DENGUE CASE INVESTIGATION REPORT
CDC Dengue Branch and Puerto Rico Department of Health
1324 Calle Cañada, San Juan, P. R. 00920-3860
Tel. (787) 706-2399, Fax (787) 706-2496
For CDC Dengue Branch use only
GCODE
Specimen # Days post onset (DPO) Type Received (Date) S pecimen #
Days post onset (DPO) Type Received (Date)
SAN ID
S1 / / S3 / /
S2 / / S4 / /
Please complete all sections
Hospitalized:
No Yes
Hospital:_______________________________
Fatal: Encephalitis:
Yes No
Yes
No
Name:
Last Name
If a minor, name of parent or person in charge:
First Name Middle Name / Initial
Home Address
Physician who referred the case:
City, Town:
Name:
Urbanization or sec tor:
Phone number:
Street : Nu mber:
Send results to:
Premise No.: B ox: P.O.Box:
Road No.: Km: Hm: Tel.:
Close to:
Additional Data
Work Address:
1) Country of birth:
Patient’s Basic Information
Date of birth:
Age:
______ years
Sex:
Male
Female
2) Have you had dengue before (fever, body pain, eye pain, rash)
Yes
No
Don’t know
3) When? (Month, Year) /
No
Don’t know
Day Month Year
Indispensable information for sample processing
4) How long have you lived in this city?
Day Month Year
Date of first symptom: .
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5) During the 14 days before onset of illness, have you traveled to other cities or
countries ? . . . . . . . . . . . . . .
yes
no
don’t know
Date specimen taken
Where?
S e r u m :
first sample illness.
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(a cute – first 5 days of sickness – for virus)
Comments
second sample .
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(convalescent - 6 or more days after sickness – for antibodies)
third sample .
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Other tissue:
/ /
Criteria for DENGUE HEMORRHAGIC FEVER (#1- 4) and shock (#5)
1. Fever ………………
yes
no
2. Any hemorrhagic manifestation
Petechiae
yes
no
Purpura/ Ecchy mosis..
yes
no
Vomit with blood.........
yes
no
Blood in stool..............
yes
no
Nasal bleeding……..
yes
no
Bleeding gums …….
yes
no
Blood in urine............
yes
no
Vaginal bleeding......
yes
no
Urinalysis - over 5 RBC/hpf or
positive for blood ….
yes
no
Tourniquet test _not done _Pos_ Neg
3. Platelets <100,000/mm
3
. .
yes
no
(count) _______________________ ___
4. Leaky capillaries
Pleural or abdominal effusion..
yes
no
Lowest
hematocrit ____________ _____
Highest hematocrit ________________ _
Lowest serum albumin ______________
Lowest serum protein _______ ________
5. Lowest blood pressure _____ __/______
Other symptoms
Headache ........ .
yes
no
Eye pain ... ......
yes
no
Body pain .........
yes
no
Joint
pain..............
yes
no
Rash .......................
yes
no
Chills ......................
yes
no
Nausea o vomiting ...
yes
no
Diarr hea ..................
yes
no
Cough .....................
yes
no
Conjunctivitis .............
yes
no
Nasal C ongestion ......
yes
no
Sore throat ...............
yes
no
Jaundice..................
yes
no
Convulsion or com a..
yes
no
Pregnant?..............
...
yes
no
YF v accination……….
yes
no
y
ear ______
doesn’t know
DENGUE CASE INVESTIGATION REPORT
FOR CDC D E N G U E BRANCH USE ONLY
SEROLOGY
Hemagglutination Inhibition
Test
Ag
Titer
Test
Ag
Titer
Test
Ag
Titer
IgG Antibody
Test
Ag
Qual
Titer
Test
Ag
Qual
Titer
Test
Ag Qual
Titer
IgM Antibody
Test Ag
Value
Test
Ag
Value
Test
Ag
Value
Neutralization
Test
Ag
Titer
Test
Ag
Titer
Test
Ag
Titer
VIROLOGY
Test
ID
Isotech
IDtech
Test
ID
Isotech IDtech
Test
ID
Isotech
IDtech
REV. 5/2004
4
Specimen No.
S
2
__________________________.
S
1
________________________
S
3 ______________________________________________
Overall interpretation:
DENGUE CASE INVESTIGATION REPORT
| File Type | application/pdf |
| File Title | DEN CASE Form Eng 2004 b.doc |
| Author | his1 |
| File Modified | 0000-00-00 |
| File Created | 2004-05-11 |