Case Investigation Form bola Virus Disease ICD-10 Code: A98.4 Bhilippine integrated Di Surveience ait Reapone iaroe ST ORT Type GRHU ECHO OGevtHossital OPrivate Hospital OCtinie FR) ergata Sites: Gov't Laboratory Private Laboratory DAirportSeaport |" PATIENT INFORMATION. [Patent omer paecerattane ‘Widate Name LastName [compte Address: feex: Male Date of Binks age “emale wae w | o oe OFemal mt op ow | O Oa 6 Yeare (Patient aamated? OY ON COTES [Date Remo a [Seen/Consut fs the palit cont of a suspectprobablavconnrmed lebola cose? OY CIN. loate or a Investigation fuzne orievostaators Jeontet nos CLINICAL DATA Fer OY ON [otier Sensi Symptoms [are there any complications? Date onset: oy oN Headache = LY GN |Anorexia/ Loss of Appetite OY ON Vomiting Nausen YON, Diarthea ay ON |irves, speciy: lWeainess/Severe fatigue DY CN —_ |othersymptoms: Signs of Hemorhage: [Abdominal pain ay on Muscular pain QY ON — |WorkingFinal Diagnose: Bleeding Gums DY GN — |oiricuty oFsreating = YON Nosebleed/Epistués. © Q'Y ON |Dificuty ofSvatowng OY ON Petechiae/purpua = LY ON |Hiccoughs ay on Red eyesieonjincivtis: DY ON Bloody Stool Meena «DY ON Hamatemesle oy oN i, EXPOSURE HISTORY History oftavel: DN GY IFYES, spect place and timing: Place of revel: 11 2-7 days fomenset C =21 days from onset ‘Was there contact wth a confirmed Ebola Vius Disease case 2-21 days prior tothe onset of fever! hemorhage? CY CIN IFES, name of contact: place of residence: Date of contact —_f_/ (Check the type of place where exposure probably eccur: CiDey care Barangay Come iSchool CHealth Care Faciity Domitory Clothers, specify ‘Are there other known cases with fever and signs ofhemonage in the community? QY ON OU V, LABORATORY TESTS: Specimen collected Damani ree] spe pie era ie inves, | Ostesereto | cotenierun [EUSAREUE | este | organ [Dalat Rut Provided) cance | RT wer Asem ee || rt ‘Dlorepharyngeay NNasepnaryagea wad | | | ao DOH-PIDSR-EVD-REVOPage 20f2 Case Investigation Form VV. FINAL CLASSIFICATION Vi SOURCE OF INFECTION 1D. Suspect Case of EVD 1D Endemie 1D Probable Care of EVD imported 1D Confirmed Case of EVD Unknown VIL OUTCOME: Alive Ol Died Date ded 7 / FINAL DIAGNOSIS: ‘Any hospitalized parson with acute onset of fever of esathan3 weeks dation with no response to tretinen for ual ensse of fever in ine aret tnd ating ot having tered feat a sudden one f high fever snd alent ree ofthe lowing eyupnts Anoreia loss ofapptite —Diliaitywsionone ee Betting shat heey Blecing aio Ln Guru) ‘Stow pa ng io in ure) ‘OR: any parson hnving hal contact with MR dispeced probable or coianed bots case ‘A dear ick mital 142 PRODABLE CASE: Any suppected ase evant by 2 cinican having an pidenolosica ‘Specimens fr labortery centirmaton 3c with contr ase (where has Been porsibeto collect, ‘OR: Aay deceased spect eae (wert nas ot been possible to cllet specimens for Iboratry contention) having an pidenio- Topical tin with» contre case 1A LAPORATORY CONFIRMED CASE: Any sup ete or probably cases wit «pore abestory reru Laboratory confined cases nm tet poltive for the vis anigen, ‘ther by detection of virus RNA by reverse trsrptasepelymerare chin Fenton (RT- PCR), oF by detection of iD abodes directed ‘gaint Marbury er Pool _Aay susp ectec er probable case with «nega abaatory esl. "Discarded Case” showel no speci salbodes, RNA er specie detect- ‘ble ntieans Shiaeiosis EHF, Fresents with airhes, pssbly bloody, accompanied by fever, oniting, cramps andtenexms Stol contains blood and mics Typical Preece of leucoestesdistinuishes bacterial ingectins Pyare Presale far ras, headache, guavobledinal gauploms, with Yuwhadenopally, dative laadjew ia, cough lescopei nd sometimes sere hr arn [Presenis wih sete fever headache and somelimes danhen Tams Fever Disease onset isusually arch, with fever, sorethoa, cough, plruynaic, and fecal cia in Inte sage Fratow Fever DOHPIDSR-EVDREVO