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pdfToday’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.
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.
Print the name and surnames of the patient in the following order: paternal and maternal
surnames, first name and middle name or initial.
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.
Check if the patient died or not. If you do not know this information, check Unk for unknown.
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.
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.
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.
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.
Print the patient’s phone number and an alternate phone number where we could contact the
patient.
Indicate a reference point close to the patient’s home (Example: next to Rivera’s Grocery
Store).
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.
Print the name of the physician who referred the patient for a dengue test, last name first.
Write the telephone and extension numbers, fax and Email of the physician attending the
patient.
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
Write the patient’s date of birth (day, month and year).
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.
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?
Print the complete name (lat name first) of the person filling the form.
Indicate your relationship with the patient (e.g.: mother, father, primary caregiver, physician).
Write the phone number, fax or e-mail address.
MUST HAVE information for sample processing WITHOUT THIS INFORMATION THE
SAMPLE WILL NOT BE PROCESSED.
Day, month and year of first symptom.
Day, month and year blood samples were taken.
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
Indicate how many years you have lived at your current address.
Specify country of birth
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.
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.
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:
Write the platelet count for the last known test during this illness.
Write the patient’s lowest and highest hematocrit during this illness.
Indicate the albumin and protein counts
Record the lowest blood pressure during this illness - Indicate systolic and diastolic blood pressure
values.
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.
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.
File Type | application/pdf |
File Title | Dengue Case Investigation Report |
Subject | Dengue Case Investigation Report |
Author | CDC |
File Modified | 2014-06-17 |
File Created | 2009-07-13 |