PFC with a Cough
 

I have a final exam on friday, so thinking through these case studies is actually fairly helpful for me in studying.

Situation: You are deployed to Afghanistan and your team is co-located with a NG infantry company on a fairly remote FOB, and you are the highest level provider on site. You are running sick call one morning, and a young PFC shows up complaining of a cough and "generally feeling like shit."

You have a reasonably well-stocked aid station at your disposal, but you didn't bring your lab kit with you this time. No fancy schmancy labs, no imaging.

Vitals: T100.5, P72, BP 110/70, R12

What do you want to know? Lets flesh out the history, and then move onto physical exam.

Duration of cough? Getting worse/better?

Is the cough productive or not?

Hemoptysis?

Shortness of breath?

Any recent sick contacts with similar symptoms?

Any recent inhalation exposures (intentional or otherwise)?

Any recent choking while eating?

What exactly does he mean by "feel like shit"? Achiness, fatigue, etc.

Any nausea/vomiting (post-tussive or otherwise), diarrhea?

Duration of cough? Getting worse/better?

Started last night, so its new enough that its getting worse by defininition.

Is the cough productive or not?

He thinks he's getting a little of the "gunk" up, but he's not really sure.

Hemoptysis?

Negative

Shortness of breath?

Negative

Any recent sick contacts with similar symptoms?

Not that he knows of.

Any recent inhalation exposures (intentional or otherwise)?

Not that he knows of

Any recent choking while eating?

No.

What exactly does he mean by "feel like shit"? Achiness, fatigue, etc.

He feels fatigued and feverish.

Any nausea/vomiting (post-tussive or otherwise), diarrhea?

Negative.

Any pain?

The cough is uncomfortable, but not much in the way of pain.

any SOB?

No

Lung sounds?

That is physical exam... we'll get to that... but lets say he has faint bilateral rales.

Anything making it better or worse?

He thinks it would help if he could get out of his patrol today and take a rest. Otherwise, no.

Blood in stools?

No.

Blood in urine?

No.

Pain when urinate?

No.

What color is urine?

Straw colored.

Past Medical history?

Appendicitis 4 years ago treated surgically. He admits he's "had the clap a few times."

On any meds? If so what?

Malaria Prophylaxis. (Doxy)

Are you taking your malaria meds?

Most of the time.

What does his skin look and feel like?

Lets give you the benefit of the doubt and assume you're doing a thorough skin exam even though he's just presenting with cold symptoms. :D When you examine his skin, you notice a rash that looks like this on the pressure points where his body armor sits. How would you describe this?

http://img834.imageshack.us/img834/3794/o276.jpg

Abd tenderness or pain?

No.

Diarrhea or constipation?

No.

What does nose, ears and throat look like?

Throat is mildly erythemetous, but no petichiae, no lesions, no exudate, and you're not seeing significant swelling of lymphatic tissues. Nose and ears unremarkable.

Has he been bitten by anything? (ie infected beaver)

Does the sorority girl on mid-tour leave count?

Any rash or sores?

See above.

Swelling anywhere?

No.

How has his appetite been?

He hasn't had much appetite today.

Has he eaten any local food or drank from unclean water source (streams rivers etc)

Just that one time when he was really thirsty.

Rash is consistent with petechiae - typically from platelet defect (either quantity of function).

Has he noticed any jaundice or yellowing of the eyes?

Any ankle/extremity swelling?

Feeling bloated? Abdominal pain?

Has he noticed any jaundice or yellowing of the eyes?

Negative.

Any ankle/extremity swelling?

Negative.

Feeling bloated? Abdominal pain?

Negative.

Any headache?

has he ever had a similar rash in the past?

Family history of autoimmune/rheumatologic conditions?

History of pneumonia or recurrent infections?

Any limb/back pain?

How long has the PFC been in country? Where before his deployment?

Headache?

Radiating peticheal hemorrhaging? Rings a bell in the ol' noggin. Need to search on that one, may be important diagnostic clue?

First things first... Is he a leg?

Yes.

Any headache?

Not really.

has he ever had a similar rash in the past?

"I've had some chafing from my kit before, but it didn't really look the same."

Family history of autoimmune/rheumatologic conditions?

"Mom has some kind of arthritis, but I'm not sure what kind."

History of pneumonia or recurrent infections?

I had pneumonia once when I was a kid I think. I don't seem to get sick more than most other people I know.

Any limb/back pain?

No, not really.

How long has the PFC been in country? Where before his deployment?

Returned from mid-tour leave in the US one week ago. Layover in Germany.

Petechiae are a sign of defective or insufficient numbers of platelets - distribution is typically in areas where skin is under stress (often at site of shoulder straps, waistline, etc. in those carrying packs). They can be seen from ITP, new onset leukemia, too much aspirin, and several other causes.

ITP would raise the potential for other diagnoses such as new-onset rheumatologic disease (e.g. lupus), underlying immunodeficiency (primary immunodeficiency, undiagnosed HIV, etc.) along with more common ITP causes (e.g. H.pylori, post-viral, etc.)

He could also have aplstic anemia [secondary to a toxic exposure or underlying bone marrow failure syndrome (e.g. Fanconi's anemia, dyskeratosis congenita, etc.) - many of these have hints on the physical examination (leukoplakia, premature graying, short stature, etc.)].

Thanks Doc. But I remembered (takes a while sometimes for the connections to be made) why this is important in a patient presenting with a low-grade fever & productive cough. This area of the world is also endemic for what I am thinking and if correct this is a medical emergency and can get ugly fast.

I want to sit back and see what else is revealed from the Hx and PE before I say what I am thinking.

I have only one question when we get to the PE - does the rash blanch when pressed with a glass?

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?

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

Gotcha - I'm tracking your line of thought. ;)

Will have to see how this one develops - could go a few directions.

Does he smoke?
How much?
Has he switched brands if he does smoke?
Has he smoked local cigarettes (or other items) as a good faith gesture?

What is his MOS?
Is he working in his MOS?
Has he been tasked out to another job?
Has he been incarcerated for any reason?
Does he have a local girlfriend?
Has he performed any fire (burning kind) control lately?
Any exposure to chemical compounds he usually hasn't experienced?
Has he been on burning shit detail lately?

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

Dairy intake?

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

(hey, stuff other people didn't ask that could be relevant)

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.

The mental state is consistent with my Dx even in the absence of a rash. Is their a productive cough? Rales? Temp? Headache? BP? RR? Pulse? What level of personal interaction has he had with Patient #1, e.g. did they share a smoke together?

What is the CC for Patient #3? Same questions for him as with #2. Any rash? What does Patient #3 have in common with #1 & #2, e.g. shared duty assignments, sleeping quarters, eat together, share smokes, share drinks?

Is their a productive cough?

No.

Rales?

No

Temp?

102

Headache?

Yes.

BP?

100/65

RR?

14

Pulse?

85

What level of personal interaction has he had with Patient #1, e.g. did they share a smoke together?

No shared tobacco products. They sleep in neighboring cots.

What is the CC for Patient #3?

Similar cold-like symptoms, he is notably pale, and complains of notable leg pain.

Same questions for him as with #2.

Pretty similar except bringing back a little stronger of a URI picture like in the first patient. Vitals in the same ballpark except a little more tachy.

Any rash?

http://img59.imageshack.us/img59/1636/hw7v.jpg

What does Patient #3 have in common with #1 & #2, e.g. shared duty assignments, sleeping quarters, eat together, share smokes, share drinks?

Shared sleeping quarters. You note that after one of the AC units went on the fritz, a large number of the NG soldiers have crammed into one room (with a working AC) to sleep.




Your overall clinical impression of case 3 is that of a combination of cases 1 & 2.

Get all the soldiers in the shared quarters to sick call ASAP! Quarantine these Patients! I will be wearing a mask and gloves from here on out if not already doing so.;) The rash on Patient #3 confirms my Dx!

Let me know when you are ready for the Rx and action plans. ;)

While we are at it, what is the result of the glass test on the rash of Patient #3?

Roger! Trapper John has more experience than I do with real-world epidemic management, so I'm going to let him take over discussion of that portion of the scenario. I am still waiting for someone (other than TJ) to ask me for the one classic exam finding that would have been absent from case one (at least at this stage!) but present in cases 2 & 3.

The rash on PT #3 is also non-blanching.

They have Kennel cough, or shipping fever... 'nuff said... take 'em to the 'tube' and make them go away... then board their medic....:eek::p:rolleyes:

Close but no cigar Bro. :p Anyone else want to offer a Dx & Rx plan at this point? Hint: This has already become an imminent medical emergency.

Just for fun let's say the NG unit is a Company size unit at this remote FOB. Let's also assume the AO is hot and Medevac may be days away. Intel reports a large Taliban force is on the move towards the FOB. You may be able to get a resupply dropped in, but the window for that is closing fast. You need to quickly assess the medical situation and request any resupply that you might need within the hour.

So, what is the Dx and Rx plan. What are the recommendations to the Team Sergeant/Team Leader. What do you recommend to the NG CO? What effect can this medical emergency have on the tactical situation? What are your recommendations to the Team Sergeant/Team Leader?

What do we know so far?

Patient 1:
Cold Symptoms
Fever
Non-blanching petechial rash
Slight Headache

Patient 2:
Cold Symptoms
Fever
Altered Mental Status
Headache
(important sign no one has asked about)

Patient 3:
Cold Symptoms
Fever
Headache
Purpural Rash
Altered Mental Status
(important sign no one has asked about)

Its probably contagious, and it seems to be moving fast. Can you make a differential?

Exam positive for nuchal rigidity! So you nailed the mystery sign! :lifter

Short term memory loss and lassitude as noted in PT two. PT 3 is becoming increasingly disoriented and does not know his location.