TB Medical History Abstraction Form - School of Nursing
TB Medical History Abstraction Form - School of Nursing
TB Medical History Abstraction Form - School of Nursing
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Site <strong>of</strong> Disease:<br />
Pulmonary Pleural Lymphatic Meningeal<br />
Other ________________________________<br />
Laboratory results:<br />
AFB positive Yes Count________ No N/A Specimen<br />
type______________<br />
Culture pos Yes No N/A Specimen<br />
type______________<br />
If culture positive, name <strong>of</strong> laboratory<br />
__________________________________________<br />
If culture positive, susceptibility results (indicate sensitive S, resistant R) N/A<br />
INH___ Rifampin___ Ethambutol___ PZA___<br />
Strep___<br />
CXR: Normal Abnormal Not done Unknown<br />
If abnormal Cavitary Non-Cavitary<br />
Therapy:<br />
Rx Start Date ___/___/___ Rx Stop Date ___/___/___<br />
Reason Rx stopped: Completed Moved Lost Refused<br />
Unknown Other ____________________________<br />
Current <strong>TB</strong>:<br />
Diagnosis:<br />
Month-year <strong>of</strong> diagnosis: ___/___<br />
Provider: Name__________________________________________________<br />
City ____________________________ State ________________<br />
Facility : Name__________________________________________________<br />
City ____________________________ State ________________<br />
Symptoms Date <strong>of</strong> onset pre-diagnosis<br />
Productive cough ___/___/___<br />
Fever ___/___/___<br />
Chills ___/___/___<br />
Weight Loss ___/___/___<br />
Night Sweats ___/___/___<br />
Hemoptysis ___/___/___<br />
Chest pain ___/___/___<br />
Other ______________________ ___/___/___<br />
Major site <strong>of</strong> disease:<br />
Pulmonary Pleural Lymphatic Meningeal<br />
Other ________________________________<br />
CXR at diagnosis: Date___/___/___<br />
Normal Abnormal Not done Unknown<br />
If abnormal Cavitary Non-Cavitary<br />
CXR prior to diagnosis, if available Date___/___/___