Dengue/Dengue Hemorrhagic Fever Case Management Form

Health Units: Please return copy of to: Joseph L. Malone, MD; Office of
Medical Services, Department of State; 2401 E. Street, NW; Washington,
DC 20522-0102. 202-663-1682. Fax-3-3673. For Questions ask JL Malone or
Dr. Ernie Davis (M/MED/DASHO, SA-1)

Ref: CDC <http://www.cdc.gov/ncidod/dvbid/dengue/index.htm>
[http://www.cdc.gov/ncidod/dvbid/dengue/resources/DEN%20CASE%20Form%20Eng%202004.pdf](http://www.cdc.gov/ncidod/dvbid/dengue/resources/DEN CASE Form Eng 2004.pdf)

  --------------------- ------------------ -------------- ----------------
  Patient Name:         Country of birth:  Date of birth: Telephone:      
                                                          

  Post:                                    Email:         Gender: M F

  Address:              Previous History                  Care provider
                        of Dengue: Yes                         
                        Year:      No                     

  Travel and illness                                      
  Hx:                                                     
  --------------------- ------------------ -------------- ----------------

  ----------------- -------------- -------------- -------------- --------------
                    Onset          First Visit    Second Visit   Third Visit

  DATE (d-MMM-yr)                                                     

  SYMPTOMS                                                       

  Headache          Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Rash              Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Abdominal pain    Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Nausea, Vomiting  Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Diarrhea          Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Fever             Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Chills            Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Eye Pain          Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Cough             Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Muscle pain       Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Bone or joint     Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.
  pain                                                           

  Hematemesis       Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Melena            Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Epistaxis         Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Bleeding gums     Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Hematuria         Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Vaginal bleeding  Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

  Sore throat       Pos Neg.       Pos Neg.       Pos Neg.       Pos Neg.

                                                                 

  PHYSICAL EXAM                                                  

  Tourniquet test                                                   
  (# of petechia)                                                

  Weight                               Lbs or         Lbs or         Lbs or    
                                   C              C              C

  Temperature                          F or    C      F or    C      F or    C

  Heart Rate                           b.p.m.         b.p.m.         b.p.m.

  Blood pressure                      /              /              /   

  Jaundice                         Pos Neg.       Pos Neg.       Pos Neg.

                                                                 

  LABORATORY                                                     

  White Blood Cells                    X 1000 /       X 1000 /       X 1000 /
                                   mm3            mm3            mm3

  Hemoglobin/Crit                       g/dl /         g/dl /         g/dl /  
                                   %              %              %

  Platelet count                       X 1000         X 1000         X 1000

  Malaria Smear                    Pos; Neg                      

  RBC in Urinalysis                Pos; Neg       Pos; Neg       Pos; Neg

  Urine Specific                                                      
  Gr.                                                            

  ALT, AST,                            ,     ,        ,     ,        ,     ,
  Bilirubin                                                          

  IgM Antibody                                                   

  Viral Culture                                                  
  ----------------- -------------- -------------- -------------- --------------

Outcome: Hospitalized Yes; No Died: Yes; No

![](media/image1.wmf){width="5.995138888888889in"
height="7.807638888888889in"}

CDC CHECK LIST FOR OBTAINING AND SHIPPING DENGUE DIAGNOSTIC SAMPLES
<http://www.cdc.gov/ncidod/dvbid/dengue/documents/TestpolEng_2.pdf>

\[ \] Sample Type of sample Interval since date of onset of symptoms
Type of Analysis

> Acute up to 3 days Virology
>
> Intermediate 4 or 5 days **\***
>
> Convalescent 6 or more days Serology
>
> **\*** Depends on the result of the convalescent serum.

\[ \] **Form -** \"Dengue Case Investigation Form\" Can be obtained from
the CDC
[http://www.cdc.gov/ncidod/dvbid/dengue/resources/DEN%20CASE%20Form%20Eng%202004.pdf](http://www.cdc.gov/ncidod/dvbid/dengue/resources/DEN CASE Form Eng 2004.pdf)

Please indicate on the sheet if the case is hospitalized. If it is a
very severe case, indicate

so on the \"Comments\" section. Only the samples received with the
information requested below, and written in a legible manner, will be
analyzed:

\- Complete name, age, and sex of patient

\- Home address

\- Date of onset of symptoms

\- Date sample was obtained

\- Complete name and mailing address of the physician, laboratory,
clinic, or

hospital

\[ \] **Tube** - Red or green top (not violet).

\[ \] **Labeling** - Tube and case form must agree (indicate the same
name of the case).

\[ \] **Volume** - 2 cc. (ml.) of centrifuged serum or plasma

\[ \] **Storage** - On ice or in a refrigerator (not in a freezer) until
it is delivered to the CDC

Dengue Branch.

\[ \] **Time of shipment** - Not to exceed a month after taking the
sample

\[ \] **Way of shipment** - Check with local Department of Health.

Reasons for **REJECTING** samples: Samples without form, form without
sample

Incomplete or illegible form -- especially regarding date of onset of
symptoms,

date of sample collection, Hemolyzed or frozen sample, or received more
than a month after onset of illness. Shipping addresss:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Dengue Branch, CDC

1324 Calle Cañada

San Juan, PR 00920-3860 Tel. (787) 706-2399

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other dengue resources: CDC Dengue info for Healthcare Practitioners:
<http://www.cdc.gov/ncidod/dvbid/dengue/dengue-hcp.htm> CDC Dengue lab
page: <http://www.cdc.gov/ncidod/dvbid/dengue/index.htm> CDC Yellow Book
dengue section:
<http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=dengue.htm&cssNav=browseoyb>
CDC: Dengue Q and A:
<http://www.cdc.gov/ncidod/dvbid/dengue/dengue-qa.htm>

Fact Sheet <http://www.cdc.gov/ncidod/dvbid/dengue/facts.htm> Dengue
Powerpoint slides
<http://www.cdc.gov/ncidod/dvbid/dengue/slideset/index.htm> Heidi
Lindbäck,Johan Lindbäck,Anders Tegnell,Ragnhild Janzon,Sirkka Vene,and
Karl Ekdahl.Dengue Fever in Travelers to the Tropics, 1998 and 1999.
Emerging Infectious Diseases Apr 2003; 9(4)
<http://www.cdc.gov/ncidod/EID/vol9no4/02-0267.htm>