Case history example

0920-0600 Attachment 4d NTM Case History Form.doc

Centers for Disease Control and Prevention Performance Evaluation Program for Mycobacterium Tuberculosis/Non-tuberculosis Mycobacteria Drug Susceptibility Testing Program

Case history example

OMB: 0920-0600

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0600 can be found here:

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Example:

M. tuberculosis/NTM Case History Form – NTM Supplemental Information

Strain O – M. marinum Case History

Patient:

39-years old

Gender:

Male

Medical History:

HIV-positive

Current Ailment/Complaint:

Developed multiple cutaneous nodules on his hand and forearm

Patient Hobbies:

Maintains a tropical fish aquarium

Physician Notes:

Because of his current anti-retroviral therapy, the physician does not wish to use a rifampin-containing regimen and asks for susceptibility testing to be performed on this isolate of Mycobacterium marinum.

NTM Supplemental Information Page

File Type	application/msword
File Title	PERFORMANCE EVALUATION PROGRAM: DRUG SUSCEPTIBILITY TESTING OF STRAINS OF MYCOBACTERIUM TUBERCULOSIS_RESULTS FORM
Last Modified By	aeo1
File Modified	2009-11-18
File Created	2009-11-18