reporting performa dengue death review

DENGUE DEATH REVIEW PROFORMA
Instructions: Please fill only those details which are available in the medical records. If the
information is not available, leave them blank.
District:
Dengue Death Review done on (dated):
1. Name of the Patient:
2. Age/ Sex of the patient:
3. Father’s/ Husband’s Name:
4. Complete Address of the patient with contact no.:
5. Date of Onset of Illness:
6. Consultation History: (Chronological Order till the date of Death)
Place of Medical Consultation
Date of
OPD / IPD
(Name of the Institute / Address)
Consultation
Provisional
Diagnosis
7. Date of Death:
8. Place of Death:
(Home/ Govt. Institution with name/ Private Hospital with name)
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9. Signs and Symptoms at the time of Admission and during hospital stay:
Date of Admission:
Signs / Symptoms
Yes / No If Yes, Date
of onset
General Signs and Symptoms
Fever (>380C)
Myalgia
Arthralgia
Erythema
Facial flushing
Rash
Bleeding Manifestations
Positive tourniquet test
Mucosal bleeding
Petechiae
Haematemesis
Capillary Permeability
Oedema
Giddiness / Postural
hypotension
Profuse perspiration
Shock
Altered mental state
Capiilary refill time >2 sec
Signs / Symptoms
Nausea
Vomiting
Diarrhoea
Abdominal Pain
Hepatomegaly
Vaginal Bleeding
GI bleeding
Purpura
Haematuria
Raised Hematocrit
Pleural effusion
Ascitis
Tachycardia
Feeble Peripheral
pulse
Narrow pulse
pressure
Metabolic acidosis
Cold, clammy extremities
Tachypnea
Organ impairment
Chest pain
Cyanosis
Respiratory distress
Decreased Urine
output
Coma
Convulsions
Co-morbid illness / Any other risk factors
Diabetes
Pregnancy
Peptic Ulcer
Liver disease
Hypertension
Infancy / old age
Renal disease
Any other (Specify)
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Yes / No If Yes, Date
of onset
10. During the hospital stay:
a) Laboratory monitoring
Parameter
Date and Findings
Haemoglobin (g/dl)
Hematocrit
WBC Count
Platelet Count
Blood sugar
Urea
Creatinine
SGOT
SGPT
Serum Bilirubin
Total Proteins
Albumin
Globulin
Sodium
Potassium
X-ray
ECG
Ultrasound
Rapid Test for
Dengue
(mention NS1 Ag or
Antibody)*
ELISA based test for
Dengue (mention
NS1 Ag or
Antibody)*
Others
* Mention the type and make of kit and whether cross check at SSH done or not
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b) Clinical Monitoring:
Parameters
Date and Time
Temparature
Respiratory rate
Pulse rate
Blood Pressure
Pulse Pressure
Capillary refill time
c) Treatment History
Treatment
Date and Dosage
IV Fluids
Normal Saline
Ringer Lactate
Colloids
Any other
Blood Transfusion
Platelet
Concentrate*
Whole blood
Packed Cells
Ionotropiuc Support
Dopamine /
Dobutamine
Adrenaline
Dialysis
Any other
(Specify)
*Please mention SDPC/RDPC
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11. Immediate cause of death:
12. Concurrent illnesses which can lead to death:
13. Underlying cause of death:
14. Was death attributed to dengue illness?
15. Reasons supporting or disapproving the cause of death due to dengue illness:
Designation
Chairman
(Civil Surgeon)
Member
(Physician)
Member
(Paediatrician)
Member
(Anaesthetist)
Member
(Pathologist/
Microbiologist)
Member
(IMA
Representative)
Member
(Other)
Member Secretary
Name in Block Letter
Mobile No.
Email id
Signatures
(Committee Members to write their name in block letters and put their signatures against the
designation with date)
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