Kiwiology Posted October 30, 2011 Share Posted October 30, 2011 (edited) I reckon this bloke has pneumonia It would seem we need to identify which bacteria is causing it How exactly we do that I am not sure Edited October 30, 2011 by kiwimedic Link to comment Share on other sites More sharing options...
DwayneEMTP Posted October 30, 2011 Share Posted October 30, 2011 ...All I know about tetracycline antibiotics is that the Defense Force uses them and not to give somebody who is on them methoxyflurane because it can cause a significant rise in fluoride ions.... Exactly the reason that I always chose to use them in tandem. Cavities being a huge problem in Afg...I like to think of that as 'out of the box' thinking.... What an amazing group of people for a scenario. This is possibly one of the best learning threads I've seen here in years... And we even have a girl in here swinging with the boys and getting hits? What is this world coming to... Cool as hell... Dwayne Link to comment Share on other sites More sharing options...
ERDoc Posted October 30, 2011 Share Posted October 30, 2011 Any exposure to animals or sandflies? Any lymphadenopathy on either cxr? Link to comment Share on other sites More sharing options...
tniuqs Posted October 30, 2011 Share Posted October 30, 2011 Do we have good evidence to begin anti microbial therapy however? Its looking like that now. APAP BTW what is this abbreviation ? A new chest X-ray shows the development of a small right sided pleural effusion. Great thread ... I had a similar patient x 4 days ago but no Cxray capabilities, bummer ! ... is their any other abnormal observations on Cxray ? I would be hesitant to start throwing broad spectrum's / i.e .. the shotgun approach at this patient, the effusion could be a result of bacterial infection likely and compounded by a malignancy, CHF, pancreatic or TB ++ Are C + S available in 'this" clinic although that said sitting around for a couple of days not the best option, in remote of rural I suspect I would be looking for a ride to a real hospital at this juncture, he could become a threat to the entire operation if he is a community acquired Pneumonia . cheers got to go do that safety meeting thang. What about Sputum ? color, volume, consistency ? Link to comment Share on other sites More sharing options...
DFIB Posted October 30, 2011 Share Posted October 30, 2011 So we don’t have a history of CHF but could his non compliance of Toprol be messing with his ticker and be a factor in the general malaise and headache although probably not related to the fever. I think this could be significant. Does he have any history of asthma? Toprol XL is contraindicated in asthmatics. Does he have edema in any of his extremities? Unilateral, Bilateral? Would a diuretic benefit our patient? What has he been eating? I mean could he malnourished and have a low serum protein level? He is anemic and Iron is essential to myoglobin production. If he is only eating the crackers out of his MREs he might be malnourished. Does he take aspirin? How would I know if the effusion is secondary to a thrombus? Is a PTT available? I suppose we would change the antibiotic to something of a wider spectrum and more specific to gram positive bacteria. Possibly a diuretic but I am not sure, I would also supplement his diet with a multivitamin + Fe and ASA 81mg once daily. Recommend that he eat a balanced diet (if such a thing is possible over there). I would also stresss the importance of compliance to Toprol XL. Link to comment Share on other sites More sharing options...
Kiwiology Posted October 30, 2011 Share Posted October 30, 2011 (edited) What an amazing group of people for a scenario ... Aw hot shit, I knew all this knowledge floating round in my head would make me look good one day Without any overt signs of CHF I don't think diuretic is going to help this bloke. His effusion could be from something lymphatic but I don't recall any lymphomegaly? Consultant Physician Geppetto would be proud, I am starting to think on a higher clinical level, bloody EMTCity, best professional development resource hands down. Wait, wasn't Geppetto a sexo? I dno ... I reckon he has a LRTI specifically bacterial pneumonia, which bacteria I am not sure, he could have one of 400 other things too ... blasted nonspecific presentations! Could we take some of the effusion fluid for culture or something? Edited October 30, 2011 by kiwimedic Link to comment Share on other sites More sharing options...
chbare Posted October 30, 2011 Author Share Posted October 30, 2011 Great discussion everybody. At this point I will tell you what we did and what occurred following our interventions: The physical exam this time is essentially unchanged. There are no other overt abnormalities on the X-ray. We went with a possible diagnosis of some sort of bacterial infection within the thorax: Pneumonia, Pneumonitis, Pleurisy and so on. The patient was given 1,000 mg of Tylenol and we started a peripheral IV. We gave the patient 2.5 mg of nebulised albuterol/salbutamol and gave the patient a 1,000 mg dose of ceftriaxone along with 1,000 ml of 0.9% saline IV. The patient improved dramatically a couple of hours later. We decided to let the patient go "home" on a rest profile with Tylenol and push fluids. We also loaded him with Zithromax 2,000 mg and discussed adding Levaquin in the event a resistant bacteria such as S. pneumoniae was the cause. Ultimately, we did not go with Levaquin. The patient was also ordered to follow up every 24 hours. If the patient was able to cough up any sputum, we would alos obtain a sample for a Gram stain + C&S. One of our physicians was involved with the case as well. After 24 hours, all appeared well. Then, the patient returned to the clinic at about the 36 hour mark with the exact same signs and symptoms. What to do? Link to comment Share on other sites More sharing options...
ERDoc Posted October 30, 2011 Share Posted October 30, 2011 Repeat cxr, blood cx X2, get ready to send out for treatment in civilization. Link to comment Share on other sites More sharing options...
DFIB Posted October 30, 2011 Share Posted October 30, 2011 (edited) Who was the wise man that said "I only know that I know nothing"? Edited October 30, 2011 by DFIB Link to comment Share on other sites More sharing options...
chbare Posted October 30, 2011 Author Share Posted October 30, 2011 Repeat cxr, blood cx X2, get ready to send out for treatment in civilization. Actually, that's basically what I did. The patient was evacuated to a military hospital. However, let's say you feel like taking the new microscope for a diagnostic adventure. You do a blood smear and note the following: Link to comment Share on other sites More sharing options...
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