SOURCE OF REPORT

Institution:__________________________________________________   Telephone:____________________ ext.:__________  

Person reporting:_____________________________________________   Date reporting:_______________________________

CASE IDENTIFICATION

Name:________________________________________________________   Date of birth:______________________________

Sex:_____            DDO-case No:__________-_____               Date of onset of symptoms:______________________________

Address (in full):____________________________________________________________   Telephone:____________________

Mother's name:______________________________________   Father's name:_______________________________________

HOSPITALIZATION

Hospitalization (yes/no):______                                   Date of admission into the hospital:______________________________

Hospital name:________________________________________________   Medical record:_____________________________

SIGNS AND SYMPTOMS

a) In the 4 weeks preceding the onset of paralysis (Y: yes; N: no; ?: unknown):

fever:___ if yes, date:____________   nausea:___ if yes, date:____________   constipation:___ if yes, date:____________

stiff neck:__ if yes, date:__________   abdominal cramps:__ if yes, date:__________   weakness:__ if yes, date:_________

corysa:___ if yes, date:__________   sore throat:___ if yes, date:___________   paraesthesia:___ if yes, date:__________

irritability:___ if yes, date:__________   muscle pains:___ if yes, date:__________   vomiting:___ if yes, date:___________

diarrhea:___ if yes, date:___________   diplopia:___ if yes, date:____________   headache:___ if yes, date:____________

rigidness:___ if yes, date:____________   other (describe and date):_________________________________________________

_______________________________________________________________________________________________________

b) At the onset of paralysis (Y: yes; N: no; ?: unknown):

headache:__  paraesthesias:__  sensorial deficit:__  lethargy:__  shortness of breath:____  muscle pain:___

fever at onset of paralysis:__ if fever, how much in ºCelsius:_____  date of onset of paralysis:____________

pattern of development of weakness/paresia (circle which apply) è  ascending  –  descending  –  bulbar  –  other

(describe):____________________________________________________________________________________

c) Signs on initial neurologic examination (Y: yes; N: no; R: right; L: left):

weakness neck extensors:__  weakness neck flexors:__  stiff neck:__  facial weakness:__  able to cough:__

difficult swallowing:__  drop lids:__  diplopia:__ if yes (R/L):__   EOM weakness:________________________

able to walk:__ if yes (circle which apply) è  with help - independent (obs:______________________________)

chest size (in cm) è inspiration:_____cm; expiration:____cm (obs:___________________________________)

limb weakness:___ if yes observe and fill blanks bellow, and è  limb fasciculation:_____________________

1. right arm:___ if yes  è   1.1 can lift arm above head:___  è   1.2 can grip hand tightly:___

2. left arm:____ if yes  è   2.1 can lift arm above head:___  è   2.2 can grip hand tightly:___

3. right leg:____ if yes  è   3.1 can lift leg above bed:___  è   3.2 can wigle toes:___

4. left leg:_____ if yes  è   3.1 can lift leg above bed:___  è   3.2 can wigle toes:___

symmetric weakness:__ if yes (circle which apply) è R>L - L<R  (> stronger; < weaker)

upper limbs:___ if yes R>L - L<R               upper limbs:___ if yes R>L - L<R

reflexes (3= increased; 2= normal; 1= decreased; 0= absent):

1. biceps è R3-R2-R1-R0 - L3-L2-L1-L0         2. triceps è R3-R2-R1-R0 -- L3-L2-L1-L0     (circle which apply)

3. knee è R3-R2-R1-R0 - L3-L2-L1-L0           4. ankle è R3-R2-R1-R0 -- L3-L2-L1-L0         (circle which apply)

5. supinator è R3-R2-R1-R0 - L3-L2-L1-L0     6. Babinski è up - down - no movement        (circle which apply)

sensation (2= normal; 1= decreased; 0= absent):

		touch (circle whichh apply)	pin (circle whichh apply)	vibration (circle whichh apply)
	hand è	R2-R1-R0  -  L2-L1-L0	R2-R1-R0  -  L2-L1-L0	R2-R1-R0  -  L2-L1-L0
	foot è	R2-R1-R0  -  L2-L1-L0	R2-R1-R0  -  L2-L1-L0	R2-R1-R0  -  L2-L1-L0
	back è	R2-R1-R0  -  L2-L1-L0	R2-R1-R0  -  L2-L1-L0

autonomic function (N: normal; A: abnormal):

bladder:___ describe if abnormal:______________________________________________________________

bowel:___ describe if abnormal:_______________________________________________________________

sweating:___ describe if abnormal:____________________________________________________________

Comments:_________________________________________________________________________________

HISTORY

a) In the 4 weeks preceding the onset of paralysis (Y: yes; N: no; ?: unknown):

recent vaccination:____ if yes, vaccine type:____________________________________, date:__________

vaccination in the family:____ if yes, vaccine type:_______________________________, date:__________

injection via IM:___ if yes, site:________________________________________________, date:__________

take of drugs:___ if yes, describe:______________________________________________, date:__________

animal bite:___ if yes, describe:__________________   insect bite:___ if yes, describe:_________________

tick bite:___ if yes, describe:_________________   animal exposure:___ if yes, describe:_______________

pesticide exposure:___ if yes, describe:_____________   trauma:___ if yes, describe:__________________

similar illness in è  school:___  workplace:___  neighborhood:___  other:______________________________

other family member ill:___ if yes, describe:______________________________________________________

recent blood transfusion:___ if yes, date:__________ (obs:________________________________________)

b) Interval history (Y: yes; N: no):

severity at maximal weakness è   quadriplegia with respirator:___   quadriplegia without respirator:___

paraplegia:___   other (describe):________________________________________________________________

date of maximal weakness:__________   respirator:___ if yes, date on:_________ and date off:__________

death:____ if yes, date:____________ and describe:______________________________________________

c) Immunization history (Y: yes; N: no; ?: unknown;  OPV: live/oral polio vaccine;  IPV: inactivated polio vaccine):

polio vaccine 1^st dose:___  OPV:___  IPV:___  immunization card:___  immunization date:_______________ 

polio vaccine 2^nd dose:___  OPV:___  IPV:___  immunization card:___  immunization date:_______________

polio vaccine 3^rd dose:___  OPV:___  IPV:___  immunization card:___  immunization date:_______________

polio vaccine 4^th dose:___  OPV:___  IPV:___  immunization card:___  immunization date:_______________

polio vaccine 5^th dose:___  OPV:___  IPV:___  immunization card:___  immunization date:_______________

usual immunization clinic:_____________________________________________________________________

d) Travel and contact history (Y: yes; N: no; ?: unknown):

Did the patient visit any place outside Macau (including China and Hong Kong, Zhuhai or Shenzhen SAR) 28 days prior to the onset of weakness/paralysis?___ (if yes, fill the blanks bellow)

Did the patient come in contact with someone who had been immunized with OPV in the previous 75 (seventy five) days?___ (if yes, fill the blanks bellow)

PRELIMINARY CLINICAL CLASSIFICATION

(circle or underline which apply) è    Discard case        Probable case

If not polio, give final diagnosis and comments:____________________________________________________

_________________________________________________________________________   date:___________

LABORATORY DATA

Name of lab:________________   Address:___________________________  Telephone:_______  Fax:______

Isolation studies:

Poliovirus strain characterization results:

Other results or comments:____________________________________________________________________

CASE FOLLOW-UP

The case was seen 60 days after onset of paralysis (Y/N)?___ if yes, date:__________ if no, why:_________

__________________________________________________________________________________________

Paralysis (Y: yes; N: no):

Paralysis present at sixty (60) days or later:_____ (if yes, fill in the blanks bellow)

left leg:____   right leg:____   left arm:____   right arm:____   face:____   respiratory muscles:____

other cranial nerves (describe):________________________________________________________________

Paralysis improved from maximal weakness to follow-up:___ if yes, comment on degree:_________________

No change in paralysis from maximal weakness to follow-up:____ (comment:____________________________)

Reflexes (R: right; L: left; 3= increased; 2= normal; 1= decreased; 0= absent):

1. biceps è R3-R2-R1-R0 - L3-L2-L1-L0         2. triceps è R3-R2-R1-R0 -- L3-L2-L1-L0     (circle which apply)

3. knee è R3-R2-R1-R0 - L3-L2-L1-L0           4. ankle è R3-R2-R1-R0 -- L3-L2-L1-L0         (circle which apply)

5. supinator è R3-R2-R1-R0 - L3-L2-L1-L0 (circle which apply)   Obs:__________________________________

Disability (Y: yes; N: no):

cannot walk:___   walks with assistance:___   walks normally:___   limps:___   other:___________________

Death (Y/N):___ if yes, date:_________ and give details:___________________________________________

CONTROL MEASURES

Include the date started, number of households searched, number of OPV (oral live trivalent polio vaccine) doses given in children less than 5 years of age, and date completed:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

FINAL DIAGNOSIS

Discarded case (Y/N):____  if yes, date:____________  and specify the diagnosis:

Guillan-Barré:___   transverse myelitis:___   traumatic neuritis:___   other (describe):____________________

Confirmed Poliomyelitis (fill in the blanks bellow)

Laboratory confirmed virus:_____     Laboratory confirmed serology:_____               No follow-up:_____

Death after compatible illness:_____     Residual paralysis after 60 days:_____

Vaccine associated:____________     Wild virus indigenous:____________     Imported case:___________

Comments/remarks:__________________________________________________________________________

___________________________________________________________________________________________

CONFIRMATION AND VALIDATION

Name of investigator:__________________________________________________________  date:__________

place of work:__________________________________________________  signature:____________________

Name of neurologist:__________________________________________________________  date:___________

place of work:__________________________________________________  signature:____________________

Name of CEP coordinator:______________________________________________________  date:__________

place of work:__________________________________________________  signature:____________________