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ender18d
12-09-2013, 14:08
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.

PedOncoDoc
12-09-2013, 14:44
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?

Brush Okie
12-09-2013, 14:49
When did it start?
Is it getting worse?
Any pain?
any SOB?
Lung sounds?
Cough? If so productive?
Anything making it better or worse?
Blood in stools?
Blood in urine?
Pain when urinate?
What color is urine?
Past Medical history?
On any meds? If so what?
Are you taking your malaria meds?
What does his skin look and feel like?
Abd tenderness or pain?
Diarrhea or constipation?
What does nose, ears and throat look like?
Has he been bitten by anything? (ie infected beaver)
Any rash or sores?
Swelling anywhere?
How has his appetite been?
Has he eaten any local food or drank from unclean water source (streams rivers etc)

I am sure I am missing something.

ender18d
12-09-2013, 14:56
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.

ender18d
12-09-2013, 15:14
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.

PedOncoDoc
12-09-2013, 15:26
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?

ender18d
12-09-2013, 15:28
Has he noticed any jaundice or yellowing of the eyes?

Negative.

Any ankle/extremity swelling?

Negative.

Feeling bloated? Abdominal pain?

Negative.

PedOncoDoc
12-09-2013, 15:36
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?

MR2
12-09-2013, 15:57
First things first... Is he a leg?

Trapper John
12-09-2013, 16:00
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?

ender18d
12-09-2013, 16:08
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.

PedOncoDoc
12-09-2013, 16:15
Radiating peticheal hemorrhaging? Rings a bell in the ol' noggin. Need to search on that one, may be important diagnostic clue?

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.)].

Trapper John
12-09-2013, 16:37
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)

PedOncoDoc
12-09-2013, 16:56
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.

x SF med
12-09-2013, 17:11
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)

Trapper John
12-09-2013, 17:17
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

x SF med
12-09-2013, 17:33
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...)

ender18d
12-09-2013, 17:43
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.

Trapper John
12-10-2013, 07:44
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.

PedOncoDoc
12-10-2013, 08:46
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?

ender18d
12-10-2013, 09:01
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....

Trapper John
12-10-2013, 09:17
***

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

Uh Oh!;)

PedOncoDoc
12-10-2013, 09:59
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....

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.

ender18d
12-10-2013, 10:05
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?

PedOncoDoc
12-10-2013, 10:24
This is where my experience/training is limited, so I appreciate hearing the decisions and reasoning of those with field experience in these cases.

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

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.

Want to see your next two patients?

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

ender18d
12-10-2013, 10:27
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?

PedOncoDoc
12-10-2013, 10:30
Your second patient complains of "cold-like" symptoms. And since it will be the first question, no, this one doesn't have a rash. :D Questions?

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

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

ender18d
12-10-2013, 10:31
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

PedOncoDoc
12-10-2013, 10:32
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.

ender18d
12-10-2013, 10:35
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.

Trapper John
12-10-2013, 11:32
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?

ender18d
12-10-2013, 11:41
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.

Trapper John
12-10-2013, 11:48
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?

ender18d
12-10-2013, 11:52
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.

x SF med
12-10-2013, 12:27
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.


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:

Trapper John
12-10-2013, 12:46
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?

Brush Okie
12-10-2013, 15:32
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?


Some type of infection is spreading fast. I don't know what, but I am going to request a shitload of antibiotics. Start every swinging dick on Zithromax, Evac the folks already sick, request IV antibiotics ie Rocephin for everyone in case it is needed and lock down the base, no one in our out. I am also going to send a blood draw culture and sensitivity with the evac folks. Also request additional medical personnel come to help.

I am also going to check everyone on base then clean everything on base with bleach solution and or some other type of disinfectant.

To be honest I am way beyond my training and knowledge here. I am really hoping it isnt some type of fungal infection in that case we would all be screwed.

Plan 2

Send all the sick troops with additional firepower to nearest village to infect the local insurgents then start treatment plan above.

ender18d
12-10-2013, 15:46
Some type of infection is spreading fast. I don't know what, but I am going to request a shitload of antibiotics. Start every swinging dick on Zithromax, Evac the folks already sick, request IV antibiotics ie Rocephin for everyone in case it is needed and lock down the base, no one in our out. I am also going to send a blood draw culture and sensitivity with the evac folks. Also request additional medical personnel come to help.

I am also going to check everyone on base then clean everything on base with bleach solution and or some other type of disinfectant.

To be honest I am way beyond my training and knowledge here. I am really hoping it isnt some type of fungal infection in that case we would all be screwed.

Plan 2

Send all the sick troops with additional firepower to nearest village to infect the local insurgents then start treatment plan above.

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?

Brush Okie
12-10-2013, 15:55
What do we know so far?

P
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?

I cant make a differential. I am worried about encephalitis but this is way past my training. Also thinking about bubonic plague with the environmental conditions here. Typhoid perhaps?

As for the altered LOC how is it presenting? When I do a neuro check any paralysis, relflxes ok? Stiff neck or back pain? Pupils? Are their eyes tracking? Weakness or facial drooping? Short term memory loss? Long term memory loss?

ender18d
12-10-2013, 15:56
I cant make a differential. I am worried about encephalitis but this is way past my training. Also thinking about bubonic plague with the environmental conditions here. Typhoid perhaps?

As for the altered LOC how is it presenting? When I do a neuro check any paralysis, relflxes ok? Stiff neck or back pain? Pupils? Are their eyes tracking? Weakness or facial drooping? Short term memory loss? Long term memory loss?

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.

Brush Okie
12-10-2013, 16:02
Exam positive for nuchal rigidity! :lifter

Ok encephalitis/meningitis of some type. Question is bacterial, viral or the ever so rare fungal.

Same treatment plan as above but add an antiviral drug. Not sure what one would be best. The hope like hell it is not fungal.

PedOncoDoc
12-10-2013, 16:09
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?

We did ask about headache - you stated when presenting the next 2 patients, "will give you all of the questions you have already asked" so I didn't repeat it.

The headache, fever and purpura raises concern a neisseria meningiditis outbreak - any nuchal rigidity noted in patient 2 and 3?

I would assume all troops have been vaccinated and have responded appropriately to the vaccine, however, so this is lower on my differential.

My top 2 bugs are:
Salmonella typhi
Neisseria meningiditis

Both can be spread to close contacts when sanitation is substandard and can cause the constellation of findings in these troops.

ender18d
12-10-2013, 16:24
So as you think of your treatment and epidemic management plans for Trapper John, here are some of the clinical pearls about neisseria meningitidis infection:

n. meningitidis should scare the heck out of you if you are a health care provider. Many times, this is the patient who just seems to have some sort of a cold, but RAPIDLY progresses to much more severe illness and death if not treated. Patients may go from initial presentation to death in hours. This is also a fairly contagious infectious agent, spread by close contact.

There are three basic manifestations of meningococcal infection:
-Meningitis (patient 2)
-Meningitis with accompanying meningococcemia (patient 3)
-Meningococcemia without clinical evidence of meningitis (patient 1... although the faint headache may point to the start of meningitis)

The three classic signs of meningitis are:
-Fever
-Altered Mental Status
-Nuchal Rigidity

Meningococcal meningitis adds a fourth "classic" sign which is often the first sign of serious illness in these patients:
-Non-blanching petichiae/purpura

Additional worrisome signs may include mottling of skin, leg pain, and cold hands/feet.

You may not get all of these signs/symptoms in all patients!

The clinical standard for treatment is to begin ABX therapy within 30min of considering the diagnosis.

And for those of you who are thinking: "but aren't soldiers immunized for this?" The current vaccine covers n. meningitidis types A, C, Y, and W-135. Type B accounts for 25% of infections, and only VERY recently has a vaccine become available (google "princeton meningitis vaccine" for the story) .

I'll let Trapper John take it from here!

Brush Okie
12-10-2013, 16:25
We did ask about headache - you stated when presenting the next 2 patients, "will give you all of the questions you have already asked" so I didn't repeat it.

The headache, fever and purpura raises concern a neisseria meningiditis outbreak - any nuchal rigidity noted in patient 2 and 3?

I would assume all troops have been vaccinated and have responded appropriately to the vaccine, however, so this is lower on my differential.

My top 2 bugs are:
Salmonella typhi
Neisseria meningiditis

Both can be spread to close contacts when sanitation is substandard and can cause the constellation of findings in these troops.

What antibiotic would you recommend?

How do you differentiate between bacterial, viral and fungal? I am guessing the rash.

Would you place everyone or at least some of the troops on prophylactic antibiotics?

PedOncoDoc
12-10-2013, 16:35
What antibiotic would you recommend?

How do you differentiate between bacterial, viral and fungal? I am guessing the rash.

Would you place everyone or at least some of the troops on prophylactic antibiotics?

Treatment of choice for these guys (in light of the newly noted nuchal rigidity) is parenteral ceftriaxone. The purpura and nuchal rigidity is the telltale sign of meningococcemia.

Viral meningitis tends to be more mild in immunocompetent hosts and does not classically present with petechiae/purpura.

Fungal meningiditis would be a red flag of a much more serious problem, such as advanced immunocompromised state (i.e. AIDS), or innoculating the CSF with tainted medications (like the recent outbreak with steroid injections).

Both fungal and viral meningitis tend to be more slowly progressive.

Prophylactic treatment would depend on availability of sufficient antibiotics - I would certainly treat the symptomatic patients and have to determine the need for prophylaxis for close contacts depending on availability of antibiotics and nature of contact with the index cases.

Sdiver
12-10-2013, 16:40
Gents,
I have no dog in this fight so I'm staying out of it, but I'm LEARNING a great deal.

I'm unfamiliar with the AO so that is one reason I've stayed out of this, but one thing did initially pop in my head when Pt. #1 presented and then #2 and #3 showed up, as Brush as asked/pointed out, what are the different mold(s) that you deal with there?

I know this is probably not along the lines that Trapper is going, but could the mold(s), if any present, help facilitate the S&S seen?

Brush Okie
12-10-2013, 16:45
Gents,
I have no dog in this fight so I'm staying out of it, but I'm LEARNING a great deal.

I'm unfamiliar with the AO so that is one reason I've stayed out of this, but one thing did initially pop in my head when Pt. #1 presented and then #2 and #3 showed up, as Brush as asked/pointed out, what are the different mold(s) that you deal with there?

I know this is probably not along the lines that Trapper is going, but could the mold(s), if any present, help facilitate the S&S seen?

hey you know as much or more than I do. I'm just guessing here. It is fun to challenge myself and I am learning a lot here. BTW I was also thinking of something spreading through rodents and their fleas along the line of bubonic plague or hunta virus (my spelling sucks)

Jump in I learn more from my mistakes than I do my success.

Trapper John
12-10-2013, 17:37
OK, so we have an early stage bacterial meningitis outbreak and this is going to escalate rapidly. Immediately start Antibiotic therapy. Two most likely causative pathogens - N. meningitidis (Gram neg) and S. pneumoniae (Gram pos). S. pneumoniae is most common in young adults. Rx: 3rd generation cephalosporin (Ceftriaxone or Cefotaxime 2g IV bid). Because of the high probability of S. pneumoniae as the causative agent and S. pneumoniae can be beta-lactamase producers, Vancomycin is indicated (20 mg/kg IV bid).

As I posted earlier-

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 supplies do you request? (A personal supply of Dexedrine might not be a bad idea 'cause you are not going to get much sleep for a while :D)
Do you consider prophylactic antibiotics for everyone?
What is the longer term containment/treatment plan?
What procedures do you implement to get ahead of this outbreak?
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?

ender18d
12-10-2013, 17:49
FWIW, I apologize if I threw anyone by not pointing out that the headache was more prominent in cases 2 & 3! I should have been a little more clear in discussing the differences between the first case and the later cases.

Brush Okie
12-10-2013, 18:24
OK, so we have an early stage bacterial meningitis outbreak and this is going to escalate rapidly. Immediately start Antibiotic therapy. Two most likely causative pathogens - N. meningitidis (Gram neg) and S. pneumoniae (Gram pos). S. pneumoniae is most common in young adults. Rx: 3rd generation cephalosporin (Ceftriaxone or Cefotaxime 2g IV bid). Because of the high probability of S. pneumoniae as the causative agent and S. pneumoniae can be beta-lactamase producers, Vancomycin is indicated (20 mg/kg IV bid).

As I posted earlier-

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 supplies do you request? (A personal supply of Dexedrine might not be a bad idea 'cause you are not going to get much sleep for a while :D)
Do you consider prophylactic antibiotics for everyone?
What is the longer term containment/treatment plan?
What procedures do you implement to get ahead of this outbreak?
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?

Yes on the prophylactic antibiotics. Not an easy decision but because of remoteness and tactical situation I say yes.

Long term you need to clean EVERYTHING with 10% bleach solution no older than 24 hours old mixed. Several other commercial will work. Also you need to pin down where it came from ie rodents etc.

Procedures ahead of this? exam EVERYONE starting with the PFC's team, then squad, Co etc. screen for any problems.

TS/TL recommend if they have roving patrols hand pick the men that go out and screen for problems before hand. Also avoid contact with locals if possible.Keep patrols short ie no longer then 8 hrs keep as short as possible.

NG co same as team leader/TS also put together decon detail. Get troops rested no patrols unless necessary and keep short.

You can loose troops due to illness before the first shot is fired. Also it affects the moral of the troops and reduce their effectiveness both mentally and physically. The side effects of medications and reactions to the medications have to be looked at. EVERYONE gets a hep lock, a class on allergic reaction to meds and decon procedures along with what to look for in themselves or their buddy. Also stock up on not only antibiotics, with an alternative, but eppi, benedryl and some type of med to reduce swelling. There are several options here.

Interestingly I remember reading until modern times more soldiers died in combat from disease than from combat its self. I think WWII was the first time that was not true. I think we take our medical care today for granted sometimes.

NurseTim
12-10-2013, 21:26
What about 1Gm rocephin IM bid, sucks but less exposure and more mobile force. But vanc is only good po for cdiff so they need the IV anyway. Or maybe Subq? You can leave a Subq button in for days. Connect and disconnect easily. Just an idea.

Trapper John
12-11-2013, 09:25
What about 1Gm rocephin IM bid, sucks but less exposure and more mobile force. But vanc is only good po for cdiff so they need the IV anyway. Or maybe Subq? You can leave a Subq button in for days. Connect and disconnect easily. Just an idea.

Good ideas, but you have 3 different groups to deal with: (1) 3 patients with active disease. No question these 3 need IV Rocephin and Vancomycin; (2) an exposed population and lets say that is the 20-30 guys that slept in crowded quarters when the AC was out; and (3) the rest of the NG company that are possible exposures. Brush Okie mentioned decontamination procedures. What about quarantine proceedures: Who? How? I agree with the reticence for prophylactic antibiotics, but in this case it would be warranted. Who should receive prophylactic antibiotics? What? Dosage and dosing regimen?

The tactical situation has dramatically changed now. The NG company has just, in effect, sustained 20%-30% casualties and is no longer an effective combat ready unit. The likelihood of a major engagement with an equivalent sized enemy force is imminent. The NG CO is not going to like this assessment. He may be in denial when you inform him of this ugly fact. How do respond to that possibility?

Up to now your Team has just been co-located at the FOB with the NG company. Does this situation change that dynamic? Remember your an Special Forces A-Team. How can your Team change the dynamic and avert a pending disaster?

No one has mentioned the Junior medic on the Team. What should he be doing?

I realize that this is a medical thread and this started out as a medical scenario, but the situations we face as SF medics and the problems we have to solve when on an operational mission rarely, if ever, compartmentalize into problems that are solely medical in nature.

No one has mentioned anything related to stockpiling medical supplies that would be useful when there are combat casualties. Your supplies were sufficient for your Team. That is no longer the situation is it?

Brush Okie
12-11-2013, 10:03
Good ideas, but you have 3 different groups to deal with: (1) 3 patients with active disease. No question these 3 need IV Rocephin and Vancomycin; (2) an exposed population and lets say that is the 20-30 guys that slept in crowded quarters when the AC was out; and (3) the rest of the NG company that are possible exposures. Brush Okie mentioned decontamination procedures. What about quarantine proceedures: Who? How? I agree with the reticence for prophylactic antibiotics, but in this case it would be warranted. Who should receive prophylactic antibiotics? What? Dosage and dosing regimen?

The tactical situation has dramatically changed now. The NG company has just, in effect, sustained 20%-30% casualties and is no longer an effective combat ready unit. The likelihood of a major engagement with an equivalent sized enemy force is imminent. The NG CO is not going to like this assessment. He may be in denial when you inform him of this ugly fact. How do respond to that possibility?

Up to now your Team has just been co-located at the FOB with the NG company. Does this situation change that dynamic? Remember your an Special Forces A-Team. How can your Team change the dynamic and avert a pending disaster?

EDIT: also I would request a medical team flown out ie MD and nurses to help. I know it probably would not happen but if you don't ask........

No one has mentioned the Junior medic on the Team. What should he be doing?

I realize that this is a medical thread and this started out as a medical scenario, but the situations we face as SF medics and the problems we have to solve when on an operational mission rarely, if ever, compartmentalize into problems that are solely medical in nature.

No one has mentioned anything related to stockpiling medical supplies that would be useful when there are combat casualties. Your supplies were sufficient for your Team. That is no longer the situation is it?


The jr team medic as well as the NG medics would be drafted. In fact I would draft a couple of 11Bs as well and do a quick train up on some basic med administration.

As for stockpiling for the impeding combat I would have had provisions for that before this popped its head up assuming the NG unit would NOT be up to speed on medical supplies.

As for quarantine procedures guess we just designated our QRF in case we were going to get over ran.

If the NG co was in denial I would have our A-team CO have a come to Jesus meeting with him. No time to screw around here. Medical can over ride CO orders in some things unless things have changed.

As for the team averting disaster to late you are in it and exposed like everyone else. You might be able to call in some help or go out and attack the the bad guys before they hit you. (my first choice no matter what) but with all the medical issues etc you are probably needed at the FOB. The TS might send out a small recon team to call in air assets to tear up and delay the opposition force but that is a situation to be look at at the time. It would be better to send out an ambush force or better yet full assault before hand, but not going to happen.

miclo18d
12-11-2013, 19:16
Well sure as sugar you have been exposed. If the jr or sr is the other medic, you segregate him and the team members not exposed. Get them off the base. They can conduct patrols in relation to finding and trying to fix this Taliban element before it attacks the compound and you're fighting with a sick NG company.

Quarantine the 30 exposed in the tight element and treat with IV Gorillacilli (I took cefoxitan with me on all my deployments but only like 25 viles, that's enough for combat wounds but would only last for about 8 hours with this problem. Make sure you have your mannitol handy (unless there is something better now). Separate the platoons and have platoon medics monitor closely. No contact between platoons. Emphasize the importance of this platoon quarantine. Put the quarantine guys back in the building and make this your home for the next week. The rest of the NG guys go on the perimeter and/or local patrols.

No way you're going to treat an entire 120 man inf company (plus SF team with ANA) prophylacticly. There won't be enough drugs in country but I would order them up just in case. Order up a doctor and/or pa and the med sustainment officer ( I think those guys do PM and infectious disease stuff). Order up PPE masks for everyone in the camp. You might look gay but you'll be able to fight when the time comes.

Trapper John
12-12-2013, 08:57
Well sure as sugar you have been exposed. If the jr or sr is the other medic, you segregate him and the team members not exposed. Get them off the base. They can conduct patrols in relation to finding and trying to fix this Taliban element before it attacks the compound and you're fighting with a sick NG company.

Quarantine the 30 exposed in the tight element and treat with IV Gorillacilli (I took cefoxitan with me on all my deployments but only like 25 viles, that's enough for combat wounds but would only last for about 8 hours with this problem. Make sure you have your mannitol handy (unless there is something better now). Separate the platoons and have platoon medics monitor closely. No contact between platoons. Emphasize the importance of this platoon quarantine. Put the quarantine guys back in the building and make this your home for the next week. The rest of the NG guys go on the perimeter and/or local patrols.

No way you're going to treat an entire 120 man inf company (plus SF team with ANA) prophylacticly. There won't be enough drugs in country but I would order them up just in case. Order up a doctor and/or pa and the med sustainment officer ( I think those guys do PM and infectious disease stuff). Order up PPE masks for everyone in the camp. You might look gay but you'll be able to fight when the time comes.

You've done this before haven't ya? :lifter

Get them off the base. They can conduct patrols in relation to finding and trying to fix this Taliban element before it attacks the compound and you're fighting with a sick NG company. IMO this is the most important thing to do given the situation.

Quarantine the 30 exposed in the tight element and treat with IV Gorillacilli[n] This is priority action #2 IMO.

Separate the platoons and have platoon medics monitor closely. No contact between platoons. Emphasize the importance of this platoon quarantine. Put the quarantine guys back in the building and make this your home for the next week. The rest of the NG guys go on the perimeter and/or local patrols.

That's #3.

Order up PPE masks for everyone in the camp. You might look gay but you'll be able to fight when the time comes.

And that's #4

Ladies and gentlemen you have just had a short tutorial on combat medicine SF style. What, XSFmedic, Ender18d, and Miclo18d have shown you are couple of key points that are emphasized in our training. (1) Limit your Hx and PE to a few key points (3-4). I had this Dx with Patient #1. (2) Speed is your friend - Act -don't second guess yourself. (3) Work with what you have, improvise if necessary. (4) SA is essential. Medical emergencies in a combat environment require decisions that take into account the tactical situation. Plan accordingly.

The actions implemented by Miclo18d would have averted a much a larger disaster IMO. It is very likely that the increased patrolling and your Team out of the FOB would have located the Taliban and dissuaded them from their present intention.

So, this raises another question in my mind. Does anyone think that the pending attack on the FOB and the emergence of bacterial meningitis in NG troops was a coincidence? With that question in mind, what would be some things that you would consider in the AAR?

I don't mean to extend this thread beyond it's usefulness in this forum, but that question just occurred to me as this scenario unfolded and I thought it might be an interesting discussion topic.

Brush Okie
12-12-2013, 09:23
Yo

Ladies and gentlemen you have just had a short tutorial on combat medicine SF style. What, XSFmedic, Ender18d, and Miclo18d have shown you are couple of key points that are emphasized in our training. (1) Limit your Hx and PE to a few key points (3-4). I had this Dx with Patient #1. (2) Speed is your friend - Act -don't second guess yourself. (3) Work with what you have, improvise if necessary. (4) SA is essential. Medical emergencies in a combat environment require decisions that take into account the tactical situation. Plan accordingly.

The actions implemented by Miclo18d would have averted a much a larger disaster IMO. It is very likely that the increased patrolling and your Team out of the FOB would have located the Taliban and dissuaded them from their present intention.

So, this raises another question in my mind. Does anyone think that the pending attack on the FOB and the emergence of bacterial meningitis in NG troops was a coincidence? With that question in mind, what would be some things that you would consider in the AAR?

I don't mean to extend this thread beyond it's usefulness in this forum, but that question just occurred to me as this scenario unfolded and I thought it might be an interesting discussion topic.

GREAT I learned a lot and not it has not gone beyond its usefulness. I got that solution ass backwards. DOH !

I assumed it was related from the get go. You need to try and ID how it got there ie water source etc?

When you quarantine the platoons how far away from each other and how is that accomplished on a FOB (other than patrolling) when security needs to be maintained? You are going to need more than one platoon to keep security at the FOB or do you cut back there and use your more aggressive patrolling to compensate?

What about auxiliary personnel ie commo folks etc that may be around but not exposed?

When it comes to quarantine procedures I know ZERO.

Anything else I should know?

miclo18d
12-12-2013, 22:31
Something to consider, especially for the line medics, is that my plan is really about common sense if you know what you're dealing with. How do you know what you're dealing with? You start with medical intelligence. You do IPB on illnesses in your AOR just like you would for enemy forces. What diseases are prevelant? What is your biggest threat to your smallest based on occurrence and danger (malaria, TB, TYPH, cholera, leishmaniasis, EEE, mgc, etc. what are S/Sx for each? Prophylaxis? Tx? Preventive Med for each or for all.

The first thing the 18Ds did when we got to a base, especially early on (02-03) was the PM plan for the base. Piss tubes, shit burning details, potable water sources, other water sources, showers, hygiene areas, food areas, etc. we had a platoon plus of 82d on the base with us and Afghan militia (before the ANA). They all had to know the PM plan. My second tour PM was much more established on many of the big bases but was still important. History has always been: more soldiers die from disease than combat. We are always 1 step out from that postulate! This scenario helps drive the point home.

Interestingly enough, I saw some afghans with TB and lots with leish. For US troops it was diarrhea and oddly enough on my team I had 2 cases of appendicitis within a month of each other. I always wondered if there is a slight chance of an endemic element to that. I'm sure lowered immune systems and strange diets and other things like that were causative, but 2 cases a month apart was like, scary!

Back to the scenario. Keep your plan simple. As Doc Illinois pointed out, MGC doesn't spread like Ebola, so your quarantine can be limited and simple, but use the PPE. We have a case here in my county in FL where an elementary aged kid died in 24 hours and they had his daycare closed for 1 day.

The plt segregation was so that you can monitor the platoons and if you see cases pop up you have limited the exposure to the other platoons. My general thought was that the platoons would be on the perimeter and you keep them there until the threat is reduced (enemy AND illness). Think 33-50% security in Ranger school. You have basically triaged the entire camp to expectant (probably exposed) to routine (unlikely exposed).

The team off the base keeps their exposure down and they're more likely to whip the living tar out of the enemy force than a battalion of NG (no offense meant here, just being realistic). SF teams roll with CCT, just a fact of life here.

In my other post I did forget to order up supportive care measures in case any of your exposed guys go south on you. You're going to need some ACLS stuff just in case.

I'll step back and let some others throw in some pointers.

Koldsteel
12-19-2013, 20:38
That was a very interesting "case study". Very thought provoking. Thanks for the lesson.

Trapper John
12-21-2013, 09:13
Anyone catch the last episode of NCIS on Tuesday 12/17? If not and you have cable that allows you to watch previous episodes, it would be interesting to watch in light of this thread.

See if you can pick up any medical discrepancies. Hint: Look for the slide showing the presumptive causative bacterium, later look for the picture of the rash, both of which were in the background while Gibbs and the team were discussing this outbreak. Then listen for the CDCs diagnosis towards the end of the episode.

Patriot007
12-21-2013, 09:20
Prophylaxis should be triaged to those closest in contact.

A single dose of cipro 500 mg PO is sufficient.

Those exposed to saliva or respiratory secretions are highest risk. If you manage an airway it is recommended to take a dose.