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Hi guys, welcome back to another episode of the Success NP
podcast, the show that sharpens your clinical skills while
bringing you real world cases carried in by NPS Foreign.
PS I'm your host today, Jackie, and we're going to be presenting
a case that may seem like a routine sick visit at 1st until
the details unfold. Picture it, we're in it right
now. It's summer, people are
traveling and sometimes they come home with more than just
souvenirs. In this episode we're going to
meet Rachel. She's a 32 year old who presents
with flu like symptoms after an overseas vacation.
As we walk through her presentation, you'll get her
vital signs, her physical exam, labs, and her history.
Your challenge is to build a differential and work through
that puzzle. See if you can make the correct
diagnosis before we reveal it at the end.
Let's dive in. Our patient, Rachel, is a 32
year old high school English teacher.
She's otherwise healthy, takes takes no medications, has no
significant past medical history and no known allergies.
She walks into your urgent care clinic on a Monday morning in
early July looking fatigued and flushed.
She says, and I quote, I just don't feel right.
She returned from Costa Rica four days ago after a 10 day
trip. She was in San Jose and also
stayed in some rural areas. While she was there.
She went zip lining, visited coffee farms, hiked to
waterfalls, and swam in a natural spring with locals.
She reports eating a lot of fresh produce and local seafood.
She did drink bottled water, but she wasn't entirely sure about
the ice and she begins to describe the following symptoms.
She says that she started to feel off about two days after
returning. It began with fatigue and a low
grade fever. Yesterday the fever peaked at a
101.8°F with chills. She has a mild persistent
headache as she describes something dull behind the eyes.
She denies sore throat, congestion, or cough.
She's a bit nauseated but has not vomited.
No diarrhea, though she says her appetite is minimal.
She denies urinary symptoms or joint pain.
She mentioned she mentions that she's just exhausted and can't
seem to think clearly. She's not pregnant and has
regular cycles. No recent St. is no new
partners. She did travel alone but met
with friends. So at this point, what are we
thinking? Are we thinking common viral
illness? A variant or traveler's diarrhea
perhaps? Or is it something more exotic?
Let's break down her risk exposure based on her social and
travel history. Rachel did not take malaria
prophylaxis. She is vaccinated for hepatitis
A, hepatitis B, and typhoid. No yellow fever vaccine was
required for Costa Rica. She did not notice any insect
bites, but does note that the mosquitoes were pretty bad near
the springs. No exposure to any animals or
insect bites that she can recall.
And she did eat ceviche from a street vendor.
So as Leonard's practitioner from the clinic, you received
the following set of vital signs.
Her temperature is 100.9°F, heart rate is 98, respiratory
rate 16, blood pressure 112 / 70 and 99% room air for O2
saturation. That is so you dive right into
that physical exam. She appears fatigued but not in
distress. She has no conjunctival
injection. Her sclera are clear.
Her neck is supple, no lymphatinopathy.
Her lungs are clear. Heart sounds irregular, abdomen
is soft, non tender, but you do notice a mild hepatomatically,
no rash, no petechia or ecchymosis and her cranial
nerves are intact, although you do note mild photophobia.
Let's pause at this point, what's on your list, right?
We need, we have a ton of symptoms here, a lot of history
to go through. So your differential diagnosis
might kind of be all over the place.
So it's really important to stay organized and go over what we do
know at the point. So we do know that she has
fever, she has fatigue, she has a retro orbital headache.
We had mild apatomegaly on her physical exam.
She recently traveled to a tropical area.
And we know that we have no Uri or GI symptoms.
So let's brainstorm. Our differentials are going to
be at this point in time in the case study.
So we do have a differential diagnosis of dengue, typhoid,
malaria, Zika virus, hepatitis A or E and possibly acute HIV.
So we need to order some labs. We don't know, it's a lot to go
through. Labs will give us a better idea
of what's going on. So as we all know, we have labs
that will come in fast, some that will not.
And so our initial work up looks something like this.
We get ACVC with a White County of 3.1 which we note to be on
the low side, a hemoglobin of 13.4 which is normal.
Our platelets are 125 kind of on the low normal side there.
Her CMP are complete metabolic. Certainly complete metabolic
panel was fairly normal with the exception of AST being 68 which
is elevated and her ALT being 72 which is elevated.
We have a normal bilirubin, normal electrolyte, a normal
your urinalysis. We did perform a malarious
smear, which is pending on the initial workup being a COVID
flu, RSV swab was negative. So we do a little clinical pause
right now, right? You're looking at this patient
and you're thinking, what do I do now?
Do I send her to the ER? Do I start her on empiric
treatment? Do I tell her to hydrate and
come back in 48 hours? You're still waiting on the
malaria smear. In the meantime, other
possibilities for ordering labs could be a Dengue NS-1 antigen
or IGN, the Hepatitis AIGN, Leptospira serologies, blood
cultures for typhoid, or even a mono spot, although you're
thinking less likely based on her physical exam.
So in this case study, two days have passed when Rachel calls
back. She's feeling worse, still
febrile, and now her temperature is maxing out at 1 or 2.2°F.
And there's a new development. She noticed a pink rash on her
trunk this morning. She also says that her eyes feel
pressurey, like she's having more pressure behind her eyes
and she's having some mild joint stiffness in her wrist.
You have the malaria smear that came back negative.
You repeat the CBC which shows a White County of 2.9 lower than
previous right guys. Platelets of 95 also trending
down and your LFTS are trending upward.
At this point you have her come in, you confirm that she has a
faint blanching maculopapular rash on her trunk.
So what are we thinking now? We got updated labs.
We got a new symptom of a rash on her trunk.
Let's review before we go to that final diagnosis.
We have symptoms of fever, low White County falling platelets,
mild hepatomegaly, retro orbital headache, a rash, and a history
of mosquito exposure in Central America.
What's our final diagnosis, guys?
You know it, Dengue fever. You order a dengue NS-1 antigen
and IGN and both come back positive.
She's managed outpatient with strict return precautions,
hydration, and follow up. Fortunately, she recovers
without complications. So let's wrap it up and go over
what we learned from this case study.
What can we take away from this? We always go back to the
history, right? We always want a thorough
history, especially if they've traveled outside the country.
We need to know our timing, geography, food, water and
insect exposures. Something that may seem
insignificant to the patient could make all the difference in
our differentials and ultimately what we choose to order.
A fever plus low white count and platelets in a returning
traveler. We always want to thank
Arboviruses Retro orbital pain is classic for dengue, but is
not always present early. And malaria is not the only
thing out there. We tend to think malaria,
malaria, malaria, it's not the only thing, although it should
be part of your differential, right?
But there are so many other possibly possible diagnosis that
we could be looking at. Remember Rachel's case look like
viral illness at first, but the labs and the timing gave her
away. All right, guys, thank you so
much for working with me through this case today.
I really enjoyed doing it with you and these are my favorite.
And it's kind of like a mystery to see what we're going to get
at the end. They always seem to stick a
little bit better as far as learning, at least when I was in
school. And as a preceptor, I love to do
this with my students. If you have any clinical
mysteries that you've encountered, please DM us on
Instagram at the Success MP and please check out our digital
tools for clinical practice at successnp.etsy.com or on our
website. Until next time.
Thanks for tuning into another episode of Success NP.
We hope today's discussion has shed some light on the diverse
career options or taught you how to improve your clinical
practice as a nurse practitioner.
Remember, whether you're considering a specialization,
pursuing advanced certification, or exploring non traditional
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Until next time, take care, stay curious, and keep advancing your
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the information on this podcast is for educational purposes
only. The information should not be
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does not represent medical or professional advice or services.
Bye for now.