Scenario
Dispatch/scene information:
You are called to an upper middle class residence for a 15 year old female feeling “sick for a couple of days.” Upon Arrival you are greeted at the door by the patient’s mother who claims her daughter has been feeling ill and spent the last few days in bed and is now difficult to arouse. On your way into the residence you notice a stack of bills on a bureau, a lack of furnishings and very limited amount of electronic devices. The dwelling is clean but the occasional damage to the drywall has not been repaired.
You make your way up the stairs to a second floor bedroom where you notice a 15 year old female wrapped tightly in blankets despite the 85F temperature outside. You next remove the blanket to start your assessment. The female is wearing sweatpants and a t-shirt, she does not appear to be sweating, though she is pale in the face and has multiple purpuric lesions on her arms. While you expose her and perform a physical exam, your partner (a brand new, 1st call ever, provider of the lowest level allowed in your country. This one is all about you) gathers a history.
Vital signs:
Heart rate: 110 regular, central pulses present and weak. Distal pulses absent.
BP: 80/60
Respiratory rate is 24/min and shallow
Temperature is 40C rectal.
Capilary blood glucose: 60
Weight is 47kg height 5’5”
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave.
Spo2: 89 on room air
ETCO2: 30
GCS: E4 V4 M5
Physical exam:
Hair is oily and matted, skin is pale and cool to the touch, nothing noted about the ears. Pupils are dilated and sluggish. Sclera has diffuse blood throughout, mucous membranes are dry, slight bleeding from the gum line, face and head is otherwise symmetrical with no obvious deformity or masses upon palpation. Trachea is midline without shift, JVD is noted and skin is also pale on the face/neck. Thyroid and lymph nodes are not enlarged carotid pulse is present and weak
Exposing her chest you observe multiple purpuric regions (>2cm in diameter), breathing is shallow and rapid at a rate of about 24/minute, breasts appear at stage 5 development. Breath sounds are diminished with crackles in the bases, Heart tones exhibit a gallop and sound distant. Apex of the heart is at the normal level, lungs also within normal topographic parameters. Back has similar purpura legions. Skin is cool to the touch.
The abdomen appears similar to the chest, however it is slightly distended, locally warm to the touch in the lower quadrants, involuntary muscle guarding is noted on palpation, you decide not to auscultate bowel sounds, liver in 2cm beneath normal margin, spleen not palpable. Diffuse echimosis in the gluteal region, constant trickling bloody discharge from the vagina, and subcutaneous emphysema in the mons pubis area .
There appears no indication of external trauma with an exhaustive exam.
Arms and legs are also cool to the touch, difuse purpura throughout. Capillary refill at +4. Femoral pulse is present and weak, distal pulses absent in all extremities.
History: Your partner (who is an exceptionally capable historian for a person green as grass) tells you the mother is extremely worried about the cost of all of this as they recently lost their health coverage. But he elicits:
Mother noticed her daughter had been sick the last few weeks with nausea and vomiting and warm to the touch. The girl continued to go to school despite the illness. She came home after hanging out with friends like usual 2 nights ago complaining of abdominal pain and went to her room. Next day pt told her mother she was too sick to go to school, was not hungry, but was drinking water and tea, vomiting had stopped. This morning mom came to check on the girl, who complained of epigastric pain. PT had spit up some gross red blood and then mom called 911. (aka: you)
The patient has been taking “femrelief” for menstrual cramps as needed for years, the dose of Nyquil on the bottle for the last 3-4 days and has no known allergies medical or otherwise. You notice no drug paraphernalia with a quick cursory search and no street drugs. You also do not notice track marks or venipuncture sites on the pt.
The mother reports the female does not have a boyfriend, is not sexually active, started menstruating at age 10 and was not regular, LMP unknown. No history of pregnancy, miscarriage or abortion.
The mother also reports that the patient uses no alcohol and does not smoke. You do not find anything in the environment that contradicts this information.
The patient has not been eating the last few days but has been drinking a lot of fluids. The mother does not know about urination or defecation habits or frequency.
The Mother also reports the girl is a straight A student and is a starter on the high school volleyball and track teams, plays in the band and sings in the choir. (since 3rd grade.)
You are working in the US, but operate under your normal protocols or standard of care. So what are your thoughts and orders Captain? Your nearest hospital is a community hospital 10 minutes away. A major academic medical center is 30 minutes away. Anyone of 10 airmed providers are at your beck and call and frequently hand out pens and other marketing items but it will take them 40 minutes to respond at best. You have anything you normally have on your responding unit. You can ask for any clarifications, repeat findings, more detailed findings, or the effect of your interventions. The only ambiguity in the scenario is what you do but I will do my best to respond accordingly and consistantly.
Hints to make your head hurt:
In this scenario there are 5 life threatening pathologies, some secondary to others.
All of the pathologies are readily identifiable by the information given except for the common primary pathology which is alluded to and can be reverse engineered from finding the others.
PS. This is also my original work and not to be distributed without permission, which you have as long as you make no money from it and proper credit is given. 04/25/2010
This scenario is hypothetical and bears no relationship to any person known or unknown by the author.
Dispatch/scene information:
You are called to an upper middle class residence for a 15 year old female feeling “sick for a couple of days.” Upon Arrival you are greeted at the door by the patient’s mother who claims her daughter has been feeling ill and spent the last few days in bed and is now difficult to arouse. On your way into the residence you notice a stack of bills on a bureau, a lack of furnishings and very limited amount of electronic devices. The dwelling is clean but the occasional damage to the drywall has not been repaired.
You make your way up the stairs to a second floor bedroom where you notice a 15 year old female wrapped tightly in blankets despite the 85F temperature outside. You next remove the blanket to start your assessment. The female is wearing sweatpants and a t-shirt, she does not appear to be sweating, though she is pale in the face and has multiple purpuric lesions on her arms. While you expose her and perform a physical exam, your partner (a brand new, 1st call ever, provider of the lowest level allowed in your country. This one is all about you) gathers a history.
Vital signs:
Heart rate: 110 regular, central pulses present and weak. Distal pulses absent.
BP: 80/60
Respiratory rate is 24/min and shallow
Temperature is 40C rectal.
Capilary blood glucose: 60
Weight is 47kg height 5’5”
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave.
Spo2: 89 on room air
ETCO2: 30
GCS: E4 V4 M5
Physical exam:
Hair is oily and matted, skin is pale and cool to the touch, nothing noted about the ears. Pupils are dilated and sluggish. Sclera has diffuse blood throughout, mucous membranes are dry, slight bleeding from the gum line, face and head is otherwise symmetrical with no obvious deformity or masses upon palpation. Trachea is midline without shift, JVD is noted and skin is also pale on the face/neck. Thyroid and lymph nodes are not enlarged carotid pulse is present and weak
Exposing her chest you observe multiple purpuric regions (>2cm in diameter), breathing is shallow and rapid at a rate of about 24/minute, breasts appear at stage 5 development. Breath sounds are diminished with crackles in the bases, Heart tones exhibit a gallop and sound distant. Apex of the heart is at the normal level, lungs also within normal topographic parameters. Back has similar purpura legions. Skin is cool to the touch.
The abdomen appears similar to the chest, however it is slightly distended, locally warm to the touch in the lower quadrants, involuntary muscle guarding is noted on palpation, you decide not to auscultate bowel sounds, liver in 2cm beneath normal margin, spleen not palpable. Diffuse echimosis in the gluteal region, constant trickling bloody discharge from the vagina, and subcutaneous emphysema in the mons pubis area .
There appears no indication of external trauma with an exhaustive exam.
Arms and legs are also cool to the touch, difuse purpura throughout. Capillary refill at +4. Femoral pulse is present and weak, distal pulses absent in all extremities.
History: Your partner (who is an exceptionally capable historian for a person green as grass) tells you the mother is extremely worried about the cost of all of this as they recently lost their health coverage. But he elicits:
Mother noticed her daughter had been sick the last few weeks with nausea and vomiting and warm to the touch. The girl continued to go to school despite the illness. She came home after hanging out with friends like usual 2 nights ago complaining of abdominal pain and went to her room. Next day pt told her mother she was too sick to go to school, was not hungry, but was drinking water and tea, vomiting had stopped. This morning mom came to check on the girl, who complained of epigastric pain. PT had spit up some gross red blood and then mom called 911. (aka: you)
The patient has been taking “femrelief” for menstrual cramps as needed for years, the dose of Nyquil on the bottle for the last 3-4 days and has no known allergies medical or otherwise. You notice no drug paraphernalia with a quick cursory search and no street drugs. You also do not notice track marks or venipuncture sites on the pt.
The mother reports the female does not have a boyfriend, is not sexually active, started menstruating at age 10 and was not regular, LMP unknown. No history of pregnancy, miscarriage or abortion.
The mother also reports that the patient uses no alcohol and does not smoke. You do not find anything in the environment that contradicts this information.
The patient has not been eating the last few days but has been drinking a lot of fluids. The mother does not know about urination or defecation habits or frequency.
The Mother also reports the girl is a straight A student and is a starter on the high school volleyball and track teams, plays in the band and sings in the choir. (since 3rd grade.)
You are working in the US, but operate under your normal protocols or standard of care. So what are your thoughts and orders Captain? Your nearest hospital is a community hospital 10 minutes away. A major academic medical center is 30 minutes away. Anyone of 10 airmed providers are at your beck and call and frequently hand out pens and other marketing items but it will take them 40 minutes to respond at best. You have anything you normally have on your responding unit. You can ask for any clarifications, repeat findings, more detailed findings, or the effect of your interventions. The only ambiguity in the scenario is what you do but I will do my best to respond accordingly and consistantly.
Hints to make your head hurt:
In this scenario there are 5 life threatening pathologies, some secondary to others.
All of the pathologies are readily identifiable by the information given except for the common primary pathology which is alluded to and can be reverse engineered from finding the others.
PS. This is also my original work and not to be distributed without permission, which you have as long as you make no money from it and proper credit is given. 04/25/2010
This scenario is hypothetical and bears no relationship to any person known or unknown by the author.
