SARS PHYSICIAN CASE REVIEW FORM

Patient Initials:  ______________________ Advice requested by: ______________________
Age:  ______________________ Telephone #: ______________________
Telephone #: ______________________ Physician: ______________________
Other: ______________________ Today's date: ______________________
Symptoms: ______________________ Epidemiologic Link: ______________________
Date of symptom onset: ______________________ Known SARS Contact
Prodrome:    malaise    headache   muscle ache Patient under quarantine
Onset: ______________________ Worked or visited category 3 hospital in the last 10 days
Fever
  Worked on SARS unit/or cared for SARS patient
Onset: ______________________ Worked or visited other "at risk" hospital (category 2)
Respiratory Symptoms: cough   shortness of breath
Visited other identified risk area with possible contact
  respiratory difficulty    
Onset: ______________________ Contact of a contact or a quarantined person
    Visited WHO identified  area in Asia
    Date of contact: ______________________
Other History:
Laboratory Test Results
Other Results
Normal
Normal
WBC O2 Sat:
CK Temp:
AST CXR
ALT    
LDH    
DIAGNOSIS: DECISION:
1. Probable SARS
 1. Hospital admission and notify Public Health
2. Suspect SARS 2. Hospital admission and notify Public Health
3. Person Under Investigation 3. Hospital admission and notify Public Health
4. Clinical SARS Symptoms no clear Epidemiology 4. Refer to I.D. expert for review
5. Other diagnosis (careful) 5. Discharge home with advice and 48 hour follow-up by physician