Patient Summary Form

OMB Approved

OMB No. 0920-0009

Expiration Date: 04/2016

ID ___ ___--___ ___

Acute Neurological Illness with Limb Weakness in Children: Patient Summary Form To be completed by, or in conjunction with, a physician who provided care to the patient during the neurological illness. Once completed, submit to Health Department (HD). HD can also facilitate specimen testing.

Confirmation of case :	Yes	No	Unknown
a. Neurological findings (upon examination by clinician) include focal limb weakness
b. MRI of spinal cord demonstrates spinal lesion largely restricted to the gray matter
c. Age at onset of limb weakness is 21 years or less
d. Onset of limb weakness was August 1, 2014 or later

Answer to ALL 4 criteria must be YES. (If not, do not complete this form)

1.Today’s Date__ __/__ __/__ __ __ __ (mm/dd/yyyy) 2.Name of person completing form: ______________________________________________

3.Affiliation_____________________________________Phone: ____________________________Email: __________________________________

4.Name of physician who can provide additional clinical/lab information, if needed _____________________________________________________

5.Affiliation_____________________________________ Phone: ___________________________ Email: __________________________________

6.Name of main hospital that provided patient’s care:_____________________________________ 7.State: _____ 8.County: __________________

9.Patientl ID: ____________________________ State ID ___ ___--- ___ ___ (HD to assign using State abbrev, then number: aa--##, use leading zero)

10.Patient sex:  M F Age: ______years and _______months 11.Patient’s residence: State________County____________________

12.Race: Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native

White (check all that apply) 13. Ethnicity: Hispanic Non-Hispanic

14. Date of onset of limb weakness: __ __/__ __/__ __ __ __ (mm/dd/yyyy) 15.Date of admission to first hospital__ __/__ __/__ __ __ __

16. Date of discharge from last hospital__ __/__ __/__ __ __ __ ( still hospitalized)

17. Current clinical status: recovered  not recovered, but improved not improved Deceased: date of death__ __/__ __/__ __ __ __

Signs/symptoms/condition at ANY time during the illness:

18.Number of limbs with acute weakness ____________
Grade of motor weakness, of most affected muscle group: ǂ
19. At peak severity  0/5 1/5  2/5 3/5 4/5  5/5 20. Date __ __/__ __/__ __ __ __
21. At most recent examination  0/5 1/5  2/5 3/5 4/5  5/5 22. Date __ __/__ __/__ __ __ __
	Yes	No	Unknown
23 .Clinical involvement of ≥1 cranial nerve(s)?
24. Sensory level or numbness present? (do not include pain)
25. Bowel or bladder incontinence?
26 .Cardiovascular instability?
27. Change in mental status?
28. Seizure(s)?
29. Received care in ICU because of neurological condition?
30. Received ventilatory support because of neurological condition?

ǂ 0/5: no contraction; 1/5: muscle flicker, but no movement; 2/5: movement possible, but not against gravity; 3/5: movement possible against gravity, but not against resistance by examiner; 4/5: movement possible against some resistance by examiner; 5/5: normal strength

Polio vaccination history:
a. How many doses of inactivated polio vaccine (IPV) have been documented to have been received by the patient before the onset of weakness?	_______doses unknown
a. How many doses of oral polio vaccine (OPV) have been documented to have been received by the patient before the onset of weakness?	_______doses unknown
c. If you do not have documentation of type of polio vaccine received: What is total number of documented polio vaccine doses?	_______doses unknown
Were any of these doses administered outside the US?	yes no unknown

ID ___ ___--___ ___

Neuroradiographic findings: indicate based on most abnormal study

MRI of spinal cord 42. Date of study __ __/__ __/__ __ __ __ (mm/dd/yyyy)

43.Levels imaged: cervical thoracic lumbosacral unknown

44. Gadolinium used? yes no unknown

45.Location of lesions:	cervical cord thoracic cord conus cauda equina unknown	Levels affected (if applicable): 46. Cervical: _________ 47. Thoracic: _________
For cervical and thoracic cord lesions	48.What areas of spinal cord affected?	gray matter white matter both unknown
	49.Was there cord edema?	yes no unknown
	50. Site of lesion(s)	mostly right side mostly left side both sides unknown
For cervical, thoracic cord or conus lesions	51.Did any lesions enhance with GAD?	yes no unknown
For cauda equina lesions	52. Did the ventral nerve roots enhance with GAD?	yes no unknown
	53. Did the dorsal nerve roots enhance with GAD?	yes no unknown

MRI of brain 54. Date of study __ __/__ __/__ __ __ __ (mm/dd/yyyy)

55. Gadolinium used?  yes no unknown

56. Any supratentorial (i.e, cortical, subcortical, basal ganglia, or thalamic) lesions	yes no unknown
57. Any brainstem lesions?	yes no unknown
	58. If yes, indicate location	midbrain ventral pons dorsal pons medulla unknown
	59.If yes, did any lesions enhance with GAD	yes no unknown
58. Any lesions affecting the deep nuclei (e.g, dentate) of the cerebellum?	yes no unknown
59. Any cranial nerve lesions?	yes no unknown
	60. If yes, indicate which CN and side:	CN_____ R L  both R and L
		CN_____ R L  both R and L
		CN_____ R L  both R and L
	61. If yes, did any lesions enhance with GAD	yes no unknown

CSF examination (if more than two examinations, list earliest and then most abnormal)

	Date of lumbar puncture	WBC/mm3	% neutrophils	% lymphocytes	% monocytes	% eosinophils	RBC/mm3	Glucose mg/dl	Protein mg/dl
62. CSF from LP1
63. CSF from LP2

ID ___ ___--___ ___

Pathogen testing performed

64. Was CSF tested for enterovirus/rhinovirus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result:
	Interpretation:
	If test result was positive, was typing performed? yes no unknown
	If yes, method and result:
65. Was CSF tested for West Nile virus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:
66. Was CSF tested for St. Louis encephalitis virus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:
67. Was CSF tested for La Crosse virus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:
68. If CSF testing identified any pathogen, describe:	Date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:

69. Was a respiratory tract specimen tested for enterovirus/rhinovirus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of specimen:
	Type of testing:
	Result:
	Interpretation:
	If test result was positive, was typing performed? yes no unknown
	If yes, method and result:

ID ___ ___-- ___ ___

70. Was a stool specimen tested for enterovirus/rhinovirus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of specimen: rectal swab  whole stool unknown
	Type of testing:
	Result:
	Interpretation:
	If test result was positive, was typing performed? yes no unknown
	If yes, method and result:

71. Was serum tested for: West Nile virus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:
72. St. Louis encephalitis virus?	yes no  unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:
73. La Crosse virus?	yes no unknown If yes, date of specimen collection __ __/__ __/__ __ __ __
	Type of testing:
	Result: Interpretation:

74. Describe any other laboratory finding(s) considered to be significant________________________________________________________

___________________________________________________________________________________________________________________

75. Was/Is a specific etiology considered to be the most likely cause for the patient’s neurological illness? yes no 76. If yes, please list etiology and reason considered most likely cause _________________________________________________________

__________________________________________________________________________________________________________________

77. Other information you would like us to know __________________________________________________________________________

__________________________________________________________________________________________________________________

78. Indicate which type(s) of specimens from the patient are currently stored, and could be available for possible additional testing at CDC:

 CSF  Nasal wash/aspirate BAL spec tracheal aspirate NP/OP swab Stool Serum  No specimens stored

page 4/4

 Other, list ________________

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0879).