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)