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    Dengue

    Uploaded by

    Therence Marie Lacson
    This case report form collects information on suspected and confirmed dengue cases in the Philippines, including patient details, clinical classification of disease severity (no warning signs, with warning signs, severe dengue), and outcome. Dengue classifications are defined as suspect, probable, or confirmed based on clinical symptoms and laboratory test results. Clinical information collected includes symptoms, signs, admission status, and dates of illness onset and consultation.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Dengue

    Uploaded by

    Therence Marie Lacson
    289 views2 pages
    This case report form collects information on suspected and confirmed dengue cases in the Philippines, including patient details, clinical classification of disease severity (no warning signs, with warning signs, severe dengue), and outcome. Dengue classifications are defined as suspect, probable, or confirmed based on clinical symptoms and laboratory test results. Clinical information collected includes symptoms, signs, admission status, and dates of illness onset and consultation.

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    This case report form collects information on suspected and confirmed dengue cases in the Philippines, including patient details, clinical classification of disease severity (no warning signs, with warning signs, severe dengue), and outcome. Dengue classifications are defined as suspect, probable, or confirmed based on clinical symptoms and laboratory test results. Clinical information collected includes symptoms, signs, admission status, and dates of illness onset and consultation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    289 views2 pages

    Dengue

    Uploaded by

    Therence Marie Lacson
    This case report form collects information on suspected and confirmed dengue cases in the Philippines, including patient details, clinical classification of disease severity (no warning signs, with warning signs, severe dengue), and outcome. Dengue classifications are defined as suspect, probable, or confirmed based on clinical symptoms and laboratory test results. Clinical information collected includes symptoms, signs, admission status, and dates of illness onset and consultation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Case Report Form

    Philippine Integrated Disease


    Surveillance and Response

    Dengue (ICD 10 Code: A90-A91)

    Region:

    ____________________________

    Name of DRU:

    _________________________________________________________________

    Address:

    ______________________________________________________

    Patient
    No.

    Response
    Codes /
    Instructions

    Patients Full Name

    Indicate First name, Middle name,


    Last name

    Age

    Province: ___________________________

    Sex
    (F/M)

    Age: Indicate
    D - days
    M - months
    Yr. - years
    Sex:F - Female
    M - Male

    Case Definition/Classification:
    Dengue without Warning signs.

    Suspect
    A previously well person with acute febrile illness of 2-7 days dura tion plus two of the following:
    Headache, Body malaise, Myalgia, Arthralgia, Retro-orbital
    pain, Anorexia, Nausea, Vomiting, Diarrhea, Flushed skin,
    Rash ( petecheal, Hermans sign)

    Probable
    A suspect cases
    AND
    Laboratory test, at least CBC (leucopenia with or without
    thrombocytopenia) and/or Dengue NS1, antigen test or
    dengue IgM antibody test (optional)

    Confirmed:
    - Viral culture isolation,
    - Polymerase Chain Reaction

    Date of
    Birth

    Municipality/City: ________________________________________
    Type:

    RHU CHO Govt Hospital Private Hospital Clinic


    Private Laboratory Public Laboratory
    Seaport/Airport

    Complete Address

    Admitted?

    Date admitted/seen/
    consulted

    Date onset
    of illness

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    Clinical
    Lab
    Case
    Case
    Classifi- classification
    cation

    Wwith
    warning
    signs

    mm/dd/yy

    Specify Street/Purok/Subdivision, House #,


    Barangay, Municipality/City, Province

    Y - Yes
    N- No

    mm/dd/yy

    mm/dd/yy

    N no warning signs
    S-Severe
    Dengue

    S - Suspect
    P - Probable
    C - Confirmed

    Outcome

    A - Alive
    D - Died
    (specify
    date)
    U - Unknown

    Dengue with Warning Signs

    Severe Dengue

    ,A previously well person with acute febrile illness of 2-7 days duration plus
    any one of the following:

    A previously well person with acute febrile illness of 2-7 days duration and
    any of the clinical manifestations for dengue with or without warning signs,
    Plus any of the following:
    Severe plasma leakage leading to
    - Shock
    - Fluid accumulation with respiratory distress
    Severe bleeding
    Severe organ impairment
    - Liver: AST or ALT >1000
    - CNS: e.g. seizures, impaired consciousness
    - Heart: e.g. myocarditis
    - Kidneys: e.g. renal failure

    - Abdominal pain or tenderness


    - Persistent vomiting
    - Clinical signs of fluid accumulation
    - Mucosal bleeding
    - Lethargy, restlessness
    - Liver enlargement
    - Laboratory: increase in Hct and/or decreasing platelet count

    Case Report Form

    Philippine Integrated Disease


    Surveillance and Response

    Patient
    No.

    Response
    Codes /
    Instructions

    Patients Full Name

    Indicate First name, Middle name,


    Last name

    Dengue (ICD 10 Code: A90-A91)


    Age

    Sex
    (F/M)

    Age: Indicate
    D - days
    M - months
    Yr. - years
    Sex:F - Female
    M - Male

    Date of
    Birth

    Complete Address

    Admitted?

    Date admitted/seen/
    consulted

    Date onset
    of illness

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    ___/___/___

    ___/___/___ ___/___/___

    mm/dd/yy

    Specify Street/Purok/Subdivision, House #,


    Barangay, Municipality/City, Province

    Y - Yes
    N- No

    mm/dd/yy

    mm/dd/yy

    Clinical
    Case
    Classification

    Lab
    CaseClassifi
    cation

    W - with
    Warning
    signs
    N no warning signs
    SSevere
    Dengue

    S Suspect
    P- Probable
    C
    confirmed

    Outcome

    A - Alive
    D - Died
    (specify
    date)
    UUnknown

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