8/13/2019 WHO Minimum Clinical Data Set for H5N1 Patients (FGH_NS 10-0

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WHO Minimum Clinical Data Set for H5N1 Patients- Page 1

Date of report(day-mont-year!"

Unique Patient Number: Age (years): Sex (male/female):

Presentation

Date of illness onset (day-month-year):

nitial sym!toms: "e#er $%&o' (yes/no) Sore throat (yes/no) 'ough (yes/no) eadahe

(yes/no) Diarrhoea (yes/no) *omiting (yes/no) A!!etite loss (yes/no) +alaise (yes/no)

,oint !ain (yes/no)

Date of initial out!atient e#aluation (day-month-year):

+anifestations: "e#er (yes/no) Sore throat (yes/no) 'ough (yes/no) Shortness of breath

(yes/no) Diarrhoea (yes/no) *omiting (yes/no)

em!erature (o'): Pulse (/min): .es!irations (/min):

Hospitali#ation (yes$no!

Date of hos!italiation (day-month-year):

+anifestations: "e#er $%&o' (yes/no) Sore throat (yes/no) 'ough (yes/no) Shortness ofbreath (yes/no) 'hest !ain (yes/no) S!utum !rodution (yes/no) 0loody s!utum (yes/no)

Diarrhoea (yes/no) *omiting (yes/no) Abdominal !ain (yes/no) Altered mental status

(yes/no)

em!erature (o'): Pulse (/min): .es!irations (/min): Sa12 (3) on room air:

Date of initial laboratory testing (day-month-year):40' (no5/mm%) P+N (3) 6ym!hoyte (3) aemoglobin (mg/dl) Platelet

(no5/mm%) AS A6 'reatinine

S!utum 7ram stain (desribe):

S!utum ulture (negati#e/!ositi#e/not done):

0lood ulture (negati#e/!ositi#e/not done):

'hest radiogra!h: infiltrates (yes/no) (unilateral/bilateral) !leural effusion (yes/no)

f diarrhoea8 stool oult blood (yes/no)8 stool 40' (yes/no)

Pre-existing onditions: Pregnany (yes/no) eart disease (yes/no) 6ung disease

(yes/no) Diabetes (yes/no) mmune defiieny state (yes/no)

Desribe:

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WHO Minimum Clinical Data Set for H5N1 Patients- Page %

Date of report(day-mont-year!"

Unique Patient Number: Age (years): Sex (male/female):

Clinical course

&reatments gi'en"

nfluen#a-specific anti'iral medication (yes) no!

Oseltami'ir (yes) no!

Drug llness onset to

start (days!

Date of start

(day-mo-year!

Dose (mg$day!

and route

Date of stop

(day-mo-year!

1seltami#ir

anami#ir

Amantadine/

rimantadine

.iba#irin

'ortiosteroids

S!eify:

Antibioti treatment (yes/no)

6ist agents:

'ortiosteroid treatment(yes/no):

S!eify ty!e8 dose8 duration:

Su!!lemental oxygen thera!y (yes/no)

Duration of su!!lemental oxygen thera!y (days):

ntubation/mehanial #entilation (yes/no)Date of intubation/mehanial #entilation (day-month-year):

Date of extubation (day-month-year):

Duration of intubation (days):

Duration of su!!lemental oxygen thera!y (days):

Secondary complications"

*'ent +es$No Date of onset

(day-mo-year!

Duration

(days!

0ateraemia

0aterial!neumonia

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*entilator-assoiated

!neumonia

y!otension

.enal failure

'oagulo!athy

1ther (desribe):WHO Minimum Clinical Data Set for H5N1 Patients- Page ,

Date of report(day-mont-year!"

Unique Patient Number: Age (years): Sex (male/female):

Outcome (reco'ery$deat!"

Duration of hos!italiation (days):Date of hos!ital disharge (day-month-year):

Date of death (day-month-year):

Post-mortem obtained (yes/no):

%