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A TALE OF TWO CASES

A TALE OF TWO CASES. Gary M. Vilke, M.D., FACEP, FAAEM Associate Professor of Clinical Medicine UCSD Department of Emergency Medicine Interim Medical Director, San Diego County EMS. Goals. Present two cases Inspire thought Clinical Operational Theoretical. Case 1: Presentation.

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A TALE OF TWO CASES

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  1. A TALE OF TWO CASES Gary M. Vilke, M.D., FACEP, FAAEM Associate Professor of Clinical Medicine UCSD Department of Emergency Medicine Interim Medical Director, San Diego County EMS

  2. Goals • Present two cases • Inspire thought • Clinical • Operational • Theoretical

  3. Case 1: Presentation • 34 yo female postal worker presents with a day of malaise, high fevers, cough, congestion and worsening shortness of breath. Today, noted streaks of blood in sputum • ROS: Headaches, myalgias,

  4. Presentation • Meds: Tylenol • NKDA • PMH: Migraines • FH: Unremarkable • SH: No travel, no tobacco, no drugs

  5. Physical exam • Vitals • T: 101.8 • BP: 103/67 • HR: 120 • RR: 24 • O2 Sat: 92%

  6. Physical exam • WDWN female, appearing mildly toxic and clearly not feeling well • HEENT dry oral mucosa • Neck supple, no meningismus • Chest crackles L base. + retractions • Coron: tachy with reg rhythm

  7. Physical exam • Abd: soft, Nontender. No HSM • Ext: No c/c/e • Skins: Warm and moist, no rashes or lesions • Neuro: CN/motor/sens nonfocal

  8. Impression • Otherwise healthy female with probable pneumonia and early dehydration. Some concerning physiologic indicators

  9. CXR

  10. Disposition • Patient admitted to hospital • Blood and sputum CX sent • IV abx • IV hydration • Oxygen

  11. The next day • Your office is called because the sputum and blood cx of the admitted patient grew out Yersinia pestis What now??!!

  12. Case 2: Presentation • 10 yo M with recent travel to Korea, presents complaining of two days of malaise and high fevers that have improved and now the patient is developing a rash and the parents are concerned that it was chicken pox. • ROS: No ill contacts, No SOB/DOE. No CP or abd pain

  13. Presentation • Meds: Tylenol • NKDA • PMH: Neg • SH: No drugs, tob. Social ETOH • FH: HTN

  14. Physical exam • Vitals • T: 100.8 • BP: 122/72 • HR: 112 • RR: 16 • O2 Sat: 98%

  15. Physical exam • WDWN nontoxic male in NAD • HEENT: Unremarkable • Neck: Supple, no TM • Chest: CTAB • Coron: Tachy with reg rhythm

  16. Physical exam • Abd: soft, Nontender. No HSM • Ext: No c/c/e • Neuro: CN/motor/sens nonfocal • Skins: Warm and moist, rash as noted primarily on head and extremities, sparing the trunk. Noted on palms and all appear roughly the same age

  17. Rash

  18. What now!! • Check your own pulse • Take a deep breath • Think happy thoughts • Get back to the task at hand

  19. Check chart on wall

  20. Pull Bioterrorism Response Plan • Dust it off • Open it

  21. What not to do!! • Do not panic • Do not expose more people than already have been exposed • Do not send the patient to the ER

  22. Key web sites • www.sdcms.org • www.emansandiego.org • www.bt.cdc.gov • www.medepi.org/sfdph/bt/syndromes/index.html • www.usamriid.army.army.mil/education/bluebook.com • www.nbc-med.org/ie40/Default.html • www.dhs.ca.gov/ps/dcdc/bt/index.htm • www.hopkins-biodefense.org

  23. Smallpox References Barquet N, Domingo P. Smallpox: The triumph over the most terrible of the ministers of death. Ann Intern Med 1997;127:635-642. Bicknell WJ. The case for voluntary smallpox vaccination. N Engl J Med 2002; 346:1323-1325. Bremen JG, Henderson DA. Poxvirus dilemmas-Monkeypox, smallpox, and biologic terrorism. N Engl J Med 1998;339:556-559. Centers for Disease Control and Prevention. Vaccinia (Smallpox) Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. Atlanta, GA: CDC; 2001:RR-10. Fauci AS. Smallpox vaccination policy: the need for dialogue. N Engl J Med 2002;346:1319.

  24. Smallpox References Franz DR, Jahrling PB, McClain DJ, et al. Clinical recognition and management of patients exposed to biological warfare agents. Clin Lab Med 2001;21:435-473. Henderson DA. Smallpox: Clinical and epidemiologic features. Emerg Infect Dis 1999;5:537-539. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: Medical and public health management. Working group on Civilian Biodefense. JAMA 1999;281:2127-2137. Jahrling PB ZG, Huggins JW. Countermeasures to the reemergence of smallpox virus as an agent of bioterrorism. Emerg Infect 2000;4:187-200.

  25. Smallpox References Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: national surveillance in the United States. N Engl J Med 1969;281:1201-1208. Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: results of ten statewide surveys. J Infect Dis 1970; 122:303-309. McClain D. Smallpox. In: Sidell F, Takafuji E, Franz D, eds. Medical Aspects of Chemical and Biological Warefare. Washington, DC: Borden Institute, Walter Reed Army Medical Center;1997:539-558. Neff JM, Lane JM, Pert JP, Moore R, Millar JD, Henderson DA. Complications of smallpox vaccination, I: national survey in the united States, 1963. N Engl J Med 1967;276:1-8. Ruben FL, Lane JM. Ocular Vaccinia. An epidemiologic analysis of 348 cases. Arch Ophthalmol 1970;84:45-48.

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