Rural Health Clinic

[chbare]

You are a paramedic working at a remote clinic in Afghanistan. You are in the mountains and supporting a DOD project at a small airfield. It is late November with generally cold conditions and an evacuation off site would present with logistical and security challenges.

A 48 year-old male presents to your clinic complaining of "feeling bad."

Take it away.

EDIT: Dwayne, your scenario privileges have been revoked on this one because you have insider knowledge on this patient.

Edited October 29, 2011 by chbare

[DwayneEMTP]

Heh...fair enough Brother...I have a feeling that I do..Awesome idea for a scenario.

Dwayne

[Kiwiology]

Of course he "feels bad" it's Afghan winter and his tent probably got smart bomb'ed or hit with a stray rocked propelled grenade or some shit

Sounds like this bloke needs the works

General impression - level of crookness / skin condition / clumps of hair falling out / obviously malnourised etc

Head/neck - sclara, work of breathing, lymph nodes, cyanosis, trachea, photophobia

Resp - lung sounds, tactile fremetus, percussion, sputum

Cardio - ECG, heart sounds, signs of CHF or pedal edema etc

Abdo/GI/U - toilet habits, diet, abdo masses, pain on urination, dysuria etc

Full set of obs and lets get some bloods (CBC, U+E, tox screen)

Whats his PMH and HPI like?

[DFIB]

Here is a long shot. As Kiwi progresses with his head to toe assessment he finds Carbon monoxide poisoning or smoke inhalation from burning cow dung or the kerosene heater that the nice soldier gave him last week.

[chbare]

Of course he "feels bad" it's Afghan winter and his tent probably got smart bomb'ed or hit with a stray rocked propelled grenade or some shit

Sounds like this bloke needs the works

General impression - level of crookness / skin condition / clumps of hair falling out / obviously malnourised etc

Head/neck - sclara, work of breathing, lymph nodes, cyanosis, trachea, photophobia

Resp - lung sounds, tactile fremetus, percussion, sputum

Cardio - ECG, heart sounds, signs of CHF or pedal edema etc

Abdo/GI/U - toilet habits, diet, abdo masses, pain on urination, dysuria etc

Full set of obs and lets get some bloods (CBC, U+E, tox screen)

Whats his PMH and HPI like?

Awake, alert and oriented to all spheres, but appears anxious. Skin appears pale and the patient appears to be an obese, middle aged American male.

Increased rate of breathing with no complaints of difficulty breathing. No lymphadenopathy is noted, no cyanosis, supple and midline trachea, no photophobia, ocular exam is unremarkable.

Lung sounds are clear upper lobes bilat and diminished to the bases bilat without adventitious sounds. Complains of an occasional non-productive cough, no increased sputum production, no fremetus noted, resonate percussion notes noted.

S1S2, tachycardia at 115 noted. No S/S of CHF appreciated.

No GI complaints other than he doest feel like eating as much as usual. Abdominal exam is unremarkable, no urinary or GU complaints.

PMHx: HTN, APPY, Lap Chole

Meds: Takes Toprol XL but is not particularly compliant.

You will have to send labs out unless you feel like running them your self. Let me know what you want to do.

Here is a long shot. As Kiwi progresses with his head to toe assessment he finds Carbon monoxide poisoning or smoke inhalation from burning cow dung or the kerosene heater that the nice soldier gave him last week.

Good consideration. Patient lives in a modified railroad container and has had no exposure to smoke or hydrocarbon burning heaters.

[Kiwiology]

I don't suppose we can do a CXR? If we could do labs it'd be nice but it not essential if it's gonna be a PITA

What are his obs like? ECG? Temp?

Sounds like a minor LRTI however I know better, and the respiratory rate is a subtle indicator of an unwell patient hmm

Edited October 29, 2011 by kiwimedic

[chbare]

Temp of 101.3 F, ECG: Sinus Tachycardia no ectopy or significant findings. You can send out basic labs. Let me know exactly what you want. Urine dipstick is negative for drugs.

Edit: You do a portable chest and note an essentially normal film with areas of atelectasis to the bases bilaterally.

Edited October 29, 2011 by chbare

[DFIB]

What is the quality, quantity and odor of his poop?

Has he eaten any local cheese or milk?

Does he have a headache, if so for how long?

When was the onset of his symptoms?

Are there any lice, flea or rat infestations in the area?

I would like to order a CBC, IgG and IgM by IFA if available. If it is not available then a Febrile Antibodies Panel will suffice.What is the turn around time for the labs?

If the lab turn around is long. Start doxicycline 500mg qid. if patient is non alergic.

Should I write what I suspect or let the suspense build?

I am way out on a limb here, hope it isn’t a strike.

Edited October 30, 2011 by DFIB

[chbare]

Stool characteristics are unremarkable. He does complain of a dull headache that comes and goes. (Off and on over the past week.) You can have your CBC in a couple of days. The febrile antibodies panel...

Oh, yes he has been eating local foods.

[DFIB]

Sitting fat and waiting on lab results while I eat a big piece of toast and fresh goat cheese.

Edited October 30, 2011 by DFIB