Form assigned Dengue

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

Specimen #

For CDC Dengue Branch use only
Received (Date)
S pecimen #

Days post onset (DPO) Type

Days post onset (DPO)

Type

Received (Date)

GCODE
SAN ID

S1

/

/

S3

/

/

S2

/

/

S4

/

/

Please complete all sections
Hospitalized:
No
Yes
Hospital:_______________________________

Fatal:
Yes

Encephalitis:
Yes
No

No

Name:

Last Name

First Name

Middle Name / Initial

If a minor, name of parent or person in charge:
Home Address
City, Town:

Physician who referred the case:
Name:

Urbanization or sec tor:

Phone number:

Street :

Nu mber:

Premise No.:
Road No.:

B ox:
Km:

Send results to:
P.O.Box:

Hm:

Tel.:

Close to:
Additional Data
Work Address:
1) Country of birth:
Patient’s Basic Information
Date of birth:
Age:

Sex:
Male

Female

2) Have you had dengue before (fever, body pain, eye pain, rash)
Yes
No
Don’t know

______ years
3) When? (Month, Year)
Day

Month

/

No

Don’t know

Year

4) How long have you lived in this city?

Indispensable information for sample processing
Day

Month

Date of first symptom: . . . . . . . . . . . . . . . . . . . . . . . . . .
Date specimen taken
Serum: first sample illness. . . . . . . . . . . . . . . . . . . . . .

Year

/

/

/

/

/

/

/

/

/

/

(a cute – first 5 days of sickness – for virus)

5) During the 14 days before onset of illnes s, have you traveled to other cities or
countries ? . . . . . . . . . . . . . .
yes
no
don’t know
Where?
Comments

second sample . . . . . . . . . . . . . . . . . . . . . . . .
(convalescent - 6 or more days after sickness – for antibodies)

third sample . . . . . . . . . . . . . . . . . . . . . . . . . . .
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/mm3 . .
yes
(count ) _______________________ ___
4. Leaky capillaries
Pleural or abdominal effusion..
yes
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

DENGUE CASE INVESTIGATION REPORT

no

no

Rash .......................
Chills ......................
Nausea o vomiting ...
Diarr hea ..................
Cough .....................
Conjunctivitis .............
Nasal C ongestion ......
Sore throat ...............
Jaundice..................
Convulsion or com a..
Pregnant?.................
YF v accination……….
year ______

yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
doesn’t know

FOR CDC D E N G U E BRANCH USE ONLY
Specimen No.

S1 ________________________

S2 __________________________.

S3 ______________________________________________

SEROLOGY

Hemagglutination Inhibition
Test

Ag

Titer

Qual

Titer

Test

Ag

Titer

Test

Ag

Titer

Qual

Titer

Ag

Value

Ag

Titer

Isotech

IDtech

IgG Antibody
Test

Ag

Test

Ag

Qual

Titer

Test

Ag

IgM Antibody
Test

Ag

Value

Test

Ag

Value

Test

Neutralization
Test

Ag

Titer

Test

Ag

Titer

Test

VIROLOGY
Test

ID

Isotech IDtech

Test

ID

Isotech IDtech

Overall interpretation:

REV. 5/2004
4

DENGUE CASE INVESTIGATION REPORT

Test

ID