Case Study: Fever
The following is a case involving a patient with fever. As the case evolves, I will present assessment findings, lab results, and diagnostic results in the hope of eliciting responses on how we would approach the care of this patient. I'm extending this to multiple parts and it may drag on for weeks. Please feel free to post your thoughts. Be nice to each other though, this is a free forum of expression but always remember to adhere to this site's TOS. Though this case is based on a real patient case from start to end, some facts have been altered to protect privacy.The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in the hospital will be portrayed in an attempt to stimulate discussion on ways to approach his care not only from a nursing standpoint but also to understand the complexity of his care from the perspective of other disciplines who will be involved in his care particularly his medical management.
Rolando is a 19-year old college student who is the son of first generation immigrants from the Philippines. His parents are divorced and he lives with his mother in a coastal town close to where he attends college. He decided to skip the fall semester and live with his father in California's Central Valley region to help him run a small business.
He presented to his family physician with complaints of productive cough for about 7 days and feeling warm and flushed. He said his phlegm looked white in color and not excessive. He appeared healthy and has no medical history other than having had his appendix removed at age 14. The physician prescribed him Azithromycin and cautioned him to seek further care if his symptoms do not improve. He recalls having some tests done at the clinic but was not sure what they were.
Three days later, Rolando was feeling worse. He feels he is warmer and may have a high fever, is having chest discomfort with coughing while not expectorating any phlegm, and is experiencing joint pains and muscle aches. He has no appetite and is feeling weaker. His father was concerned and brought him to the nearest ED at a community hospital setting.
His social history is notable for being a college student with an undecided major. He admits to drinking alcohol occasionally but denies binge drinking, he does not smoke, he admits to having smoked marijuana in the past but not recently. He has a girlfriend in college and is sexually active.
You are Rolando's first contact in the ED as the triage nurse. After gathering the above, you obtained the following data:
Subjective complaints: "feeling warm, headache, little short of breath".
Temperature 39 C, HR 112, RR 32, BP 110/65, O2Sat 88% on room air
Neuro: AOx3, moving all extremities, pupils equal and reactive.
CV: EKG showed Sinus Tachycardia with no ST changes, no murmurs were heard on auscultation, no edema in extremities.
Pulm: Harsh breath sounds bilaterally but no accessory muscle use. He does breathe fast as you noted in his respiratory rate.
Skin: Warm and flushed, you notice what looks like a red rash in his bilateral shins.
Rest of the system exam is WNL.
How would you triage Rolando and what tests would you expect to be done in his case? What would you tell the next ED nurse who will take care of Rolando once you determined the appropriate ED treatment area he should be treated at? What concerns do you have about what is likely the reason for his symptoms?Last edit by Joe V on Jun 21, '13
Juan De La Cruz, RN, NP, CCRN-CSC is a board-certified Acute Care Nurse Practitioner working with a multidisciplinary team of intensivists in a number of multi-specialty Adult Critical Care Units at a university-affiliated tertiary medical center.
juan de la cruz has '20+' year(s) of experience and specializes in 'APRN, Adult Critical Care'. From 'California'; 46 Years Old; Joined Nov '06; Posts: 3,166; Likes: 3,261.3Jun 21, '13 by jadelpn, LPN, EMT-B GuideTriaged as emergent. Droplet precautions. Negative pressure room if indicated. MERS or SARS could be of concern--travelling, in a dorm in recent past.
On the monitor, CO monitor as well. ABG's. Next nurse should follow through with testing, and perhaps overnight observation necessary.
Curious how he got across country--and r/o a clot. PT, PTT, PTINR, BL leg ultrasound.
The rash could be strep in nature, also r/o strep--or be redness from a clot. I also would assess feet carefully--coastal town, bare feet, cuts turn MRSA, fungus has travelled stranger places....or could be a viral rash, indicitive of Fifth's disease.
I would do tick panel, to r/o tick disease. Liver panel and platlet count would help with this diagnosis.
I would also see if all of his childhood immunizations are UTD. HIB pneumonia could be a r/o as well.
What type of small business? Could he be exposed to toxins? Pollen, smog, does he have asthma?
He is a smoker, and a pot smoker. Fast track to COPD. I also would look at a tox screen. It is amazing what college kids smoke--from crack cocaine (ooops, "freebasing" cocaine) to meth, to their ADHD medications (or someone else's)--certainly presents with heightend body temperature (fever)high resp and heart rate
TB could also be a thought, but again, a r/o if clinically indicated.
Spontaneous Pneumo. (r/o with chest x-ray)
Sputum culture (although problematic due to Z-pak),
Tox screen and above rule outs. chest x-ray, CT of the chest, CBC, CMP, U/A with culture. Blood cultures (again, problematic with Z-pak)
Also, sexually trasmitted disease r/o's. HIV test.
Another interesting case study!2Jun 21, '13 by nrsang97Treat as emergent. Place in droplet precaution area. CXR, sputum sample, blood cultures, urine cultures. Maybe TB skin test (not sure if done in ER or wait till pt is on floor). Could possibly be allergy to zithromax with rash on shins. Rule out other causes with rash. CT chest. CBC w/ diff, CMP. ID consult. Pulmonary consult. Find out about any pets, what kind of business is he helping dad run? Ask about recent travels.3Jun 21, '13 by nrsang97Valley fever. Rash is consistent with this right?Last edit by nrsang97 on Jun 21, '131Jun 21, '13 by ScoobieSnackSarcoidosis? Possibly triggered by exposure to chemicals/dust at dads business.1Jun 21, '13 by katynurs22Emergent . Place on Droplet Precautions. Test: Chest X-ray , CBC, Blood cultures, sputum testing. Immunizations UTD? Joint & muscle aches & skin rash ???
Immunocompromised? HIV testing. Pulmonary consult. Pneumonia? But skin rash: need to r/o other causes like Psoriasis may appear on knees/shin area, ID consult. Gather more history , what type of work? when did rash appear?1Jun 21, '13 by jadelpn, LPN, EMT-B GuideI am still leaning toward tick borne illness as a "it COULD happen" diagnosis, but along those same lines, Flu swab?0Jun 22, '13 by juan de la cruz, MSN, RN, NP GuideRolando was appropriately triaged as emergent and was placed on Airborne Precautions in negative room pressure. The triage nurse appropriately secured an order for high flow nasal cannula. You are now his nurse in the ED.
Orders were for:
Respiratory Viral Panel, Sputum bacterial and gram stain, Legionella serum Ab, Pneumococcal serum Ag, Sputum for AFB. You were able to send all the appropriate specimens for these tests.
You were also asked to obtain ABG with lactate, CBC, Basic Metabolic Panel, and Coagulation Studies. Blood cultures were ordered. UA with tox screen was also ordered.
A portable CXR was obtained.
Available labs revealed:
Ph 7.40 pCO2 37 pO2 56 HCO2 22 BE 0 Sat 90% Lactate 2.5 on HF at 100% FiO2
WBC 18,000 Hgb 16 Hct 48 Plt 300 (+) Eosinophilia
Na: 140 K 4.0 Cl 100 CO2 22 BUN 15 Crea 0.5 Gluc 87
PT 14 INR 1.1 PTT 23
negative for UTI or drugs
Rolando is working a bit harder to breathe after 1 hour of being under your care. What would you anticipate next?Last edit by juan de la cruz on Jun 22, '133Jun 22, '13 by jadelpn, LPN, EMT-B GuideYikes! A flash pulmonary endema, (or he had a clot, and it is travelling.....) Chest xray looks like garbage--with a ton of infiltrate, however, could be due to portable chest. AP and lateral chest, chest ct needed.
WBC 18000--bacterial process, however, tick borne panel and flu swab shoud not be ruled out.
Duoneb, albeturol nebs (alternating) and think about if lasix is clinically indicated (what are the lung sounds at this point?)
Kidney function ok, IV levaquin, also solumedrol IV.
PCO2 a little high (?) so no increase in the oxygen to decrease drive....
Also, not entirely thrilled with the glucose #. Not awful, but it is glaring out at me--
OP, quick guide on acidosis/alkaline.....is this pertainant to this case?
Ok, as a complete aside, I am really pleased that this small town LPN is right on with some of my critical thinking...especially in a critical access hospital. This stuff is like gold.1Jun 22, '13 by blondy2061h, MSN, RNI'm curious on a BNP and a d dimer, but I'm definitely thinking infectious. I'd anticipate bipap being added if he's still working hard on hi-flow NC and possible prepare for intubation if things don't turn around. Jadelpn, why is a glucose of 87 glaring at you?1Jun 23, '13 by jadelpn, LPN, EMT-B GuideQuote from blondy2061hYoung, relatively usually/historicaly healthy guy 87 a tad on the low side., unless there's some fasting involved.I'm curious on a BNP and a d dimer, but I'm definitely thinking infectious. I'd anticipate bipap being added if he's still working hard on hi-flow NC and possible prepare for intubation if things don't turn around. Jadelpn, why is a glucose of 87 glaring at you?2Jun 23, '13 by Nurseboy1, MSN, NP87 is a completely normal blood glucose. Not at all a "tad on the low side". If he is fasting so much the better his fasting BG then would be completely normal
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