MELIOIDOSIS INVESTIGATION FORM SECTION A: TO BE COMPLETED BY TREATING HOSPITAL

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MELIOIDOSIS INVESTIGATION FORM SECTION A: TO BE COMPLETED BY TREATING HOSPITAL
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  1 MELIOIDOSIS INVESTIGATION FORM   SECTION A: TO BE COMPLETED BY TREATING HOSPITAL   PERSONAL INFORMATION  1.00 Date of registration DD MM YYYY 2.00 RN  3.00 Name  4.00 New IC - - 5.00 Other IC  6.00 Date of birth DD MM YYYY 7.00 Age years/months/days* 8.00 Gender [1] Male [2] Female 9.00 Race [1] Malay [2] Chinese [3] Indian [4] Orang Asli [5] Other 10.00 Nationality [1] Malaysian [2] Non-Malaysian Specify: 11.00 Occupation Current occupation. Choose only ONE answer.   Managerial and professional specialty occupations: [1] Executive, administrative, and managerial occupations [2] Professional specialty occupations Technical, sales, and administrative support occupations:   [3] Technicians and related support occupations [4] Sales occupations [5] Administrative support occupations, including clerical Service occupations:   [6] Private household occupations [7] Protective service occupations [8] Service occupations, except protective and household [9] Farming, forestry, and fishing occupations [10] Precision production, craft, and repair occupations Operators, fabricators, and labourers:   [11] Machine operators, assemblers, and inspectors [12] Transportation and material moving occupations [13] Handlers, equipment cleaners, helpers, and labourers Others   [14] Housewife [15] Student [16] Not relevant (children) [17] Unemployed [18] Others. Please specify : Appendix 3  2 12.01 12.02  Address  12.03 Poscode 12.04 City 12.05 State 13.00 Tel (H)  14.00 Tel (O)  15.00 Tel (H/P)   PAST HISTORY  16.00 Previous melioidosis infection [1] Yes [2] No (If No, go to Question 23)    17.00 When was the previous infection? years/months/weeks/days* ago 18.00 Organ involved  18.01 Unknown [1] Yes [2] No 18.02 Pulmonary [1] Yes [2] No 18.03 Liver [1] Yes [2] No 18.04 Spleen [1] Yes [2] No   18.05 Skin/Subcutaneous tissue [1] Yes [2] No   18.06 Musculoskeletal [1] Yes [2] No   18.07 Others [1] Yes [2] No   If others, please specify 19.00 How the diagnosis was made  19.01 Culture [1] Yes [2] No 19.02 Serology [1] Yes [2] No 19.03 Clinical [1] Yes [2] No 19.04 Others [1] Yes [2] No   If others, please specify  3 Intensive Phase   Dose   Duration   Ceftazidime   Amoxycillin-clavulinic   Cefoperazone-sulbactam   Trimethoprim-sulfamethoxazole   Tetracycline   Imipenam   Meropenam   Ciprofloxacin   Others (Specify: )   Others (Specify: )   Others (Specify: )   Maintenance Phase   Dose   Duration   Amoxicillin-clavulinic   Chloramphenicol   Trimethoprim-sulfamethoxazole   Tetracycline   Ciprofloxacin   Others (Specify: )   Others (Specify: )   Others (Specify: )   Treatment History  20.00    20.01 20.02 20.03 20.04 20.05 20.06 20.07 20.08 20.09 20.10 20.11 21.00    21.01 21.02 21.03 21.04 21.05 21.06 21.07 21.08 22.00 No antibiotic given 23.00 Underlying illnesses  23.01 Diabetes mellitus [1] Yes [2] No 23.02 Chronic renal failure [1] Yes [2] No 23.03 Alcohol abuse [1] Yes [2] No 23.04 Chronic lung disease [1] Yes [2] No 23.05 HIV/AIDS [1] Yes [2] No 23.06 Other immunocompromised [1] Yes [2] No state (e.g. Steroid) 23.07 Others [1] Yes [2] No   If others, please specify  4 CURRENT MEDICAL HISTORY  24.00   Date of admission:   [1]   DD MM YYYY 25.00   Clinical presentation   25.01   Fever   [1]   Yes [2]  No 25.02   Duration   months/weeks/days* 25.03   Cough   [1]   Yes [2]  No 25.04   Duration   months/weeks/days* 25.05   Sputum   [1]   Yes [2]   No 25.06   Sputum colour   [1]   White [2]   Y ellow [3]   Green [4]   Others (Specify: ) 25.07   Hemotsis   [1]   Yes   [2]   No   25.08 Abdominal ain [1]   Yes   [2]   No   25.09 Dsuria [1]   Yes   [2]   No   25.10 Headache [1]   Yes   [2]   No   25.11 Others [1]   Yes   [2]   No   Specify 26.00 Physical findings  26.01 Blood ressure  / SBP DBP 26.02 Pulse rate  /min 26.03 Repiratory rate  /min 26.04 Jaundice [1]  Yes   [2]   No   26.05 Joint swelling [1]  Yes   [2]   No   If YES, how many joints involved?    26.06 Ulcer   [1]  Yes   [2]   No   Specify : 26.07 Cut/abrasion [1]  Yes   [2]   No   Specify : 26.08 Heatomeal  [1]  Yes   [2]   No   26.09 Splenomegaly [1]  Yes   [2]   No   26.10 Pleural effusion [1]  Yes   [2]   No   26.11 Others [1]  Yes   [2]   No   Specify 27.00   Final clinical diagnosis   27.01   Pneumonia   [1]   Yes   [2]   No   27.02   Soft tissue abscess   [1]   Yes   [2]   No   27.03   Septic arthritis   [1]   Yes   [2]   No   27.04   Osteomylitis   [1]   Yes   [2]   No   27.05   Prostatic abscess   [1]   Yes   [2]   No   27.06   Liver abscess   [1]   Yes   [2]   No   27.07   Splenic abscess   [1]   Yes   [2]   No   27.08   Meningoencephalitis   [1]   Yes   [2]   No   27.09   Brain abscess   [1]   Yes   [2]   No   27.10   Pyelonephritis/UTI/Perinephric Abscess   [1]   Yes   [2]   No   27.11   Others   [1]   Yes   [2]   No   Specify  5 INVESTIGATION   28.00   Investigation Findings   28.01   Hb   . g/dL 28.02 WBC x 1000/mL 28.03 Platel x 1000/mL 28.04   PT   Patient Control 28.05   PTT   Patient Control 28.06   INR   . 28.07   RBS   . mmol/L UFEME   28.08   WBC [1]   1+ [2]  2+ [3]  3+ [3]  4+ 28.09   RBC [1]   1+ [2]  2+ [3]  3+ [3]  4+ 28.10   Protein [1]   1+ [2]  2+ [3]  3+ [3]  4+ 28.11   Urea   mmol/L 28.12   Creatinine   umol/L Bilirubin 28.13   Conjugated   umol/L 28.14   Unconjugated   umol/L 28.15   Albumin   g/L 28.16   Globulin   g/L 28.17   AST   U/L 28.18   ALT   U/L 28.19   ALP   U/L 28.20   CXR   USG Abdomen (Looking for abscess) 28.21 Liver abscess   [1]  Single [2]  Multiple [3]  Normal 28.22 Spleenic abscess [1]  Single [2]  Multiple [3]  Normal 28.23 Kidney abscess [1]  Single [2]  Multiple [3]  Normal 28.24 Prostate abscess [1]  Single [2]  Multiple [3]  Normal 28.50 Other finding:   28.25 CT Scan
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