Date:

Time: CLERKING SHEET FOR SUSPECTED DENGUE CASES

am/pm

Patient s demographic data:

History: (please circle and tick ( 1. 2. 3. 4. 5.

) as appropriate) Yes/No Yes/No Yes/No days Yes/No Yes/No Yes/No Yes/No

Are you from a dengue prone area/recent fogging? Anyone with recent history of fever in your house? Previous history of dengue illness? How many days of fever? Any concurrent: y Bodyache? y Headache? y Retroorbital pain? y Rash?

Clinical Manifestations: ALERT SIGNS present? 1. Vomiting? Yes (no. Of times /days, For days) 2. Diarrhoea? Yes (no. Of times /days, For days) days) 3. Abdominal pain? Yes (For 4. Bleeding/bruising? Yes( please specify site ) 5. Plasma leakage? Yes ( ascites pleural effusion) Resp. Rate* ( per min): *>24/<24 Pulse Rate* : bpm mmHg Bld. Pressure - SBP : -DBP : mmHg mmHg Pulse Pressure(PP) : (PP= SBP-DBP) *PP 20 mmHg is an ALERT SIGN Temperature: C kg Weight: HCT/PCV : % *(female:<40%, male:>45%) Hb : g/dL Platelet : x 109/L WCC : x 109/L Dengue serology (date taken): Ig M+/NS1 Ag+/Ig G (high titre) +/-

No No No No No

Name of docter, signature and official stamp:

*these are ALERT SIGN and needs IMMEDIATE resus. PLEASE seek senior consult.