LMAOROF. The really sick thing is I know what your thinking and those ?s are relevant? :D

Doc... as Rocky taught me, there are no stupid questions in a good Hx, irrelevant is nonexistent, complete may have chaff, but you may just find the needle if the haystack is big enough.

I am not quite sure enough to call mycoplasmic pneumonia, but it is a dusty area with a propensity for poor hygiene and many "-ine" critters and roaming fowl... with a medical history of endemic soil and dust born pneumoniae... with a low penicillin/tetracycline usage, there is a good chance that low spectrum abx could be used to good effect if the medical practitioner is astute enough to catch it.

low grade fever, mild headache, some body aches (feels like shit), semi productive cough, bilat rales... and the AO .. are the main contributors to the prelim Dx of Mycoplasmic pneumonia... (that and I was hit with a death board in Medlab and the 48 hr assignment from the Merck was Pneumonia... most people don't realize how friggin big the pneumonia section in the Merck is...)

Does the rash blanch when pressed with a glass?

No.

When you say "not really" to the headache question - what does that mean? I take it to mean yes, but low grade. If so, how long?

"I mean, if you really pressed me I guess maybe a small headache, but its not really noticeable."

When did the rash appear? (OK, it was 2 questions)

"I didn't even know I had it."

Does he smoke?

Yes.

How much?

1ppd

Has he switched brands if he does smoke?

He'll take what he can get when he's deployed.

Has he smoked local cigarettes (or other items) as a good faith gesture?

No.

What is his MOS?

11B

Is he working in his MOS?

Yes.

Has he been tasked out to another job?

What sorts of manual jobs DON'T 11B's get tasked out for?

Has he been incarcerated for any reason?

Never convicted.

Does he have a local girlfriend?

No.

Has he performed any fire (burning kind) control lately?

Yeah, he ran the burn pit one day.

Any exposure to chemical compounds he usually hasn't experienced?

Not that he can think of.

Has he been on burning shit detail lately?

Yes.

Hygiene schedule, habits and exposures to local soldiers/militia?

He's only been back a week, so he hasn't fully settled into his field funk yet. Showers at least every few days. Brushes teeth at least daily. His unit does joint patrols with locals.

Dairy intake?

None since his return to theater.

Has he been through a chicken coop on a recent op?

No.





Happy to start taking PE once you guys are confident you have your history.

No further PE required for me. I'm moving to a Rx plan and action plan.

I'll keep quiet for now and see what the rest of you reveal through the PE portion.

To be thorough on PE:

Any gingival hyperplasia/gum hypertrophy (you mentioned the rest of the oropharyngeal exam earlier)?

Abdomen - any organomegaly or mass?

GU/Testicular exam?

Any other abnormal skin findings?

Cranial nerve, mentation, motor and sensory examination? DTRs?

Any gingival hyperplasia/gum hypertrophy?

Negative.

Abdomen - any organomegaly or mass?

Negative.

GU/Testicular exam?

Unremarkable.

Any other abnormal skin findings?

No.

Cranial nerve, mentation, motor and sensory examination? DTRs?

CN II-XII intact to confrontation (CN I not tested, but PT denies changes in olefaction). Mini mental status exam unremarkable. Motor 5/5 in all extremities. Light touch, pain, vibration intact in all extremities bilat. Biceps, triceps, brachioradialis, patellar, achillies DTRs 2+ bilat. Negative babinksi.


***

As you conduct your exam, you notice two other soldiers have shown up and are waiting for sick call....

Uh Oh!;)

Given the location and the PFC's symptoms and exam, I'm worried about Typhoid. I assume he received his vaccination, but his drinking the local water supply is concerning and if he drank enough he may still become sick.

I believe ciprofloxacin is still the first line therapy for this, but if he fails cipro I would consider a switch to azithromycin or ceftriaxone on the assumption he has a drug restitant bug. I would treat on presumption without confirmation of the diagnosis given my limited ability to confirm the infection and knowing the natural course of this infection without intervention.

OK, so you've put the patient on Cipro (IV or PO?). Calling in the bird to come get him? Want to see your next two patients?

This is where my experience/training is limited, so I appreciate hearing the decisions and reasoning of those with field experience in these cases.

My initial gut is that he has a mild case without any GI sypmtoms, so I would treat him orally and I don't think he needs to get flown out.

Hand hygiene and avoiding local water sources need to be stressed to everyone.

Do I have a choice, and can I wash my hands first? :D

Your second patient complains of "cold-like" symptoms including significant body aches and cold hands and feet. And since it will be the first question, no, this one doesn't have a rash. This one denies drinking local water. He is the E5 team leader for your first patient. :D Questions?

Any drinking of the local water or contact with the previous patient?

Hopefully our last guy wasn't serving up chow. :D

I updated my response above with a few of the things I knew you'd ask. :D

I think anyone with cold or diarrheal symptoms would need to be treated for presumed typhoid.

This patient's presentation is not identical to the first... I think it's worth a good PE.

I will give you all of the questions you have already asked: the only difference from patient one (other than the absence of rash) is that the patient flunks his short-term memory test on the MMSE, and appears noticeably listless.