Case Report Form
Acute Meningitis - Encephalitis
I. INFORMATIONABOUTTHEDISEASE REPORTING UNIT(DRU)
Name of DRU:
Address:
Contact number:
Type
Government
Private
I. PATIENT INFORMATION
Find
EPI ID:
Patient Number:
Patient's Last Name
First Name:
Middle Name:
Current Address: (Specify House No./Street/Subdivision/Purok/Brgy/Municipality/City/Province)
Present Address:
(Specify House No./Street/Subdivision/Purok/Brgy/Municipality/City/Province)
District:
Region:
Sex:
Male
Female
Is patient member of the Indigenous People (IP):
Yes
No
If YES, Specify:
ILHZ:
Date of Birth:
Sentinel Site
non sentinel site
Age:
Days
Months
Years
III. CLINICAL DATA (Put a check [✓] in the appropriate box)
IV. DETAILS OF INVESTIGATION/REPORTING
Was patient admitted?:
Yes
No
If YES, date admitted:
Date of onset of illness:
Sign and Symptoms?
Fever:
Yes
No
*Change in mental status:
Yes
No
New onset seizures:
Yes
No
Neck stiffness:
Yes
No
Meningeal sign:
Yes
No
*Change in mental state includes altered consciousness, confusion, or inability to talk.
Admission Diagnosis:
CNS Infection
Suspected Bacterial Meningitis
Suspected Encephalitis
Others
*If the clinical presentation of the CNS infection is more of either suspected Bacterial Meningitis or suspected Encephalitis, check the specific box
If the patient fulfills the case definition of Acute Flaccid Paralysis, refer to the AFP surveillance point person.
Name of Investigator:
Designation:
Contact Number:
Date of Investigation:
Date of report to CHD
V. ILLNESS/VACCINATION HISTORY
Tick appropriate box(□) for the corresponding vaccination
Date Last Dose
No. of Doses
Date Last Dose
No. of Doses
JE
Meningococcal
Penta-Hib
Pneumococcal
Measles
PCV PCV10
MMR/MR
PCV13
*Exposure History:
Tick the type of place where exposure occur:
Daycare
Barangay
Home
School
Dormitory
Healthcare Facility
Work Place
Others, specify
*Exposure means any other member have similar symptoms.
Did the patient travel outside the province in 2 weeks prior to illness?
Yes
No
If YES, specify
Date traveled:
From:
To:
III. Case Management
Were blood/CFS extracted before the first dose of antibiotics was given to the patient? (Fill up if case is a suspected Bacterial Meningitis case)
Yes
No
Unknown
VI. Laboratory Data
Sample
Collected
Date/Time Collected
Date/Time Received at the hospital laboratory (to be filled by Sentinel hospital laboratory)
CSF Appearance (To be filled by Sentinel hospital)
Microbiology Result (To be filled by Sentinel hospital)
CSF Cytology (To be filled by Sentinel hospital)
Date sent to RITM
Date Received and Volume of sample (To be filled by RITM)
Date of testing and RITM Result (To be filled by RITM)
CSF
Y
N
Clear
Turbid-purulent
Blood stained
Others, specify
Gram stain:
Y
N
Result
Culture:
Y
N
Result
Others:
Result
Test
Result
Units
WBC
Protein
Glucose
ml
JE
Dengue
H.influenza
S.pneumoniae
N.meningitis
Negative
SERUM
1
(Acute)
Y
N
Date sent to RITM:
Date Received and Volume of Sample
ml
Date of Testing:
Result:
JE
Dengue
Negative
1
(Convale-scent)
Y
N
Date sent to RITM:
Date Received and Volume of Sample
ml
Date of Testing:
Result:
JE
Dengue
Negative
VII. CASE CLASSIFICATION
(*Case Classification will be filled out by Epidemiology and Surveillance Units)
A. For Acute Encephalitis Syndrome
Case Classification:
Suspected
Laboratory confirmed JE
Probable JE
AES unknown:
AES other agent:
B. For Bacteria Meningitis
Case Classification:
Suspected Meningitis
Probable Bacteria Meningitis
Confirmed Meningitis; if confirmed case, please state confirmatory test
Final Diagnosis
VIII. OUTCOME
Alive Date of Discharge:
Died Date of Death
Recovered w/ sequelae:
Yes
No
If YES, specify
Home Against Medical Advice (HAMA)
Date if HAMA:
Transferred/Referred To
If JE, ff-up after 3mos:
Date of ff-up:
Status at ff-up:
CASE DEFINITION of Acute Meningitis-Encephalitis Surveillance
A combined case definition for AES and BM surveillance shall be used. Suspected cases will be captured through the standard case definition of
Acute Meningitis-Encephalitis Surveillance
System (includes meningitis, encephalitis and overlapping cases).
Suspected
A case of suspected Acute Meningitis-Encephalitis A person of any age, at any time of year, with the acute onset of fever and a change in mental status (including symptoms such as confusion, disorientation, coma or inability to talk) AND/OR new onset of seizures (excluding simple febrile seizures). Other early clinical findings can include an increase of irritability, somnolence or abnormal behavior greater than that seen with usual febrile illness.
Laboratory-confirmed Japanese Encephalitis - An Acute Encephalitis Syndrome case that has been laboratory-confirmed as Japanese Encephalitis
Confirmed BM:
A case that is laboratory-confirmed by growing (i.e. culturing) or identifying (i.e. by Gram stain or antigen detected methods) a bacteria pathogen (Hib, pneumococcus or meningococcus) in the CSF or from the blood in a case with a clinical syndrome consistent with bacterial meningitis
Probable Japanese Encephalitis
An Acute Encephalitis Syndrome case that occurs in close geographical and temporal relationship to a laboratory-confirmed case of Japanese Encephalitis, in the context of an outbreak.
Probable BM:
A case with CSF examination showing at least one of the following:
Turbid appearance;
leukocytosis (> 100 cells/mm3);
leukocytosis (10-100 cells/mm3) AND either an elevated protein (>100mg/dl) or decreased glucose (<40mg/dl)
Acute Encephalitis Syndrome - other agent
An Acute Encephalitis Syndrome case in which diagnostic testing is performed and an etiologic agent other than Japanese Encephalitis virus is identified.
Acute Encephalitis Syndrome - unknown
An AES case which diagnostic testing is not performed or testing was performed but no etiological agent was identified or in which the test result were indeterminate
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