‫ﺗﻘﺼﻲ ﺍﻟﺤﺎﻻﺕ‬ ‫‪Case investigation‬‬ ‫ﺑﺭﻧﺎﻣﺞ ﺍﻟﺗﺭﺻﺩ ﺍﻟﻭﺑﺎﺋﻲ‬ ‫ﺗﺷﺭﻳﻥ ﺍﻻﻭﻝ ‪۲۰۱٤‬‬ ‫ﺍﻟﻤﺼﺎﺩﺭ‬ ‫• ﺗﻌﻣﻳﻡ ﻭﺯﺍﺭﺓ ﺍﻟﺻﺣﺔ ﺍﻟﻌﺎﻣﺔ‬ ‫ﺍﻟﻨﻘﺎﻁ‬ ‫•‬ ‫•‬ ‫•‬ ‫•‬ ‫ﺍﻻﺳﺗﻣﺎﺭﺓ‬ ‫ﺍﻻﺳﺋﻠﺔ‬ ‫ﺍﻟﻔﺣﺹ‬ ‫ﺍﻟﺗﺻﻧﻳﻑ‬ :‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ case notification / ‫ﺍﻻﺑﻼﻍ ﻋﻦ ﺍﻟﺤﺎﻟﺔ‬ ‫ﻛﻳﻑ ﺗﻡ ﺍﻻﺑﻼﻍ ﻋﻥ ﺍﻟﺣﺎﻟﺔ ؟‬ Case ID Suspected disease Health facility Date of case detection Treating physician Date of notification Phone Date of investigation Contact person Date filling the form Phone Form filled in by : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ patient identity / ‫ﺍﻟﻤﺮﻳﺾ‬ ‫ﻣﻥ ﻫﻭ ﺍﻟﻣﺭﻳﺽ؟ ﻫﻝ ﻳﻘﻳﻡ ﻓﻲ ﺑﻠﺩ ﺍﻓﺭﻳﻘﻲ ؟‬ Name Date of birth Gender Nationality I residence: Country II residence: Country Governorate Governorate City/village City/village Contact details Contact details : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ patient profession / ‫ﻣﻬﻨﺔ ﺍﻟﻤﺮﻳﺾ‬ ‫ﻣﺎ ﻫﻲ ﺍﻟﻣﻬﻧﺔ ؟ ﻫﻝ ﻫﻲ ﻣﻬﻧﺔ ﻧﻌﺭﺿﻪ ﺑﺎﻟﻌﺩﻭﻯ ؟‬ I occupation: Country II occupation: Country Occupation Occupation Institution name Institution name Institution address Institution address Specific professions: Health care worker Laboratory worker Hunter Mineworker DK DK DK DK No No No No Yes, specify: Yes, specify: Yes, specify: Yes, specify: : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ vital status / ‫ﻭﺿﻊ ﺍﻟﻤﺮﻳﺾ‬ ‫ﻣﺎ ﻫﻭ ﺍﻟﻭﺿﻊ ﺍﻟﺻﺣﻲ ؟ ﻫﻝ ﻣﺎ ﺯﺍﻝ ﺣﻳﺎ ؟‬ Status at reporting Alive Dead If death: Date of death Country of death Place of death House Other Place of burial ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ ‪:‬‬ ‫ﺑﺪء ﺍﻟﻌﻮﺍﺭﺽ ‪onset of signs /‬‬ ‫ﻣﺗﻰ ﺑﺩﺃﺕ ﺍﻟﻌﻭﺍﺭﺽ ؟ ﻣﺗﻰ ﺑﺩﺃ ﻳﺎﺻﺑﺢ ﻣﺻﺩﺭ ﻟﻠﻌﺩﻭﻯ؟‬ ‫ﺍﻳﻥ ﻅﻬﺭﺕ ﺍﻟﻌﻭﺍﺭﺽ ؟ ﻓﻲ ﻟﺑﻧﺎﻥ ﺍﻭ ﺍﻟﺧﺎﺭﺝ؟‬ ‫‪Date of onset‬‬ ‫‪Date of fever onset‬‬ ‫‪Country of onset‬‬ : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ ‫ﺍﻟﻌﻮﺍﺭﺽ‬ ‫ﻫﻝ ﺗﺷﻣﻝ ﺍﻟﻌﻭﺍﺭﺽ ﻭﺟﻭﺩ ﻧﺯﻳﻑ ؟‬ Signs and symptoms: General Fever, headaches, lethargy, myalgia, arthralgia, skin rash Digestive Diarrhea, stomach pain, vomiting, difficulty swallowing Respiratory Difficulty breathing, cough, pulmonary lesions Central Nervous Meningitis, encephalitis System Purpura, bleeding gums, conjunctival injection, melena, Bleeding hematemesis, epistaxis, vaginal bleeding, other Other : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ exposure / ‫ﺍﻟﺘﻌﺮﺽ‬ ‫ﻫﻝ ﺧﺎﻟﻁ ﺍﻭ ﺍﺣﺗﻙ ﻣﻊ ﻣﺭﻳﺽ ﺷﺧﺹ ﻟﻪ ﻋﺩﻭﻯ ﺑﻔﻳﺭﻭﺱ ﺣﻣﻰ ﻧﺯﻓﻳﺔ ؟‬ Exposure history in the 3 weeks before onset Suspected Contact with Probable VHF: Confirmed If yes, specify: - WHEN, - WHERE, - WHO - WHAT disease : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ exposure / ‫ﺍﻟﺘﻌﺮﺽ‬ ‫ﻫﻝ ﺗﻌﺭﺽ ﺍﻟﻣﺭﻳﺽ ﺍﻟﻰ ﺍﻻﺣﺗﻛﺎﻙ ﻣﻊ ﺣﻳﻭﺍﻥ ﻣﻥ ﺍﻓﺭﻳﻘﻳﺎ ؟‬ Exposure history in the 3 weeks before onset Funerals Animal pets Contact with: Animal in zoo Animal in reserve Cave / mine If yes, specify: - WHEN, - WHERE, : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ exposure / ‫ﺍﻟﺘﻌﺮﺽ‬ ‫ﻫﻝ ﻣﺻﺩﺭ ﺍﻟﻌﺩﻭﻯ ﺍﻟﻘﻁﺎﻉ ﺍﻟﺻﺣﻲ ؟‬ Exposure history in the 3 weeks before onset Admission to hospital Contact with health care Visited hospital system: Traditional healer If yes, specify: - WHEN, - WHERE, : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ medical history / ‫ﻭﺟﻮﺩ ﺍﻣﺮﺍﺽ ﺍﺧﺮﻯ‬ ‫ﻫﻝ ﺗﻭﺟﺩ ﺍﻣﺭﺍﺽ ﺗﻔﺳﺭ ﺍﻟﻌﻭﺍﺭﺽ ﺍﻟﺣﺎﻟﻳﺔ ؟‬ Medical history Chronic diseases Infectious diseases Chronic treatment Other : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ travel prior to onset / ‫ﺳﻔﺮ ﻗﺒﻞ ﻅﻬﻮﺭ ﺍﻟﻌﻮﺍﺭﺽ‬ Travel history 3 weeks before onset Country Cities Means (company) Airports Dates (from, to) ‫ﺍﻳﻥ ﻣﺻﺩﺭ ﺍﻟﻌﺩﻭﻯ ؟‬ Symptoms : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ travel after onset / ‫ﺳﻔﺮ ﺑﻌﺪ ﻅﻬﻮﺭ ﺍﻟﻌﻮﺍﺭﺽ‬ Travel history after onset Country Cities Means (company) Airports Dates (from, to) Symptoms ‫ﺍﻱ ﻣﻧﺎﻁﻕ ﺗﻌﺭﺿﺕ ﻟﻠﻌﺩﻭﻯ ﻣﻥ ﺍﻟﻣﺭﻳﺽ ؟‬ : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ case management / ‫ﺍﻟﻌﻨﺎﻳﺔ ﺍﻟﻄﺒﻴﺔ‬ Case management from onset Health facility Physician Date consultation /admission Date discharge Infection control ‫ﻛﻳﻑ ﺗﻣﺕ ﺍﻟﻌﻧﺎﻳﺔ ﺍﻟﻁﺑﻳﺔ ؟‬ ‫ﻣﻥ ﻫﻲ ﺍﻟﻣﺅﺳﺳﺎﺕ ﺍﻟﺻﺣﻳﺔ ﺍﻟﺗﻲ ﻗﺩ ﺗﻌﺭﺿﺕ ﻟﻠﻌﺩﻭﻯ؟‬ Notes : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ patient transport / ‫ﻧﻘﻞ ﺍﻟﻤﺮﻳﺾ‬ Patient transportation to hospital Date Means From To Infection control ‫ﻛﻳﻑ ﺗﻡ ﻧﻘﻝ ﺍﻟﻣﺭﻳﺽ ؟‬ ‫ﻣﻥ ﻫﻲ ﺍﻟﻌﻧﺎﺻﺭ ﺍﻟﺗﻲ ﻗﺩ ﺗﻌﺭﺿﺕ ﻟﻠﻌﺩﻭﻯ ؟‬ ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ ‪:‬‬ ‫ﺍﻟﻨﺘﺎﺋﺞ ﺍﻟﻤﺨﺒﺮﻳﺔ ‪laboratory results /‬‬ ‫‪Laboratory results:‬‬ ‫‪Specify:‬‬ ‫‪- Date‬‬ ‫‪- Result‬‬ ‫‪Malaria test‬‬ ‫‪Platelets count‬‬ ‫‪Other‬‬ ‫ﻫﻝ ﻳﻭﺟﺩ ﺗﺷﺧﻳﺹ ﺁﺧﺭ ؟‬ ‫ﻫﻝ ﺗﻡ ﻓﺣﺹ ﻟﻠﻣﻼﺭﻳﺎ ؟‬ ‫ﻣﺎ ﻫﻲ ﺷﺩﺓ ﺍﻧﺧﻔﺎﺽ ﺍﻟﺻﻔﺎﺋﺢ ﺍﻟﺩﻣﻭﻳﺔ ؟‬ : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ specimen collection / ‫ﺟﻤﻊ ﺍﻟﻌﻴﻨﺎﺕ‬ Specimen to confirm the disease Type (nb) Date of collection Place of collection Conservation ‫ﻣﺎ ﻫﻲ ﺍﻟﻌﻳﻧﺎﺕ ﺍﻟﺗﻲ ﺟﻣﻌﺕ ﻟﺗﺛﺑﻳﺕ ﺍﻟﺣﺎﻟﺔ ؟‬ : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ specimen shipment / ‫ﺍﺭﺳﺎﻝ ﺍﻟﻌﻴﻨﺎﺕ‬ Reference laboratory Courier Category A B Ice Ice pack Dry ice Date of packaging Date of shipment Ref Date of arrival Problems: ‫ﻛﻳﻑ ﺗﻡ ﺍﺭﺳﺎﻝ ﺍﻟﻌﻳﻧﺎﺕ ﺍﻟﻰ ﺍﻟﺧﺎﺭﺝ ؟‬ ‫ﻫﻝ ﻭﺍﺟﻬﺕ ﻋﺭﺍﻗﻳﻝ ﻟﻠﻭﺻﻭﻝ ﻓﻲ ﺍﻟﻭﻗﺕ ﺍﻟﻣﻧﺎﺳﺏ ﺍﻟﻰ ﺍﻟﻣﺧﺗﺑﺭ ﺍﻟﻣﺭﺟﻌﻲ؟‬ ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ ‪:‬‬ ‫ﻧﺘﺎﺋﺞ ﺍﻟﻔﺤﻮﺹ ﺍﻟﻔﻴﺮﻭﺳﻴﺔ ‪Laboratory results /‬‬ ‫‪Laboratory results from the reference lab‬‬ ‫‪Results‬‬ ‫‪Date‬‬ ‫‪Laboratory‬‬ ‫ﻣﺎ ﻫﻲ ﺍﻟﻧﺗﺎﺋﺞ ﻣﻥ ﺍﻟﻣﺧﺗﺑﺭ ﺍﻟﻣﺭﺟﻌﻲ ؟‬ ‫ﻫﻝ ﻫﻲ ﺍﻳﺟﺎﺑﻳﺔ ﻟﻔﻳﺭﻭﺳﺎﺕ ﺍﻟﺣﻣﻳﺎﺕ ﺍﻟﻧﺯﻓﻳﺔ ؟‬ ‫‪Test‬‬ : ‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﻘﺼﻲ ﺍﻟﺤﺎﻟﺔ‬ final classification /‫ﺗﺼﻨﻴﻒ ﺍﻟﺤﺎﻟﺔ‬ Final classification Date Classification Final diagnosis Evolution Notes ‫ﻛﻳﻑ ﺻﻧﻔﺕ ﺍﻟﺣﺎﻟﺔ ﻑ ﺍﻟﺑﺩﺍﻳﺔ ؟‬ ‫ﻛﻳﻑ ﺻﻧﻔﺕ ﺍﻟﺣﺎﻟﺔ ﺑﻌﺩ ﺍﺟﺭﺍء ﺍﻟﺗﺣﺎﻟﻳﻝ ؟‬ ‫• ﺍﺳﺋﻠﺔ‬