CS case 2

Doorway Information:

22 yo WM with abdominal pain and fever.
Pulse: 80, BP: 126/82, RR: 14 T: 99

If the SP tells you his/her name, please write it down to help you if you forget.

The examinee went into the room to meet the SP.

He introduced himself as a 24 yo clerk who works in a school. Has abdominal pain with chills and rigors.

History:

I have had this pain for 3 days and found it difficult to talk.

(This young patient was behaving very nervously)

In his social history, he admitted to doing cocaine and his last usage was 3 days ago.

(At this point, one should also be thinking of alcohol withdrawal.)

At which point the cage questionnaire comes to mind and from the response of the examiner, it seemed that this is what he was looking for.

1. Have you ever felt the need to Cut down on your drinking?

2. Have you ever felt Annoyed by people complaining about your drinking?

3. Have you ever felt Guilty about your drinking?

4. Do you ever drink an Eye-opener in the morning to relieve the shakes?

Cocaine withdrawal.

At this point, it is important to understand drug dependence:

Substance Dependence: For an individual to be diagnosed with substance dependence, s/he must have experienced three (or more) of the following in the same 12-month period:

Tolerance, defined as either: a) a need for markedly increased amounts of the substance to achieve the desired effect; or b) a markedly reduced effect with same dose as before the “high” initially derived from smaller amounts (Ray et al., 1996).

Withdrawal, defined as: a) the occurrence of a withdrawal syndrome when the substance is not used or there is a reduction of use after prolonged use (e.g., with crack, becoming irritable and/or depressed; with heroin, becoming shaky and/or nauseous); b) the use of the same or related substance to relieve or avoid withdrawal symptoms.

The substance is often taken in larger amounts or over a longer period than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control substance use.
Lot of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors, driving long distances), use the substance (e.g., chain-smoking), or recover from its effects.

Important social, occupational, or recreational obligations are given up or reduced because of substance use.
Uses (e.g., continued alcohol consumption despite a known ulcer) without fear of complications and inspite of them.

This same patient had mild fever. Did not allow examination.

The patient certainly has a right not to be examined and this should be respected. (PROVIDED that patient is competent)

On the other hand if he had allowed examination, it is important to realize the causes of fever in the patient who has a history of illicit drug usage.

The usual causes of fever must not be ignored. For instance, Viral infections, sinusitis, pneumonia, urinary infections top the list.

On exams, patients with alcohol intake particularly get Klebsiella pneumonia. Klebsiella pneumonia shows up on x-ray as bulging margins of the affected lobe. Aspiration pneumonia is a also common. The commonest pneumonia in an alcoholic is Pneumococcal (same as in someone who is not alcoholic)

Infective endocarditis must be kept in mind in intravenous drug users. The commonest bacteria among them is Staphylococcus aureus.

The patient also admitted to having unprotected sexual encounter.

He should be advised about the risks of various sexually transmitted diseases. Among the important ones, are, HIV, hepatitis B., syphilis, herpes,

at the same time, one should counsel the patient about practicing safe sex in the future - using condoms.

Also sometimes one can be asked what to do if the patient is a minor who is involved in unprotected sex:

for that see Minor wanting contraception

Risks of STDs is an important topic for this case and can be seen at Healthcare worker and ID.

One should also remember the transmission of STDs is higher in the presence of an ulcerating lesion other than the STD in question - for example, HIV transmission is more common if patient has a syphilitic chancre (or other genital lesion) during exposure. The reason is obvious that there is a higher exposure to body fluids and blood.

Another important fact is that it is easier for a diseased male to transmit disease to a healthy female than it is for a diseased female to a healthy male.

Both the above facts have appeared on tests so please pay attention to them.

One would do an interview with the SP based upon the above information discussed.

Then you would let the SP know your thoughts and plan as is outlind below or in a similar way using layman's terms.

Mr. ...., the possibilities at this point include a few things, the most most likely is a simple viral illness just like an ordinary cold. The other possibilities could be a Sexually transmitted disease like HIV or hepatitis. Street drug usage can also pose a high risk for infection of a valve inside the heart - especially if you inject them.

Sometimes though, people who drink almost everyday can suffer from withdrawal.

We will run some important tests to get to the bottom of it. Someone will take blood from you to run some tests for hepatitis and other such diseases,

Most likely you do not have STDs but it is important to make sure.

Then transfer the info neatly onto the provided form. and in the bottom, include a simple but logical plan.

Differential diagnosis

1. Viral syndrome

2. Ac. HIV

3. Alcohol withdrawal

4. Infective endocarditis

5. Gonorrhea

6. Acute cholecystitis or cholangitis

Investigations:

1. Urethral swab/Genprobe

2. CBC

3. Blood cultures

4. Urinalysis

5. HIV/STD screening

6. U/S RUQ