A 42-year-old woman appears in the emergency center with a two day history of fever, headache, and vomiting. This morning she experienced several bouts of watery diarrhea. She has recently returned from Sierra Leone where she had been volunteering as a humanitarian aid worker at a local hospital. Her duties involved caring for patients with any and all illnesses with some direct patient contact as a nurse. She has been in the United States for approximately eight days prior to symptom onset. Her medical history is unremarkable.
On exam she has a temperature of 102.7° F, pulse 109 beats per minute, RR 17 breaths per minute, and BP 110/72 mmHg. She appears pale and ill, and it is difficult for her to focus on the evaluation due to severe malaise. She is tachycardic but the remainder of her cardiopulmonary exam is normal, as is the abdominal exam. Her extremities show scattered bruises which appear new.
Which of the following is the most likely diagnosis?
A. Start an IV and initiate saline boluses
B. Swab for influenza and start oseltamavir
C. Isolate the patient and admit to the ICU with contact and droplet precautions
D. Call the local health department for advice
E. Admit to the hospital and perform lumbar puncture
Correct answer: C – Isolate the patient and admit to the ICU with contact and droplet precautions
Key Point: Patients exhibiting signs and symptoms who have high risk exposure to Ebola virus need to be immediately isolated and admitted to an intensive care unit.
Discussion:The CDC has declared the 2014 Ebola outbreak the largest in history and a Public Health Emergency of International Concern. It is also the first Ebola epidemic the world has ever known and at the time of this writing affects six countries including one case diagnosed in the United States. This requires all health care workers and health care institutions to know how to recognize and triage patients suspected or confirmed to have Ebola infection. The most immediate action that should be taken for patients suspected of having Ebola infection is isolation of the patient. In the scenario described in the question stem this would involve requesting that the patient remain in the examination room and removing any family members or friends that may have accompanied the patient to the emergency center. Currently the CDC considers household family members as “low risk” of exposure. To prevent them from becoming infected they need to be removed. In addition, these family members would need quarantining for at least the maximum known incubation period for the Ebola virus which is thought to be 21 days.
The patient will need IV hydration but this is not as important as immediately isolating the patient. Although influenza is a possible diagnosis, the testing should be done once the patient is admitted to the ICU and the appropriate precautions are in place. Performing a lumbar puncture in a patient with fever, headache and nausea is also reasonable but not until after immediate care is instituted. In addition, needles, blood draws and other testing that involves risk of exposure to body fluids need to be minimized to those absolutely necessary for diagnostic and therapeutic reasons. Calling the local health department (as well as the CDC) is also required but should be done after the isolation has occurred.
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