mdebord Posted January 20, 2014 Share Posted January 20, 2014 While not nearly as interesting as Rev's case, I think this one requires a fair amount of critical thinking. A little background: In Texas we are currently having the worst allergy season from mountain cedar ever recorded, so there's a lot of that. Please keep in mind that this was done in a family practice environment, as I'm sure the ER management would have been slightly different. 33yo WM presents with 2 days of fever, chills, sinus congestion/drainage and cough; says "I think it's the cedar." Recently returned from work trip a few hours south. No known sick contacts. Has been taking OTC meds w/o relief. Vitals done already and are as follows: Height/Weight both WNL T: 102 HR: 128 BP: 170/110 You enter the room. What questions do you ask the patient? Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 21, 2014 Share Posted January 21, 2014 cocaine or anphetimine use? Link to comment Share on other sites More sharing options...
mdebord Posted January 21, 2014 Author Share Posted January 21, 2014 cocaine or anphetimine use? Good thought! Not what's going on here, but I hadn't considered it. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 21, 2014 Share Posted January 21, 2014 Start simple and ask about flu and vaccination. HTN hx. Color of nasal discharge and sputum color, if any. Consider frontal sinusitis (true emergency). "South" as in where? South of the border? South Texas? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 21, 2014 Moderator Share Posted January 21, 2014 Start simple and ask about flu and vaccination. HTN hx. Color of nasal discharge and sputum color, if any. Consider frontal sinusitis (true emergency). "South" as in where? South of the border? South Texas? cough, cough, student case, cough , cough..... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 21, 2014 Share Posted January 21, 2014 Ah (hand slap). Should read title I guess. Link to comment Share on other sites More sharing options...
mdebord Posted January 21, 2014 Author Share Posted January 21, 2014 That's ok, in the interest of moving this along, I will respond. No flu vaccine this year. H/o HTN previously controlled on lisinopril 10 but doesn't take it "some days." Not a lot of nasal discharge, but sputum is gray. South Texas. Any students out there?! What other specific questions do you ask about the patient's history? Questions for the ROS? Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 21, 2014 Share Posted January 21, 2014 foreign body causing abcess? what does he do at his job? Link to comment Share on other sites More sharing options...
mdebord Posted January 21, 2014 Author Share Posted January 21, 2014 Oilfield work Link to comment Share on other sites More sharing options...
winterallsummer Posted January 21, 2014 Share Posted January 21, 2014 Trouble breathing at rest or w exertion? HA, blurred vision, diaphoresis, AMS? Does he know what his BP usually runs and did he take lisonopril today? What other meds is he on and what medical problems does he have? Link to comment Share on other sites More sharing options...
mdebord Posted January 21, 2014 Author Share Posted January 21, 2014 Trouble breathing at rest or w exertion? HA, blurred vision, diaphoresis, AMS? Does he know what his BP usually runs and did he take lisonopril today? What other meds is he on and what medical problems does he have? Very good! Dyspnea only with coughing, denies the other acute symptoms (including chest pain). These are important, and usually what I ask first. If the patient is unstable, EMS gets called before we go any further! Patient is very vague with me about BP, says it's been "high," but won't quantify; did not take lisinopril today. No other meds or problems. Two other pertinent negatives: no asthma and a non-smoker. Okay, let's move on to the physical. What do you examine, what are you looking for? Link to comment Share on other sites More sharing options...
winterallsummer Posted January 22, 2014 Share Posted January 22, 2014 Well biggest red flag is 110 diastolic although in a chronic hypertensive this may not be emergent from what I understand. Nevertheless look for papilledema. Also check for unequal BP per UEs or abnormal pulse. Unlikely dx would be a pheo but he would have had past episodes per history. Check pupils. Per infection would do HEENT eg dull TMs, pharynx injection. Lungs for any foci of infxn or aign of PTX. Heart for dysthymia or murmur. Skin for rash. Legs for edema. Generalized abdomen exam. Look for adenopathy at neck. Link to comment Share on other sites More sharing options...
mdebord Posted January 22, 2014 Author Share Posted January 22, 2014 Good, although not all necessary. As this pt has fever, vitals are likely so elevated secondary to acute illness. Here's what I got: Const: well nourished, no acute distress, appears ill HEENT: PERRL, conjunctiva clear, turbinates benign, no nasal drainage, oral mucosa moist, pharynx WNL, TMs benign. No frontal or maxillary sinus tenderness. Neck: No LAD. CV: tachy, regular rhythm; pulses 2+ and symmetric; no peripheral edema Resp: CTAB, although breath sounds diffusely diminished due to pt not breathing deeply. I got the pulse ox at this point: 96% on RA. Abd: nl bowel sounds, no tenderness Any tests you'd like to run? Link to comment Share on other sites More sharing options...
AREID Posted January 22, 2014 Share Posted January 22, 2014 U/A, EKG, CXR? Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
mdebord Posted January 22, 2014 Author Share Posted January 22, 2014 Previously well man with a cough; what would a UA show you? EKG shows sinus tach, otherwise nl. CXR would be excellent but we do not have the capability in office. Anything else? Link to comment Share on other sites More sharing options...
Will352ns Posted January 22, 2014 Share Posted January 22, 2014 I will assume the rest of the ROS is neg....no neck pain, HA, rashes, N/V/D/constipation....? What are the OTC meds? pseudoephedrine...if so how much? A CBC would be nice. You keep mentioning "South Texas"....not sure where you are going there. Environmental or endemic disease? Why is he not taking normal breaths? Pain? Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 22, 2014 Moderator Share Posted January 22, 2014 egophony ? bronchophony? exposures? (mold, mildew, fungi (oil field)) std hx (initial hiv infection) sinus tenderness... okay, gotta pay attention to where I am driving to the next house call.... Link to comment Share on other sites More sharing options...
AREID Posted January 22, 2014 Share Posted January 22, 2014 Urine could show hematuria/proteinuria in wegners.. wells score? Rapid influenza test? Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
mdebord Posted January 23, 2014 Author Share Posted January 23, 2014 Alright! Now we're getting some good stuff. I mentioned the South Texas oilfield work because the patient did - It's not necessarily relevant, but that's up to you (like it was to me initially) to consider. As far as exposures go, the most common one there is poisonous gases. Of course UA COULD show Wegener's, but is that really a likely diagnosis here? Remember we don't want to order a lot of testing if we don't have to. The rest of the ROS is negative (I'm sorry, I should have stated that). Likewise, the rest of the PE is negative. Deep breaths limited by pain. CBC again not done because I don't have STAT labs, but definitely a good idea. OTC meds include phenylephrine per usual instructions but only once the night before. Wells score is 1.5 (for the HR only). Rapid flu is POSITIVE! So, let's move on to treatment plan. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 23, 2014 Moderator Share Posted January 23, 2014 bonus question: if the pt can not tolerate the standard treatment regimen what are some alternatives( found this out last week, will describe why as thread continues). Link to comment Share on other sites More sharing options...
Will352ns Posted January 23, 2014 Share Posted January 23, 2014 Alrighty then, flu it is. I still think basic so I will address problems as in order of importance. First, fix the V/S as much as I can. T: 102 HR: 128 BP: 170/110 I will go stray from the others and state that I am actually more impressed with the HR than I am with the BP. Although the HR is most likely being caused by the fever, it does seem a bit high even for a febrile patient (although certainly not unheard of). Give the patient whatever antipyretic you prefer; I am prior military, so I would go with good old Motrin. Hopefully this is will fix the temp and HR....maybe ease the BP a bit. Re-check V/S before pt D/C. About that BP....here is my problem, this might actually be this guys norm and could very well be a distracting V/S. Make sure the guy has enough of his ACEI and tell him to F/U with his PCP or with me if he is going to be in town. Reinforce schedule before D/C. Now the root of the problem. Flu. Traditionally, we could just treat symptomatically, or we could add Tamiflu to the tradition Tx's. I am actually not sure what is normally done in the civilian world....guidelines are a little vague. Open for discussion. Motrin/Tylenol for fevers Albuterol for cough/Codeine at night Decongestants Hydrate! (solution to pollution is dilution) What am I missing? Any zebras? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 23, 2014 Moderator Share Posted January 23, 2014 Will- Influenza classically can cause high fevers. also you can get 10 points of pulse increase for every degree of temp elevation over 98.6 so 101.6 or thereabouts would give you 130(considering the top of the nl range to be 100). consider also that someone sick may not be able to keep down their regular meds which control an arrhythmia. I had a guy 2 weeks ago with afib and gastroenteritis who was very dry. after 3 L of IV fluid and correcting his temp his pulse was still 135. a dose of IV cardizem brought it back down to the normal range. now, anyone want to try my bonus question? Link to comment Share on other sites More sharing options...
Will352ns Posted January 23, 2014 Share Posted January 23, 2014 I was thinking about maybe IV hydration, but the BP was making me think conservative. My issue with the HR was really if it was from the fever alone or was the guy dry....both? I went with what was presented and assumed he wasn't dry. I have to study some pharm at the moment, so I will see if I can figure out the bonus later. Unless someone else does. Link to comment Share on other sites More sharing options...
AREID Posted January 23, 2014 Share Posted January 23, 2014 Treatment included oseltamivir or zanamivir. So many people forget it's not just supportive care. Treatment exists lol Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
AREID Posted January 23, 2014 Share Posted January 23, 2014 Emed...alternative treatment options secondary to N/V? Promethazine supp? Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
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