CDC Unknown Infectious Disease

Case Surveillance Report

State Case No: 877

CSID No: 757

Patient name (last, first): Bennet, Vicki

Age: 56

Date of symptom onset of this attack:

(mm/dd/yyyy): 06/01/2014

Sex:

Height: 5 ft. and 9 in.

Patient admitted to hospital:

Hospital: Ketchikan General Hospital

1.

Weight: 169 lbs.

Yes

No

Unknown

Date: 06/02/2014

Has patient traveled or lived outside the U.S. during the past 2 years?
Country:

Male
Female
Unknown

Date of Birth: 11/24/1957

Is patient pregnant? Y N

Physician name (last, first): Davidson, P.

State reporting case: Ketchikan, AK
County: Ketchikan County

Case No: 14-663

Yes

No

2.

3.

Date returned/arrived in U.S.:

Duration in country:

Did the patient reside in U.S. prior to most recent travel?

Principle reason for travel for most recent trip:

Yes
No, (specify country):

Blood transfusion/organ transplant within last 12 months:

If yes, Date:

Tourism
Military
Business
Peace Corps
Unknown
Other

Yes

Visiting friends/relatives
Airline/ship crew
Missionary/dependent
Refugee/immigrant
Student/teacher

No

Unknown

CDC Unknown Infectious Disease

Patient Medical History

Name: _____Vicki Bennet ___________

Phone #__________N/A_____________

D.O.B. __11/24/1957________ Height __59__ Weight__169___ Date of Visit __06/02/2014___

Address 1200 Woodside Dr., Apt A1, Ketchikan, AK 99901
West park village, 9902 Brompton Dr, Tampa, FL 33626
Reason for visit: Fever, muscle aches

Personal Medical History

Medication allergies: ___None_____

Reaction: _____None______

Latex Sensitivity
Heart Problem
High blood pressure
Valve replacement
Pacemaker/AICD
Stroke
Diabetes
Kidney Problems
Seizures
Liver Problems

Pregnant
Yes
No
Breast Feeding
Yes
No
Smoker
Yes
No
Breathing problems
Yes
No
If Yes, explain ______________
Sleep Apnea
Yes
No
Alcohol Use:
Yes
No
Cancer:
Yes
No
If Yes, type:
_________________

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No

Treatment: Given broad spectrum antibiotics and antiviral agents via IV, along with supportive
treatment in the form of fluids and steroids. He succumbed to the infection on 06/03/2014.