Case Study: Fever

Triaged 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!

Treat 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.

Valley fever. Rash is consistent with this right?

Edited Jun 21, 2013 by nrsang97

Sarcoidosis? Possibly triggered by exposure to chemicals/dust at dads business.

Emergent . 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?

I am still leaning toward tick borne illness as a "it COULD happen" diagnosis, but along those same lines, Flu swab?

Rolando 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:

ABG:

Ph 7.40 pCO2 37 pO2 56 HCO2 22 BE 0 Sat 90% Lactate 2.5 on HF at 100% FiO2

CBC:

WBC 18,000 Hgb 16 Hct 48 Plt 300 (+) Eosinophilia

BMP:

Na: 140 K 4.0 Cl 100 CO2 22 BUN 15 Crea 0.5 Gluc 87

Coags:

PT 14 INR 1.1 PTT 23

UA:

negative for UTI or drugs

CXR:

Rolando is working a bit harder to breathe after 1 hour of being under your care. What would you anticipate next?

Edited Jun 22, 2013 by juan de la cruz

Yikes! 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.

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?

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?

Young, relatively usually/historicaly healthy guy 87 a tad on the low side., unless there's some fasting involved.

Was a rapid HIV done?