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Old 12-10-2013, 11:41   #31
ender18d
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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.
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Old 12-10-2013, 11:48   #32
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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?
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Old 12-10-2013, 11:52   #33
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Quote:
Originally Posted by Trapper John View Post
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.
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Old 12-10-2013, 12:27   #34
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Quote:
Originally Posted by ender18d View Post
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....
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Old 12-10-2013, 12:46   #35
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Quote:
Originally Posted by x SF med View Post
They have Kennel cough, or shipping fever... 'nuff said... take 'em to the 'tube' and make them go away... then board their medic....
Close but no cigar Bro. 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?
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Last edited by Trapper John; 12-10-2013 at 13:04. Reason: Expanded Scenario; grammar correction
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Old 12-10-2013, 15:46   #36
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Quote:
Originally Posted by Brush Okie View Post
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?
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Old 12-10-2013, 15:56   #37
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Quote:
Originally Posted by Brush Okie View Post
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!

Short term memory loss and lassitude as noted in PT two. PT 3 is becoming increasingly disoriented and does not know his location.
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Old 12-10-2013, 16:09   #38
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Quote:
Originally Posted by ender18d View Post
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.
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Old 12-10-2013, 16:24   #39
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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!
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Old 12-10-2013, 16:35   #40
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Quote:
Originally Posted by Brush Okie View Post
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.
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Old 12-10-2013, 16:40   #41
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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?
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Old 12-10-2013, 17:37   #42
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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 )
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?
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Old 12-10-2013, 17:49   #43
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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.
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Old 12-10-2013, 21:26   #44
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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.
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Old 12-11-2013, 09:25   #45
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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?
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