Case Information Transferred ___/___/___
02-TB-513
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