Case Report (English)

Today’s date: _______/_______/_______

Day
Month Year

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
Case number

Specimen #

SAN ID

GCODE

Days post onset (DPO) Type

Date Received

Specimen #

Form Approved OMB No. 0920-1011
Exp. Date 03/31/2017

0009

Days post onset (DPO)

Type

Date Received

S1

_____/_____/_____ S3

_____/_____/_____

S2

_____/_____/_____ S4

_____/_____/_____

Please read and complete ALL sections
Patient Data

Hospitalized due to this illness: No

→ Hospital Name:

Yes

Record Number:
Fatal:

Name of Patient:
Last Name

First Name

Yes

Middle Name or Initial

No

Unk

Mental status changes:

If patient is a minor, name of father or primary caregiver:
Last Name

First Name

Middle Name or Initial

Home (Physical) Address

Yes

No

Unk

Physician who referred this case

Home address here

Name of Healthcare Provider:
Tel:

Fax:

Email:

Send laboratory results to (mailing address):
City:

Zip code: __ __ __ __ __ - __ __ __ __

Tel:

Other Tel:

Residence is close to:
Work address:

Patient’s Demographic Information

Date of Birth:

Age:

month Sex:

_______/_______/_______ or Age:
Day

Month

years

Who filled out this form?
M

F

Pregnant: Y

N

UNK

Weeks pregnant (gestation):

Year

Name (complete)
Relationship with patient:
Tel:

Fax:

Day

Date of first symptom:

Month

Year

How long have you lived in this city?

_______/_______/_______

Country of birth
Have you been diagnosed with dengue before?

Date specimen taken:
Serum:

Email:

Additional Patient Data

Must have the following information for sample processing

First sample

(Acute = first 5 days of illness – check for virus)

When diagnosed?

_______/_______/_______

Second sample

_______/_______/_______

Third sample

_______/_______/_______

Month

Got Yellow Fever Vaccine

Yes

No

Unk

Unk

Year

Yes

No

Unk

Year vaccinated

During the 14 days before onset of illness, did you TRAVEL to other cities or countries?

(Convalescent = more than 5 days after onset – check for antibodies)

Fatal cases (tissue type):_______________________

_______/_______

Yes, another country

Yes, another city

No

Unk

WHERE did you TRAVEL? _____________________________________________________________

_______/_______/_______

PLEASE indicate below the signs and symptoms that the patient has at the time that this form is being completed
Yes

No

Fever lasting 2-7 days……………......
Fever now(>38ºC)…………………......
Platelets ≤100,000/mm3………..….....
Platelet count: ______________________________
Any hemorrhagic manifestation

Unk

Evidence of capillary leak

Warning signs

Lowest hematocrit (%) __________________

Persistent vomiting...................................

Highest hematocrit (%) __________________

Abdominal pain/Tenderness…………..

Lowest serum albumin __________________

Mucosal bleeding …………………….....

Lowest serum protein

Lethargy, restlessness……….…………...

__________________

Lowest blood pressure (SBP/DBP)

__________/_______

Lowest pulse pressure (systolic - diastolic)

_________

Petechiae………………………..

Lowest white blood cell count (WBC)

_________

Purpura/Ecchymosis…………..

Symptoms

Vomit with blood……………….

Yes

No

Unk

Liver enlargement >2cm………………..
Pleural or abdominal effusion………….
Additional symptoms
Diarrhea……………………………...……..

Rapid, weak pulse……………...

Cough…………………………………….…

Blood in stool……………………

Pallor or cool skin……………….

Nasal bleeding…………………

Conjunctivitis……………………………....

Chills………………………….……

Nasal congestion…………………………

Rash…...........................................

Sore throat………………………………....

Bleeding gums………………….
Blood in urine…………………...
Vaginal bleeding………………
Positive urinalysis……………....
(over 5 RBC/hpf or positive for blood)
Tourniquet test

Pos

CDC 56.31 A REV. 06/2009 (Front)

Neg

Not done

Headache……………….……….

Jaundice………………………..................

Eye pain…………………………..

Convulsion or coma……………………..

Body (muscle/bone) pain…….

Nausea and vomiting (occasional)…..

Joint pain…………………………

Arthritis (Swollen joints)……....................

Anorexia……………………….....

Yes

No

Unk

FOR CDC DENGUE BRANCH USE ONLY
Specimen No.
S1 _________________________________

S2 _________________________________

S3 _________________________________

SEROLOGY
LUMINEX (MIA)
S1

S2

Test Date

Ag

Titer

S3

Test Date

Ag

Titer

Test Date

Ag

Titer

IgG ELISA
S1
Test Date

S2
Ag Screen

Titer

Test Date

S3

Ag Screen

Titer

Test Date

Ag Screen

Titer

IgM ELISA
S1

S2

Test Date

Ag

P/N

Test Date

S3
Ag

P/N

Test Date

Ag

P/N

Screen

Titer

Isotech

IDtech

Neutralization
S1

S2

Test Date

Screen

Titer

Test Date

S3
Screen

Titer

Test Date

DENV-1
DENV-2
DENV-3
DENV-4
WEST NILE
SLE
YFV

Viral Isolation & PCR
S1
Test Date

S2
ID

Isotech

IDtech

Test Date

ID

S3
Isotech

IDtech

Test Date

ID

Serology Lab Director Signature: ______________________________________

Virology Lab Director Signature: ______________________________________ Overall dengue interpretation: _________________________________
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).
CDC 56.31 A REV. 07/2009 (Back)

DENGUE CASE INVESTIGATION REPORT

CS110856

Instructions to fill the Dengue Case Investigation Report
Law 81 of 1912 establishes that dengue and dengue hemorrhagic fever are reportable diseases to the
Puerto Rico Department of Health. The health provider will complete in print lettering every question
of the Dengue Case Investigation Report and will accompany the serum sample with this form. Please
verify that the date of onset of symptoms and the date the serum sample was obtained are included.
Without this information the sample will not be processed. On the upper left corner of the form, write
the date (day, month, year) in which the report was completed.
Patient Data The complete name and information of the patient is essential because many persons
have similar names and information.
ƒ Check Yes or No to indicate whether or not the patient was hospitalized due to this illness. If
the patient was hospitalized, write the name of the hospital.
ƒ Print the name and surnames of the patient in the following order: paternal and maternal
surnames, first name and middle name or initial.
ƒ If the patient is a minor, print the name of the parent or primary caregiver. Please, write the
surnames first and then the first name.
ƒ Check if the patient died or not. If you do not know this information, check Unk for unknown.
ƒ Check if patient presents or does not present mental status changes. This information is
important because these changes could be associated with encephalitis.
Home Address Obtaining the address where the patient resides will allow us to follow-up on the
patient and to implement vector control measures in specific areas as needed.
ƒ If the patient lives in an urban area, print the name of the area, street name or number, block
and house number, City/Town and ZIP code + 4 digits where patient resides.
ƒ If the patient lives in a suburb, print the road number, kilometer, house or premise number,
county, sector, City/Town and ZIP code + 4 digits where patient resides.
ƒ If the patient lives in a condominium or public housing, print apartment number, building,
name of condominium or housing complex, street, City/Town where patient resides and ZIP
code + 4 digits.
ƒ Print the patient’s phone number and an alternate phone number where we could contact the
patient.
ƒ Indicate a reference point close to the patient’s home (Example: next to Rivera’s Grocery
Store).
ƒ If the patient has a job, write the name of the employer, including street or sector and
City/Town.
Physician who referred this case This information is critical, since, by law, results will only be
mailed to service providers.
ƒ Print the name of the physician who referred the patient for a dengue test, last name first.
ƒ Write the telephone and extension numbers, fax and Email of the physician attending the
patient.
ƒ In the block “Send laboratory results to” print the complete mailing address of the physician
submitting the sample. Please, fill all blanks including the ZIP code + 4 digits to guarantee you
receive the results.

Patients Demographic Information
ƒ Write the patient’s date of birth (day, month and year).
ƒ Indicate patient’s age. Write the age in months if the patient is an infant or in years if older than
1 year of age.
ƒ Check the M box for male or F for female. If female, please indicate if the patient is pregnant
and how many gestational weeks, if known.
Who filled out this form?
ƒ Print the complete name (lat name first) of the person filling the form.
ƒ Indicate your relationship with the patient (e.g.: mother, father, primary caregiver, physician).
ƒ Write the phone number, fax or e-mail address.
MUST HAVE information for sample processing WITHOUT THIS INFORMATION THE
SAMPLE WILL NOT BE PROCESSED.
ƒ Day, month and year of first symptom.
ƒ Day, month and year blood samples were taken.
ƒ If sample is tissue, specify type of tissue (e.g. kidney, spleen, heart, etc.) to be sent to our
laboratory and the date the sample was taken.
Additional Patient Data
ƒ Indicate how many years you have lived at your current address.
ƒ Specify country of birth
ƒ Answer Yes, No or Unk if unknown when asked if patient has been diagnosed with dengue before.
o If the response is Yes, indicate month and year in which the patient had dengue before this
illness.
o Check Unk if the patient does not know the date when diagnosed with dengue before.
ƒ If the patient traveled to other countries or cities 14 days before beginning of symptoms check
“Yes, another country” or “Yes, another city”. If the patient did not travel or doesn’t remember,
check No or Unk if unknown.
ƒ If the patient traveled, indicate country or city visited by the patient 14 days before beginning of
symptoms.
Criteria for Dengue Hemorrhagic Fever, Shock and other symptoms
Check (√) the boxes to mark Yes, No, or Unk for each question related to symptoms. Please
answer ALL questions. In the space provided:
ƒ Write the platelet count for the last known test during this illness.
ƒ Write the patient’s lowest and highest hematocrit during this illness.
ƒ Indicate the albumin and protein counts
ƒ Record the lowest blood pressure during this illness - Indicate systolic and diastolic blood pressure
values.
ƒ Calculate the pulse pressure by subtracting the systolic minus diastolic. Calculate the minimal
pulse pressure using the arterial pressure which subtraction results in the lowest number.
ƒ Write the lowest White Blood Cell Count (WBC) during this illness.
Do not complete the blanks on the back of the form. These are for laboratory use only.