Kiwiology Posted February 1, 2013 Posted February 1, 2013 (edited) This is a real case I have recently had at work however minor details have been altered to decrease any chance the patient can be identified ... not that I imagine they could be but still. It's 1pm and you are called to a small three bedroom unit (apartment) on a divided lot in a reasonably well kept neighbourhood in a major metropolitan city. The chief complaint on the magic telly box in the big white van has been listed as "feeling unwell". You arrive to find the house is quite messy and unkempt, very dirty with lots of dishes piled high in the kitchen and several cats running around inside. There is lots of newspaper laid down on the kitchen floor and the house reeks. Many Middle Eastern students in their 20s exclaim "to be coming the quickly, yes please, sick, sick!" while yelling at each other in some foreign language. In the lounge there are 3 mattresses on the floor, one of which contains the patient. A total of 8 people live in the home. The patient is a female in her early 20s, she appears very unwell. PMHx - none; is on an international student visa for last 4 months; "never sick" in home country HPI 10/7 feeling unwell, malaise, fever, diarrhoea, malena, nausea, vomiting, no hameotemesis, low appetite, abdo pain, low urine output O/E she is conscious but confused with many cutaneous spots and a blotchy rash Obs BP 90/40 PR 120 RR 38 SpO2 92 (RA) T 40.1 (104 F) BGL 4 (80 mg/dl) CR 3 The other people tell you that while she has been sick they have been feeding her "the helping curry" which is basically vegetables and rice with some curry spices, and lots of water. You notice a large plastic milk container nearby filled with water, the container is very dirty. They have not taken her to see a Doctor as she is an international student so is not eligible for publicly funded healthcare and cannot afford to pay for the Doctor (a typical non-enrolled visit fee for a 15 minute (!) consult with the GP is anywhere from $70 to $100 NZD). What do you reckon is wrong with this young lady and more interestingly, where did it come from? Edited February 1, 2013 by Kiwiology
scubanurse Posted February 1, 2013 Posted February 1, 2013 I'd like to know more about the water... Could be any number of parasites/bacteria from unclean water.
MikeEMT Posted February 1, 2013 Posted February 1, 2013 My initial assumption would be something like Hantavirus. Since the place is so messy I would assume that their might be rodents running around. I would look for such. I wouldn't rule out Menningitis either. Especially since she has confusion. Any difficulty with movement, stiffness? If Dengue Fever exists down there I would consider that too. Dirty water makes me think Giardiasis. Anyone else been sick? What was patient doing prior to onset of symptoms? Lung sounds? Regardless I am going to mask up in an N95, safety glasses and gloves.
Timmy Posted February 2, 2013 Posted February 2, 2013 PEAL? GCS? Neck pain on flexion/extension? Photophobia? Chest Auscultation? Approximate fluid balance (intake + output) Skin turgor/mucus membrane? Abdominal examination? ECG? Are any of the other 8 people displaying symptoms? Has she been in contact with anyone who is unwell?
scubanurse Posted February 2, 2013 Posted February 2, 2013 PEAL? What does PEAL stand for? I've never heard of that abbreviation :/
Timmy Posted February 2, 2013 Posted February 2, 2013 Pupils equal and reactive to light. Also, I’d like to add an immunisation status.
scubanurse Posted February 2, 2013 Posted February 2, 2013 Sounds good.. I've always seen that as PERRL or PERL or PERRLA PERRL--pupils equal round reactive to light PERL--pupils equal reactive to light PERRLA--pupils equal round reactive to light with accommodation
Kiwiology Posted February 2, 2013 Author Posted February 2, 2013 I'd like to know more about the water... Could be any number of parasites/bacteria from unclean water. The water itself looks fine, the container just looks a bit suspect i.e. dirty My initial assumption would be something like Hantavirus. Since the place is so messy I would assume that their might be rodents running around. I would look for such. I wouldn't rule out Menningitis either. Especially since she has confusion. Any difficulty with movement, stiffness? If Dengue Fever exists down there I would consider that too. Dirty water makes me think Giardiasis. Anyone else been sick? What was patient doing prior to onset of symptoms? No rodents; just a few domestic cats that are clearly not cleaned up after These are all reasonable differential diagnoses and ones that were considered. Nobody else has been sick. PEAL? GCS? Neck pain on flexion/extension? Photophobia? Chest Auscultation? Approximate fluid balance (intake + output) Skin turgor/mucus membrane? Abdominal examination? ECG? Has she been in contact with anyone who is unwell? PEARL + GCS 13 (E2 M5 V6) No neck pain No photophobia B/L basal crackles Approx 1 L day of water input and maybe ~ 200 mL of urine output Skin sweaty with cutaneous rash and some small purpura Abdo NAD ECG ST No contact with anybody else who has been sick
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