Manitowoc County Health Department
Pertussis Case Report Form
Name of Patient (Last, First, Middle Initial)  1 Native American / Alaskan Native  5 White  2 Asian / Pacific Islander  8 Other Culture/PCR
Was patient tested for Bordetella pertussis? PCR? ____Yes ____No Date:
Culture? ____Yes ____No Date:
(Both a PCR and culture are recommended when testing for pertussis.) Attenti on Health Care Provider: The information on this form is to be completed and faxed to the
woc County Health Dept. (920-683-4156) within 24 hours on any patients meeting the following criteria –
 Any pat ient tested (PCR and/or culture) for Bordetella pertussis  Any patient exhibiting symptoms of pertussis and prescribed antibiotic treatment (if testing was not done, please fax copy of notes from patient’s visit as well)  Any patients needing antibiotic treatment due to an exposure to pertussis If you hav e questions or concerns, please contact our office at (920)683-4155. Thank you. rrhal (cold-like) symptoms started:________________ Date catarrhal (cold-like) cough started: ___________________ Paroxysmal cough:  Yes  No Whoop:  Yes  No Sleep disturbance:  Yes  No Apnea:  Yes  No Vomiting:  Yes  No Was patien t exposed to a known or suspect case of pertussis?  Yes  No If yes, please provide as much information as possible about source of exposure (if there was no exposure, feel free to utilize this extra space for additional comments):
me Isolation: If patient is symptomatic, did you instruct them that they must be on 5 day home isolation?  Yes  No
(Anyone sy mptomatic and on treatment, MUST be on home isolation for the first 5 days of appropriate treatment.)
t: Note – The antimicrobial agents and dosages used for chemoprophylaxis of contacts are the same as that
ded for treatment of a clinical case. Were antib iotics given?  Yes  No If yes, what date were antibiotics started? __________________
Number of days antibiotics are to be taken: _________ Check below as to which antibiotic was prescrib
 Azithrom ycin Infants <6 months: 10mg/kg per day for 5 days. Infants >6 months and children: 10 mg/kg (maximum 500 mg) day 1, followed by 5mg/kg per day (max. 250 mg) on days 2-5. Adults 500 mg day 1, followed by 250 mg per day on days 2-5.  Clarithro mycin Infants < 1 month: not recommended. Infants > 1 month and children: 15 mg/kg per day (maximum 1 g per day) in 2 divided doses each day for 7 days. Adults 1 g per day in 2 divided doses for 7 days.  Erythro mycin Infants < 1 month: not preferred. Infants > 1 month and older children: 40-50 mg/kg per day (maximum 2 g per day) in 4 divided doses for 14 days. Adults 2 g per day in 4 divided doses for 14 days.  Trimethoprin-Sulfamethoxazole (TMP-SMZ) Alternative treatment for patients who have contraindications to the use of macrolides. Infants < 2 months: contraindicated. Infants > 2 months and children: trimethoprim 8mg/kg per day, sulfamethoxazole 40 mg/kg per day in 2 divided doses for 14 days. Adults trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg per day in 2 divided doses for 14 days. Clinic Name and City:
Reporting Physician Name (please print legibly):
Name of CLINIC Contact Person and DIRECT Phone Number (if we have questions):


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