chbare Posted June 8, 2009 Share Posted June 8, 2009 You are working by your lonesome in a remote clinic in Afgoochistan. You have access to labs; however, you need to justify your orders because your runner has to drive them into a lab that is at least an hour away via dangerous road. So, when you decide to put his life in danger, you had better convince him of the reason why you want to order or do something. Here goes: You are called to respond to a sick patient who is across the small camp where you are pulling medical support. Take it from here. Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted June 9, 2009 Share Posted June 9, 2009 Dude, first of all I wouldn't be in Afgoatastan I'd be on the job in that ad I saw online for medics in Ziare making the mint cash ... anyway - Where are we? i.e. out in the desert, down on the bayou, remote wilderness etc - What type of camp is this? - i.e. camping ground, vocational base site e.g where forrest workers or fishermen live - What sort of facilities do they have? e.g. water, food, toilet/cooking facilities; is the water clean, food can be cooked to adequate temp, store properly ... - Who lives there? what do they do for work, kind of like #2 above; i.e. could something on the job make them sick that they can bring back? - How do the people here live? do they all live in one big tent or something, you know, thinking infection control/isolation I'd rock on down with the usual (first in bag, monitor, O2) and for some reason something tells me taking the N95 would be wise I would speak to somebody first before seeing the patient to ascertain if he was vomiting or coughing up anything nasty; bleeding from the eyes etc; this is obviously a remote facility with what I'd take to be limited outside assistance and supplies; I don't want to contaminate myself in case this guy got ebola from some monkey out in the forrest or something. Usual crap, SAMPLE, vitals, ECG, primary and secondary survey, pertinent negatives .... Link to comment Share on other sites More sharing options...
chbare Posted June 9, 2009 Author Share Posted June 9, 2009 Dude, first of all I wouldn't be in Afgoatastan I'd be on the job in that ad I saw online for medics in Ziare making the mint cash ... anyway - Where are we? i.e. out in the desert, down on the bayou, remote wilderness etc High desert. In a valley between two mountain ranges with an elevation of 1800 meters. - What type of camp is this? - i.e. camping ground, vocational base site e.g where forrest workers or fishermen live Small fuel depot for military vehicles about two square kilometers in size. - What sort of facilities do they have? e.g. water, food, toilet/cooking facilities; is the water clean, food can be cooked to adequate temp, store properly ... Good facilities that adhere to western hygienic standards. - Who lives there? what do they do for work, kind of like #2 above; i.e. could something on the job make them sick that they can bring back? Mainly internationals from a variety of countries. Primary work is fuel management with a mix of hard labor and skilled labor positions. - How do the people here live? do they all live in one big tent or something, you know, thinking infection control/isolation Non skilled labor lives in small rooms of three people per room. Skilled workers live in individual berths. I'd rock on down with the usual (first in bag, monitor, O2) and for some reason something tells me taking the N95 would be wise I would speak to somebody first before seeing the patient to ascertain if he was vomiting or coughing up anything nasty; bleeding from the eyes etc; this is obviously a remote facility with what I'd take to be limited outside assistance and supplies; I don't want to contaminate myself in case this guy got ebola from some monkey out in the forrest or something. No cough, no bleeding, nausea without vomiting. Usual crap, SAMPLE, vitals, ECG, primary and secondary survey, pertinent negatives .... S: "I am weak and tired all the time, now my abdomen hurts." A: NKA M: None P: None L: 4 hours ago E: Generalized weakness and malaise over the past three months with abdominal pain times two days. Primary Survey: NAD Secondary Survey: NAD Ask for specific information. BP: 134/82 P: 90 RRR R: 21 NL SPO2: 95% RA T: 37 Celsius ECG: NSR Lead II without ectopy. Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted June 9, 2009 Share Posted June 9, 2009 - How is his physical condition; does he "look sick", yellow eyes, mottled skin, hair falling out etc - Has he been sick like this before? - If he has, is it better/worse than last time? What caused it last time, does he know? What made it go away? - What was he doing 3 mo. ago when he started to feel sick? Has he changed jobs i.e. could something there have made him sick etc? - Does anything make him feel better or worse? - Has he been toileting, eating, drinking the same as usual? Is he eating/drinking the same [food and water] as everybody else? - Is there anybody else sick? I'd like to check his bowel sounds, blood sugar, XII lead, pedal pulses and sensation and palpate abdo Link to comment Share on other sites More sharing options...
medibrat Posted June 9, 2009 Share Posted June 9, 2009 I would like to know where he normally lives, (what elevation), what his hobbies are (like is he climbing those said mountains?) Breath sounds? New SOB? Rogue cough producing phlegm? If so what kind? What is he doing specifically at the camp? (did we ask about allergies?) How much time is he spending around the fuel tanks with/without breathing apparatus? How long on site? (sorry if I'm repeating...it's late and I'm tired). Blood gases based on his answers to the questions and a blood sugar just to cover our bases. (I know the blood gases will be on the runner's list...just saying it would be good to take a sample to the lab) Brat Link to comment Share on other sites More sharing options...
chbare Posted June 9, 2009 Author Share Posted June 9, 2009 - How is his physical condition; does he "look sick", yellow eyes, mottled skin, hair falling out etc He looks a little pale without obvious acute distress. - Has he been sick like this before? Nope. - If he has, is it better/worse than last time? What caused it last time, does he know? What made it go away? N/A - What was he doing 3 mo. ago when he started to feel sick? Has he changed jobs i.e. could something there have made him sick etc? He does not remember anything specific. - Does anything make him feel better or worse? Nope. - Has he been toileting, eating, drinking the same as usual? Is he eating/drinking the same [food and water] as everybody else? He is eating a little less than usual due to the nausea, no changes in food types, and he is eating the same food as everybody else. No change in bowel or bladder habits. - Is there anybody else sick? You have treated two cases of acute diarrheal illness that responded well to Cipro PO, and did an I&D on an abscess that is responding well in the past month. I'd like to check his bowel sounds, blood sugar, XII lead, pedal pulses and sensation and palpate abdo How long are you going to listen? Bystanders keep asking why you are still on scene and if you will take him to the clinic. BGL is 105 mg/dl ~5.8 mmol/L, XII Lead is unavailable on scene, pedal pulses are intact with intact two point discrimination of sensation to the extremities, you note a strange swollen or enlarged sensation over the RUQ and the patient complains of tenderness to palpation of the RUQ. Take care, chbare. I would like to know where he normally lives, (what elevation) United States, East coast, near sea level. , what his hobbies are (like is he climbing those said mountains?) Spends time on computer, no hiking outside in Afgoochistan. Breath sounds? New SOB? Rogue cough producing phlegm? If so what kind? What is he doing specifically at the camp? (did we ask about allergies?) No dyspnea or cough, other question answered above. How much time is he spending around the fuel tanks with/without breathing apparatus? How long on site? (sorry if I'm repeating...it's late and I'm tired). Does not inhale fumes, works as a chemical engineer, testing fuel samples for quality control. Blood gases based on his answers to the questions and a blood sugar just to cover our bases. (I know the blood gases will be on the runner's list...just saying it would be good to take a sample to the lab) It will take at least an hour to get the sample to the lab, provided the traffic is good. In addition, you have no ABG kits. Would you still draw a sample and why? Brat Take care, chbare. Link to comment Share on other sites More sharing options...
medibrat Posted June 9, 2009 Share Posted June 9, 2009 I would take the sample. Maybe you can get something brought in in the way of ABG kit? As he lives near sea level, he may be suffering the effects of altitude sickness. Granted he isn't super high up, some people just don't have the tolerance for that kind of thing. I would settle for a pH...at least for now (I know I know, convince the runner). How long has he had the tenderness in the RUQ? What kind of family history? Cancer? He mentioned his bowel habits were normal...what is normal for him? Has he ever spent any time at an altitude like this before? And listening for bowel sounds...15-30s should do... Brat Link to comment Share on other sites More sharing options...
chbare Posted June 9, 2009 Author Share Posted June 9, 2009 I would take the sample. Maybe you can get something brought in in the way of ABG kit? As he lives near sea level, he may be suffering the effects of altitude sickness. Granted he isn't super high up, some people just don't have the tolerance for that kind of thing. I would settle for a pH...at least for now (I know I know, convince the runner). How long has he had the tenderness in the RUQ? What kind of family history? Cancer? He mentioned his bowel habits were normal...what is normal for him? Has he ever spent any time at an altitude like this before? And listening for bowel sounds...15-30s should do... Brat -Will you even have good results after an hour or more? Does blood taken for an ABG need to be placed in a special container or solution? -Think about the common findings associated with AMS, does this patient appear to be exhibiting the typical signs and symptoms? -He states his brother has had similar problems. -Will 15-30 seconds of listening provide you with an accurate assessment? What are "normal" bowel sounds? -He has been in country for about two years. Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted June 9, 2009 Share Posted June 9, 2009 Lets see .... RUQ contains gallblader, duodenum, right kidney, part of the liver, pancreas and colon (go Marieb's A&P) ... could be anything from a big ass hernia to a ruptured liver or something in between If it were altitude sickness or elevational hypoxia he sure isint showing it What did hsi brother have? What is the enlarged area like; does it pulse, change colour, move etc, what does palpating it produce; tendernedd, rigidity, pain etc? Link to comment Share on other sites More sharing options...
chbare Posted June 9, 2009 Author Share Posted June 9, 2009 It feels like a firm enlarged area just under the rib. You do not note any pulsatile masses or color changes. It is tender to palpate however. He is not sure what his brother has. States his brother has the same signs and symptoms and was being worked up the last time the patient talked with his brother. Take care, chbare. Link to comment Share on other sites More sharing options...
Recommended Posts