CASE REPORT FORM

(April 2012)

Surveillance of Paediatric Dengue

National Paediatric Hospital, Phnom Penh
Kingdom of Cambodia

Study contact:
I am confident that the information supplied in this case record form is complete and accurate data. I
confirm that the study was conducted in accordance with the protocol and any protocol amendments
and that written informed consent was obtained prior to the study.

Name of the Investigator:

Investigators Signature:
Date of signature:

Subject Initials: I__I__I__I

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF January 2012 (120106)

Subject ID Number I__I__I__I__I

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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

I. Informed Consent
Written informed consent must be given by the parents before inclusion in this study.

etIBtmannkaryl;RBm)anpl;[beT?Has informed consent been given?

0 No

1 Yes

If NO, do NOT proceed.

II. karsMrakBa)alAdmission

bnb;Ward

fcUlsMrakBa)al/Date

1 Infectious Diseases

em:agTime

2 Emergency

Admission Number ______

Demographic Data

GayuAge

Years

or

Months

ePTSex

RbusMale

RsIFemale

Address: ________________________________________________________________________________
Medical History
Previous dengue infection

0 No

1 Yes

9 Dont know How recently?

Confirmed where? ______________________________________

History of YF Vaccination

0 No

1 Yes

9 Dont know

History of JE vaccination

0 No

1 Yes

9 Dont know

Months
or

Yrs ago

Fever days prior to admission I___I___I Days

Infusion prior to admission

0 No

1 Yes

9 Dont know

Symptoms on Admission (Day I)

Fever

0 No

1 Yes

History Fever (2-7 days)

0 No

1 Yes

Chills

0 No

1 Yes

Rash

0 No

1 Yes

Pallor or cool skin

0 No

1 Yes

Vomiting

0 No

1 Yes

Headache

0 No

1 Yes

Nausea

0 No

1 Yes

Retro-orbital pain

0 No

1 Yes

Anorexia

0 No

1 Yes

Muscle pain

0 No

1 Yes

Abdominal pain

0 No

1 Yes

Joint pain

0 No

1 Yes

Abdominal distension

0 No

1 Yes

Backache

0 No

1 Yes

Diarrhoea (> 3 stools/day)

0 No

1 Yes

Convulsion or coma

0 No

1 Yes

Jaundice

0 No

1 Yes

Restless

0 No

1 Yes

Sore throat

0 No

1 Yes

Lethargy

0 No

1 Yes

Cough

0 No

1 Yes

Confusion
0 No
1 Yes
Breathlessness
0 No
1 Yes
Other (specify):____________________________________________________________________

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF April 2012 (120414ek)

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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

Clinical Examination on Admission (Day I)

lkxNTUeTAGeneral condition
TMgn;Weight
sItuNPaBTemperature
sMBaFQamBlood Pressure

emIleTAlLooks Well
.

kg

C (digital)
/

mm Hg

emIleTAminlLooks Unwell
kMBs;Height
CIBcrPulse
kMhab;GuksIuEsnSaO2

cm
bpm
I__I__I__I %

Haemorrhagic Manifestations
Dry Bleeding
Petechiae

0 No

1 Yes

Purpura or ecchymosis

0 No

1 Yes

Bleeding nose (epistaxis)

0 No

1 Moderate

2 Severe

Bleeding gums

0 No

1 Moderate

2 Severe

Hematemesis, melena

0 No

1 Moderate

2 Severe

Hematuria

0 No

1 Moderate

2 Severe

Vaginal bleeding

0 No

1 Moderate

2 Severe

0Negative

1 Positive

9 Not Done

Abdominal tenderness
Persistent vomiting
Lethargy/restlessness
Liver enlargement > 2 cm
Plasma Leakage

0 No
0 No
0 No
0 No

1 Yes
1 Yes
1 Yes
1 Yes

Ascites
Pleural effusion
Facial Oedema
Shock Signs

0 No
0 No
0 No

1 Yes
1 Yes
1 Yes

0 No
0 No
0 No
0 No

1 Yes
1 Yes
1 Yes
1 Yes

Wet Bleeding

Tourniquet test
Warning Signs

Cold / clammy extremities

Hypotension, weak/undetectable pulse
Delayed capillary refill (> than 3 seconds)
Narrow pulse pressure (< 20 mm Hg)
Other Complications
Coma / Impaired Consciousness
Heart Failure
Myocardiopathy
Respiratory Distress
Encephalitis, Encephalopathy
Acute Liver Failure
Acute Renal Failure
Surveillance of Paediatric Dengue, NPH, Cambodia
CRF April 2012 (120414ek)

0 No
0 No
0 No
0 No
0 No
0 No
0 No

1 Yes
1 Yes
1 Yes
1 Yes
1 Yes
1 Yes
1 Yes
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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

Treatment on Admission (Day I)

Corticosteroid

0 No

1 Yes

Paracetamol 0 No

1 Yes

NSAID

0 No

1 Yes

Antibiotic

1 Yes

Aspirin

0 No

1 Yes

Lactate Ringer's

0 No

1 Yes

mL total / 24h

Acetate Ringer's

0 No

1 Yes

mL total / 24h

5% Dextrose Lactate Ringer's

0 No

1 Yes

mL total / 24h

5% Dextrose Acetate Ringer's

0 No

1 Yes

mL total / 24h

5% Dextrose Normal Saline Sol

0 No

1 Yes

mL total / 24h

Dextran 40 Plasma Expander

0 No

1 Yes

mL total / 24h

Blood Transfusion

0 No

1 Yes

mL

Packed Cells

0 No

1 Yes

mL

0 No

sarCatiTwkEdleyIgpwktammat;Oral Intake
cMNuHTwkenamEdlhUrecj Urine Outcome

mL total / 24h
mL total / 24h

Investigations and Lab Testing on Admission (Day I)

Haematology
(x 109/L)

Platelets

0 No

1 Yes

Leukocytes

0 No

1 Yes

(x 109/L)

Lymphocytes

0 No

1 Yes

(x 109/L)

Neutrophils

0 No

1 Yes

(x 109/L)

Hematocrit

0 No

1 Yes

Hemoglobin

0 No

1 Yes

MCV

0 No

1 Yes

(g/dL)

MCH

0 No

1 Yes

(fl)

AST

0 No

1 Yes

(UI/L)

ALT

0 No

1 Yes

(UI/L)

Protein

0 No

1 Yes

(g/L)

(x 109/L)
(%)

Chemistry

Ultrasound
If abnormal

Normal

Abnormal

Not Done

Ascitis

Hepatomegaly

Pleural effusion

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF April 2012 (120414ek)

Other

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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

Day II

Day III

Day IV

Day V

Date
Day of fever
General status

1 Well

Temperature ( C)

2 Unwell

1 Well

2 Unwell
.

1 Well

2 Unwell

1 Well

2 Unwell

Pulse (bpm)
Systolic BP
Diastolic BP
SaO2 % (%)
Hemorrhagic Manifestations
Petechiae
Purpura / ecchymosis
Bleeding nose / gums
Hematemesis / melena
Vaginal bleeding

0 N
0 N
0 N
0 N
0 N

0 N
0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y
1 Y

Tourniquet Test

1 Y
1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y
1 Y

(Code 0Negative, 1 for positive, "9" for not performed)

Warning Signs

Abdominal tenderness
Persistent vomiting
Lethargy/ restlessness
Liver enlargement

0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N
0 N

1 Y
1 Y
1 Y
1 Y

0 N
0 N
0 N

1 Y
1 Y
1 Y

0 N
0 N
0 N

1 Y
1 Y
1 Y

0 N
0 N
0 N

1 Y
1 Y
1 Y

0 N
0 N
0 N

1 Y
1 Y
1 Y

Plasma Leakage Signs

Ascites
Pleural effusion
Facial edema
Ultrasound
If abnormal, specify

(Code 1for normal, 2 for abnormal, "9" for not performed)

(Code 1for ascites, 2 for hepatomegaly, "3" for pleural effusion, and "4 for other)

Shocks Signs
Cold / clammy extremities

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

Hypotension, weak or
undetectable pulse

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N
0 N

1 Y
1 Y

0 N
0 N

1 Y
1 Y

0 N
0 N

1 Y
1 Y

0 N
0 N

1 Y
1 Y

0 N 1 Y
0 N
1 Y

0 N
0 N

1 Y
1 Y

0 N
0 N

1 Y
1 Y

0 N
0 N

1 Y
1 Y

Delayed capillary refill

Narrow pulse pressure
Coma / Impaired Consciousness
Other Severe Organ Involvement

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF April 2012 (120414ek)

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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

Day I__I

Day I__I

Day I__I

Day I__I

Date
Medications
Corticosteroid

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

NSAID

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

Aspirin

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

Paracetamol

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

Antibiotic

0 N

1 Y

0 N

1 Y

0 N

1 Y

0 N

1 Y

Fluid infusion
Lactate Ringer's

mL

mL

mL

mL

Acetate Ringer's

mL

mL

mL

mL

D5 Ringer Lactate

mL

mL

mL

mL

D5 Ringer Acetate

mL

mL

mL

mL

D5 Normal Saline

mL

mL

mL

mL

Dextran 40

mL

mL

mL

mL

Blood transfusion

mL

mL

mL

mL

Packed cells

mL

mL

mL

mL

Oral Intake

mL

mL

mL

mL

Urine Outcome

mL

mL

mL

mL

Laboratory (Compulsory)
Hematocrit (highest)
Time:

In
%

In
%

Hematocrit (lowest)
Time:

Laboratory (Optional)
Platelets (lowest)
Leukocytes (lowest)

Lymphocytes (lowest)

Neutrophils

Hemoglobin (lowest)

(x109/
L)
(x109/
L)
(x109/
L)
(x109/
L)
(g/dl)

MCV

(fl)

MCH

(pg)

AST (highest)

Units
/L
Units
/L

ALT (highest)

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF April 2012 (120414ek)

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Subjects Initials I__I__I__I

Subject ID Number I__I__I__I__I

Assessment at Discharge

Date:

Compulsory Tests at Discharge

Blood Count

0 Not Performed

Platelets

1 Performed

(x 109/L)

Hematrocrit

(%)

Leukocytes

(x 109/L)

Hemoglobin

Lymphocytes

(x 109/L)

MCV

(fl)

Neutrophils

(x 109/L)

MCH

(pg)

(g/dL)

Clinical Outcome at Discharge

The patient has a clinical diagnosis of dengue
0 No
1 Yes
If the patient has a clinical diagnosis of dengue, what is the clinical outcome according to the
WHO 1997 Classification (tick only 1 case)
0 Uncomplicated Dengue Fever (no DHF, no DSS)
1 Dengue Hemorrhagic Fever, Grade I
2 Dengue Hemorrhagic Fever, Grade II
3 Dengue Hemorrhagic Fever, Grade III
( Grade III = "mild" DSS: bleeding with moderate circulatory failure)
4 Dengue Hemorrhagic Fever, Grade IV
(Grade IV = "severe" DSS: bleeding with undetectable blood pressure)
If the patient has a clinical diagnosis of dengue, what is the clinical outcome according to the
WHO 2009 Classification (tick only 1 case)
1 Dengue Fever WITHOUT any Waning Signs
2 Dengue Fever WITH Warning Sign(s)
3 Severe Dengue
The patient has a confirmed diagnosis of malaria

0 No

1 Yes

The patient has a clinical diagnosis of ARI / Flu

0 No

1 Yes

The patient has another clinical condition

0 No

1 Yes

If "yes", specify: .................................................................

Status at Discharge
1 Recovered
2 Died
3 Transferred
4 Left against medical advice

Surveillance of Paediatric Dengue, NPH, Cambodia

CRF April 2012 (120414ek)

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