2013 camc uri upper respiratory (including sinusitis) infection worksheet



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2013 CAMC URI - UPPER RESPIRATORY (INCLUDING SINUSITIS) INFECTION WORKSHEET

Name



TEST PERIOD

UNIT

DOB



Age


MR#

Adm date

D/C date

Admitting Diagnosis



M F

Birthweight gms.

(Neonates only)

ICU Adm date

ICU D/C date

Attending Physician:



Consultants:

Event date:



Culture date

Pathogen

Culture date

Pathogen



































SINUSITIS

UPPER RESPIRATORY TRACT

SINU – Sinusitis

UR- Upper respiratory tract, pharyngitis, laryngitis, epiglottitis

Sinusitis must meet at least 1 of the following criteria:

Upper respiratory tract infections must meet at least 1 of the following criteria:

Date




Date







1. Organisms cultured from purulent material obtained from sinus cavity.




1. Patient has at least 2 of the following signs or symptoms with no other recognized cause: fever (>38oC), erythema of pharynx, sore throat, cough, hoarseness, or purulent exudates in throat.




2. Patient has a at least 1 of the following signs or symptoms with no other recognized cause: fever (>38oC), pain or tenderness over the involved sinus, headache, purulent exudates, or nasal obstruction




AND at least 1 of the following:



a. Organisms cultured from the specific site.
AND at least 1 of the following:

b. Organisms cultured from blood.
a. Positive trans-illumination
c. Positive antigen test on blood or respiratory secretions.




b. Positive imaging test




d. Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for pathogen.

Notes:






e. Physician diagnosis of an upper respiratory infection.




2. Patient has an abscess seen on direct examination during a surgical operation, or during a histopathologic examination.




3. Patient < year of age has at least 2 of the following signs or symptoms with no other recognized cause: fever (>38oC rectal), hypothermia (<37oC rectal), apnea, bradycardia, nasal discharge, or purulent exudates in throat.




AND at least 1 of the following:




a. Organisms cultured from the specific site.




b. Organisms cultured from the blood.




c. Positive antigen test on blood or respiratory secretions.




d. Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for pathogen.




e. Physician diagnosis of an upper respiratory infection.




3/15/2013


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