Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Suspected/Confirmed Ebola Virus Disease (EVD)
Reason for Visit:
Document the reason for this visit.
Is this a suspected case with recent travel history to an EVD-affected area and compatible symptoms?
Is this a confirmed case being monitored for clinical progression and complications?
Subjective:
Travel History: Inquire about recent travel to EVD-affected areas within the past 21 days.
Symptoms (onset date):
Fever (sudden onset, high grade)
Severe headache
Muscle pain (myalgia)
Weakness (asthenia)
Fatigue
Loss of appetite (anorexia)
Abdominal pain
Diarrhea (may be bloody)
Nausea and vomiting
Sore throat
Chest pain
Difficulty breathing (dyspnea)
Bleeding (from gums, nose, injection sites)
Macular rash (may appear later in the course of illness)
Exposure History:
Contact with known or suspected EVD cases (including deceased patients)
Contact with non-human primates (e.g., monkeys, apes) or their body fluids
Objective:
Vital Signs:
Include temperature, heart rate, respiratory rate, blood pressure, oxygen saturation (SpO2).
Monitor for hypotension, tachycardia, and tachypnea (indicators of severe illness).
Physical Exam:
General: Assess for appearance of illness (prostration, lethargy).
Skin: Look for macular rash (may not be present in all cases).
HEENT: Assess for pharyngeal erythema (reddened throat).
Lymph nodes: Palpate for lymphadenopathy (swollen lymph nodes).
Lungs: Auscultate for rales (crackling sounds) indicating pulmonary involvement (can occur in later stages).
Abdomen: Assess for tenderness, hepatomegaly (enlarged liver), splenomegaly (enlarged spleen).
Neurological: Assess mental status for confusion, lethargy, or seizures.
Laboratory:
Document any laboratory tests performed, such as:
Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay for EVD diagnosis (considered the gold standard).
Complete blood count (CBC): May show leukopenia (low white blood cell count), lymphopenia (low lymphocyte count), thrombocytopenia (low platelet count).
Electrolytes: May show abnormalities due to dehydration and electrolyte imbalances.
Liver function tests (LFTs): May show elevations indicating liver injury.
Coagulation studies: May show abnormalities indicating bleeding risk.
Imaging:
Imaging studies are not typically used for diagnosis but may be performed to rule out other conditions with similar symptoms (e.g., chest X-ray for pneumonia).
Assessment:
Suspected EVD based on travel history, clinical presentation, and ongoing evaluation for confirmation.
OR
Confirmed EVD based on a positive RT-PCR test for Ebola virus.
Assess the severity of illness (mild, moderate, severe) based on clinical presentation and laboratory findings.
Consider differential diagnoses depending on the specific symptoms.
Plan:
Isolation: Implement strict isolation protocols to prevent further transmission.
Supportive Care:
Intravenous fluids for hydration and electrolyte replacement.
Antipyretics (fever reducers) and pain management medications.
Anti-emetics (for nausea and vomiting).
Blood product transfusions (if needed).
Respiratory support (if necessary).
Investigational Therapies:
Discuss the possibility of investigational therapies specific for EVD if available and the patient meets eligibility criteria.
These therapies should be administered in a specialized treatment center.
Public Health Reporting: Notify public health authorities immediately of a suspected or confirmed case of EVD.
Contact Tracing: Identify and monitor close contacts of the patient to prevent further spread.
Follow-up:
Closely monitor vital signs, clinical status, and laboratory results.
Implement strict infection control measures to protect healthcare workers.
Provide emotional support