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Questionnaire for Thesis titled “Developing In-House Polymerase Chain Reaction

(PCR) for ameliorating diagnostic modalities of Scrub Typhus and its comparison with
IgM Capture ELISA”

A. Patient Information:

Name Age Sex – M/F


Address Contact No
ID Department
Date of sample collected Ward /Bed no.
Referring Doctor:
Family History With Scrub Typhus:

B. Symptoms

Duration of fever days Headache Yes/No Breathlessness Yes/No


Extreme weakness Yes/No Cough Yes/No Rash Yes/No
Myalgia/Arthralgia Yes/No Chills Yes/No Calf muscle tenderness Y/N
Abdominal pain Yes/No Jaundice Yes/No Decreased urine output Y/N
Nausea/Vomiting Yes/No Loose stool Yes/No Overt bleeding Yes/No
Specify GI/Haematuria/Heamoptysis/Skin/ Gums/ CNS/Epistaxis/vaginal
Feeding difficulty Irritability

C. Co – morbidities

DM Yes/No CKD Yes/No CVA Yes/No Malignancy Yes/No None


HTN Yes/No CLD Yes/No IHD Yes/No HIV Yes/No
Asthma Congenital Developmental
Heart Disease delay

D. Physical signs

Pulse Temperature
Blood pressure Respiratory rate
Anterior fontanel examination Eschar Yes/No
Conjunctival suffusion Yes/No Crepitations Yes/No
Bilateral pitting oedema Yes/No Neck stiffness Yes/No
Icterus/Jaundice Yes/No Signs of dehydration Yes/No
Abdominal tenderness Yes/No Lymphadenopathy Yes/No
Hepatomegaly Yes/No Splenomegaly Yes/No
Rash Yes/No UL/LL/Face/Neck/Palms/soles
Macular/Papular/Maculopapular/Vesicular/Petechial/Ecchymotic/Erythematous/Pustular
E. Laboratory Investigations

Haemoglobin Na/K Bilirubin(D/T)


TLC Bicarbonate SGOT/SGPT
Neutrophil Urea/Creatinine ALP
Lymphocyte Amylase/lipase PT/APTT
Platelets ABG pCO2 /O2 SpO2
Urine RBC/WBC pH
Urine culture CXR

Malaria Pos/Neg/nd Brucella IgM/IgG Pos/Neg/nd Blood culture


Widal Pos/Neg/nd Scrub typhus IgM Pos/Neg/nd Dengue IgM/IgG Pos/Neg/nd
Any other

F. Study Result Test

Scrub Typhus IgM ELISA


PCR for Scrub Typhus

G. Management and outcome of illness

Antimicrobial Dose Duration

Had any of the following IV fluid/ transfusion /ventilator support/ pacemaker/


ionotropes/dialysis
Complications Renal failure/ARDS/Massive bleeding/ meningitis/
myocarditis/ fulminant hepatic failure
Outcome Alive/dead Total stay
Date admitted Date discharge/died

Pos- Positive

Neg- negative

ND – not done

 Please send blood samples in plain vial (Red cap) and EDTA vial (purple cap) to
Microbiology Department, Medical college building.

 For Any Query Please Contact: Dr. Rishika Prakash ( 8434183508, 8986756844)