0920-0009 (17AXX) Non-substantive Change 0920-0009_Acute Flaccid Myelitis

Acute Flaccid Myelitis: Patient Summary Form

FOR LOCAL USE ONLY

Name of person completing form: ______________________________________________________ State assigned patient ID: ____________________________

Affiliation__________________________________________ Phone: ____________________________Email: __________________________________________

Name of physician who can provide additional clinical/lab information, if needed ___________________________________________________________________

Affiliation_____________________________________________ Phone: ___________________________ Email: ________________________________________

Name of main hospital that provided patient’s care: ________________________________________________ State: _____ County: ______________________

-------------------------------------------------------------DETACH and transmit only lower portion to limbweakness@cdc.gov if sending to CDC-------------------------------------------------------------

Form Approved

OMB No. 0920-0009

Exp Date: 06/30/2019

Acute Flaccid Myelitis: Patient Summary Form

Please send the following information along with the patient summary form (check information included):

 History and physical (H&P)  MRI report  MRI images  Neurology consult notes  EMG report (if done)

 Infectious disease consult notes (if available)  Vaccination record  Diagnostic laboratory reports

1. Today’s date__ __/__ __/__ __ __ __ (mm/dd/yyyy) 2. State assigned patient ID: ______________________________

3. Sex:  M F 4. Date of birth __ __/ __ __/ __ __ __ __ Residence: 5. State_______ 6. County______________________

7. Race: American Indian or Alaska Native Asian Black or African American 8. Ethnicity: Hispanic or Latino

Native Hawaiian or Other Pacific Islander White (check all that apply) Not Hispanic or Latino

9. Date of onset of limb weakness __ __/__ __/__ __ __ __ (mm/dd/yyyy)

10. Was patient admitted to a hospital? yes no unknown 11.Date of admission to first hospital__ __/__ __/__ __ __ __

12.Date of discharge from last hospital__ __/__ __/__ __ __ __(or  still hospitalized at time of form submission)

13. Did the patient die from this illness? yes no unknown 14. If yes, date of death__ __/__ __/__ __ __

SIGNS/SYMPTOMS/CONDITION:
		Right Arm			Left Arm		Right Leg	Left Leg
15. Weakness? [indicate yes(y), no (n), unknown (u) for each limb]		Y N U			Y N U		Y N U	Y N U
15a. Tone in affected limb(s) [flaccid, spastic, normal for each limb]		 flaccid  spastic  normal  unknown			 flaccid  spastic  normal  unknown		 flaccid  spastic  normal  unknown	 flaccid  spastic  normal  unknown
	Yes		No	Unk
16. Was patient admitted to ICU?						17. If yes, admit date: __ __/__ __/__ __ __ __

In the 4-weeks BEFORE onset of limb weakness, did patient:	Yes	No	Unk
18. Have a respiratory illness?				19. If yes, onset date __ __/__ __/__ __ __ __
20. Have a gastrointestinal illness (e.g., diarrhea or vomiting)?				21. If yes, onset date __ __/__ __/ __ __ __ __
22. Have a fever, measured by parent or provider ≥38.0°C/100.4°F?				23. If yes, onset date __ __/__ __/__ __ __ __
24. Travel outside the US?				25. If yes, list country:
26. At onset of limb weakness, does patient have any underlying illnesses?				27. If yes, list:

Other patient information:

28. Was MRI of spinal cord performed?  yes  no  unknown 29. If yes, date of spine MRI: __ __/__ __/__ __ __ __

30. Was MRI of brain performed?  yes  no  unknown 31. If yes, date of brain MRI: __ __/__ __/__ __ __ __

CSF examination: 32. Was a lumbar puncture performed?  yes  no  unknown

If yes, complete 32 (a,b) (If more than 2 CSF examinations, list the first 2 performed)

	Date of lumbar puncture	WBC/mm3	% neutrophils	% lymphocytes	% monocytes	% eosinophils	RBC/mm3	Glucose mg/dl	Protein mg/dl
32a. CSF from LP1
32b. CSF from LP2

Acute Flaccid Myelitis Outcome – 60-day follow-up (completed at least 60 days after onset of limb weakness)

33. Date of 60-day follow-up: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

34. Sites of Paralysis:  Spinal  Bulbar  Spino-bulbar 35. Specific sites: __________________________________________________

36. 60-day residual:  None  Minor (any minor involvement)  Significant (≤2 extremities, major involvement)

 Severe (≥3 extremities and respiratory involvement)  Death  Unknown

37. Date of death: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

Acute Flaccid Myelitis case definition (http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2015PS/2015PSFinal/15-ID-01.pdf)

Criteria

An illness with onset of acute focal limb weakness AND

● a magnetic resonance image (MRI) showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments, OR

● cerebrospinal fluid (CSF) with pleocytosis (white blood cell count >5 cells/mm³)

Case Classification

Confirmed:

● An illness with onset of acute focal limb weakness AND

● MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments

Probable:

● An illness with onset of acute focal limb weakness AND

● CSF showing pleocytosis (white blood cell count >5 cells/mm³).

Acute Flaccid Myelitis specimen collection information

(https://www.cdc.gov/acute-flaccid-myelitis/hcp/instructions.html)

Acute Flaccid Myelitis job aid

(https://www.cdc.gov/acute-flaccid-myelitis/downloads/job-aid-for-clinicians.pdf)

Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333.

Page 1 of 2 Version 5.0 March 27, 2017