TABLE 6.1.
Diagnostic and Epidemiological Data Recorded in an Admission History and Physical Examination
| Type of Data | Examples of Data Relevant to Clinical Diagnosis (Case Detection), Outbreak Detection, or Characterization |
|---|---|
| Demographics | Age, gender, home and work address |
| History of present illness | Symptoms (cough, fever, diarrhea) and their timing; significant negatives |
| Physical examination | Temperature, rashes, evidence of pneumonia |
| Laboratory results | Blood, stool, and sputum cultures; cerebrospinal fluid analyses; examinations of stool for ova and parasites |
| Radiology results | Chest radiographs |
| Travel and exposure histories | Travel to endemic area, drinking of unboiled water, animal bites |
| Vaccinations | Measles, hepatitis, influenza, yellow fever vaccinations |
| Personal/social history | Intravenous drug use, sexual practices, occupation, household members |
| Past medical history | Diabetes, HIV, transfusions |
| Allergies | Medications, insects |
| Current medications | Ciprofloxacin, Tamovir |
| Diagnostic impression | “pneumonia, rule out anthrax” |
Data are checked if they could be used in a case-control study to elucidate outbreak characteristics such as source or to determine if a patient matches a case definition.