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Dengue

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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Therence Marie Lacson
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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421 views

Dengue

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.

Uploaded by

Therence Marie Lacson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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