Case Investigation Form
Chikungunya Virus Disease
(ICD 10 Code: A92.0)
Name of DRU:
Address:
Type:
RHU
CHO
Gov't Hospital
Private Hospital
Clinic
Gov't Laboratory
Private Laboratory
Airport/Seaport
I. PATIENT INFORMATION
Find
Patient Number:
Patient's Last Name
First Name:
Middle Name:
Complete Address:
Sex:
Male
Female
Date of Birth:
Age:
Days
Months
Years
Patient Admitted?:
Yes
No
Unknown
Date Admitted/Seen/Consult:
Date Onset of Illness
Date of Report:
Name of Reporter:
Contact Nos.:
Date of Investigation:
Name of Investigators:
Contact Nos.:
II. CLINICAL INFORMATION
Column 1
Column 2
Number of days with symptoms:
Morbidity week:
Symptoms:
Fever:
Yes
No
Yes
No
Myalgia
Back Pain
Headache
Nausea
Mucosal bleeding
Vomiting
Asthenia
Menigoencephalitis
Arthritis:
Yes
No
If Yes:
Hands
Yes
No
Feet
Yes
No
Ankles
Yes
No
Other
Yes
No
Arthralgia:
Yes
No
Periarticular edema:
Yes
No
Skin manifestations:
Yes
No
If Yes, describe:
Other S/Sx:
Clinical Diagnosis:
Outcome:
Alive
Died
Date Died:
III. LABORATORY INFORMATION
Blood sample testing for CHIKV Infection:
Date of collection:
Date sent to RITM
Serology-IgM:
Yes
No
Result
Positive
Negative
Date of Result
Serology-IgG:
Yes
No
Result
Positive
Negative
Date of Result
RT-PCR
Yes
No
Result
Positive
Negative
Date of Result
Viral Isolation
Yes
No
Result
Positive
Negative
Date of Result
IV. EPIDEMIOLOGICAL INFORMATION
History of travel within the previous 30 days prior to symptom onset:
Yes
No
If Yes, where:
Place of residence:
Have you received blood or blood products within the previous 30 days prior to symptom onset?
Yes
No
FINAL CLASSIFICATION:
Discarded
Suspected
Confirmed
Date of Notification:
Name of reporting personel:
Contact Number:
CASE DEFINITION/CLASSIFICATION:
Suspected case:
a patient with acute onset of fever, rash (over limbs or trunk) and severe arthralgia or arthritis Not explained by other medical conditions.
Confirmed case:
a suspect case with any of the following CHIK specific tests:
Detection of viral RNA by RT-PCR.
Detection of IgM in a single serum sample (collected during acute or convalescent phase).
Four-fold increase in CHIKV-specific antibody titers (samples collected at least two to three weeks apart).
Viral isolation
During an epidemic, all patients need Not be subjected to confirmatory tests as above. An epidemiologic link can be sufficient.
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