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Hi guys, welcome back to another
episode of the Success NP 

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00:01:47,920 --> 00:01:50,960
podcast, the show that sharpens 
your clinical skills while 

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bringing you real world cases 
carried in by NPS Foreign. 

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PS I'm your host today, Jackie, 
and we're going to be presenting

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a case that may seem like a 
routine sick visit at 1st until 

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the details unfold. 
Picture it, we're in it right 

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now. 
It's summer, people are 

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traveling and sometimes they 
come home with more than just 

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souvenirs. 
In this episode we're going to 

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meet Rachel. 
She's a 32 year old who presents

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with flu like symptoms after an 
overseas vacation. 

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As we walk through her 
presentation, you'll get her 

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vital signs, her physical exam, 
labs, and her history. 

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Your challenge is to build a 
differential and work through 

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that puzzle. 
See if you can make the correct 

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diagnosis before we reveal it at
the end. 

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Let's dive in. 
Our patient, Rachel, is a 32 

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year old high school English 
teacher. 

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She's otherwise healthy, takes 
takes no medications, has no 

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significant past medical history
and no known allergies. 

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She walks into your urgent care 
clinic on a Monday morning in 

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early July looking fatigued and 
flushed. 

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She says, and I quote, I just 
don't feel right. 

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She returned from Costa Rica 
four days ago after a 10 day 

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trip. 
She was in San Jose and also 

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stayed in some rural areas. 
While she was there. 

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She went zip lining, visited 
coffee farms, hiked to 

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waterfalls, and swam in a 
natural spring with locals. 

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She reports eating a lot of 
fresh produce and local seafood.

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She did drink bottled water, but
she wasn't entirely sure about 

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the ice and she begins to 
describe the following symptoms.

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She says that she started to 
feel off about two days after 

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returning. 
It began with fatigue and a low 

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grade fever. 
Yesterday the fever peaked at a 

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101.8°F with chills. 
She has a mild persistent 

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headache as she describes 
something dull behind the eyes. 

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She denies sore throat, 
congestion, or cough. 

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She's a bit nauseated but has 
not vomited. 

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No diarrhea, though she says her
appetite is minimal. 

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She denies urinary symptoms or 
joint pain. 

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She mentioned she mentions that 
she's just exhausted and can't 

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seem to think clearly. 
She's not pregnant and has 

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regular cycles. 
No recent St. is no new 

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partners. 
She did travel alone but met 

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with friends. 
So at this point, what are we 

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thinking? 
Are we thinking common viral 

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illness? 
A variant or traveler's diarrhea

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perhaps? 
Or is it something more exotic? 

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Let's break down her risk 
exposure based on her social and

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travel history. 
Rachel did not take malaria 

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prophylaxis. 
She is vaccinated for hepatitis 

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A, hepatitis B, and typhoid. 
No yellow fever vaccine was 

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required for Costa Rica. 
She did not notice any insect 

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bites, but does note that the 
mosquitoes were pretty bad near 

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the springs. 
No exposure to any animals or 

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insect bites that she can 
recall. 

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And she did eat ceviche from a 
street vendor. 

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So as Leonard's practitioner 
from the clinic, you received 

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00:05:01,440 --> 00:05:03,040
the following set of vital 
signs. 

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Her temperature is 100.9°F, 
heart rate is 98, respiratory 

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rate 16, blood pressure 112 / 70
and 99% room air for O2 

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saturation. 
That is so you dive right into 

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00:05:18,280 --> 00:05:21,600
that physical exam. 
She appears fatigued but not in 

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00:05:21,600 --> 00:05:24,200
distress. 
She has no conjunctival 

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injection. 
Her sclera are clear. 

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Her neck is supple, no 
lymphatinopathy. 

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00:05:29,360 --> 00:05:33,120
Her lungs are clear. 
Heart sounds irregular, abdomen 

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00:05:33,120 --> 00:05:37,240
is soft, non tender, but you do 
notice a mild hepatomatically, 

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no rash, no petechia or 
ecchymosis and her cranial 

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00:05:42,200 --> 00:05:45,000
nerves are intact, although you 
do note mild photophobia. 

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00:05:46,240 --> 00:05:49,520
Let's pause at this point, 
what's on your list, right? 

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We need, we have a ton of 
symptoms here, a lot of history 

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to go through. 
So your differential diagnosis 

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might kind of be all over the 
place. 

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So it's really important to stay
organized and go over what we do

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know at the point. 
So we do know that she has 

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fever, she has fatigue, she has 
a retro orbital headache. 

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We had mild apatomegaly on her 
physical exam. 

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00:06:11,160 --> 00:06:13,080
She recently traveled to a 
tropical area. 

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And we know that we have no Uri 
or GI symptoms. 

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So let's brainstorm. 
Our differentials are going to 

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be at this point in time in the 
case study. 

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So we do have a differential 
diagnosis of dengue, typhoid, 

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malaria, Zika virus, hepatitis A
or E and possibly acute HIV. 

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00:06:35,600 --> 00:06:38,520
So we need to order some labs. 
We don't know, it's a lot to go 

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00:06:38,520 --> 00:06:40,600
through. 
Labs will give us a better idea 

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00:06:40,600 --> 00:06:44,120
of what's going on. 
So as we all know, we have labs 

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that will come in fast, some 
that will not. 

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00:06:46,480 --> 00:06:49,240
And so our initial work up looks
something like this. 

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We get ACVC with a White County 
of 3.1 which we note to be on 

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00:06:53,960 --> 00:06:58,120
the low side, a hemoglobin of 
13.4 which is normal. 

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00:06:59,160 --> 00:07:02,720
Our platelets are 125 kind of on
the low normal side there. 

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00:07:03,800 --> 00:07:07,040
Her CMP are complete metabolic. 
Certainly complete metabolic 

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00:07:07,040 --> 00:07:13,440
panel was fairly normal with the
exception of AST being 68 which 

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00:07:13,440 --> 00:07:16,720
is elevated and her ALT being 72
which is elevated. 

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00:07:17,400 --> 00:07:22,560
We have a normal bilirubin, 
normal electrolyte, a normal 

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00:07:22,560 --> 00:07:26,240
your urinalysis. 
We did perform a malarious 

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00:07:26,240 --> 00:07:30,120
smear, which is pending on the 
initial workup being a COVID 

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00:07:30,120 --> 00:07:35,280
flu, RSV swab was negative. 
So we do a little clinical pause

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00:07:35,280 --> 00:07:38,480
right now, right? 
You're looking at this patient 

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00:07:38,560 --> 00:07:39,800
and you're thinking, what do I 
do now? 

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00:07:40,000 --> 00:07:42,560
Do I send her to the ER? 
Do I start her on empiric 

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00:07:42,560 --> 00:07:44,640
treatment? 
Do I tell her to hydrate and 

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00:07:44,640 --> 00:07:48,000
come back in 48 hours? 
You're still waiting on the 

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00:07:48,000 --> 00:07:51,160
malaria smear. 
In the meantime, other 

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00:07:51,160 --> 00:07:56,040
possibilities for ordering labs 
could be a Dengue NS-1 antigen 

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00:07:56,040 --> 00:08:02,640
or IGN, the Hepatitis AIGN, 
Leptospira serologies, blood 

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00:08:02,640 --> 00:08:05,720
cultures for typhoid, or even a 
mono spot, although you're 

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00:08:05,720 --> 00:08:07,880
thinking less likely based on 
her physical exam. 

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00:08:11,200 --> 00:08:14,120
So in this case study, two days 
have passed when Rachel calls 

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00:08:14,120 --> 00:08:17,560
back. 
She's feeling worse, still 

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00:08:17,560 --> 00:08:22,040
febrile, and now her temperature
is maxing out at 1 or 2.2°F. 

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00:08:22,880 --> 00:08:26,480
And there's a new development. 
She noticed a pink rash on her 

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00:08:26,480 --> 00:08:29,720
trunk this morning. 
She also says that her eyes feel

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00:08:30,000 --> 00:08:32,880
pressurey, like she's having 
more pressure behind her eyes 

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00:08:32,880 --> 00:08:35,480
and she's having some mild joint
stiffness in her wrist. 

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00:08:36,799 --> 00:08:39,159
You have the malaria smear that 
came back negative. 

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00:08:39,600 --> 00:08:44,440
You repeat the CBC which shows a
White County of 2.9 lower than 

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00:08:44,440 --> 00:08:48,440
previous right guys. 
Platelets of 95 also trending 

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00:08:48,440 --> 00:08:51,480
down and your LFTS are trending 
upward. 

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00:08:52,480 --> 00:08:55,440
At this point you have her come 
in, you confirm that she has a 

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00:08:55,440 --> 00:08:58,880
faint blanching maculopapular 
rash on her trunk. 

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00:08:59,520 --> 00:09:02,120
So what are we thinking now? 
We got updated labs. 

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00:09:02,440 --> 00:09:04,320
We got a new symptom of a rash 
on her trunk. 

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00:09:05,800 --> 00:09:08,800
Let's review before we go to 
that final diagnosis. 

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00:09:09,720 --> 00:09:13,840
We have symptoms of fever, low 
White County falling platelets, 

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00:09:14,440 --> 00:09:20,160
mild hepatomegaly, retro orbital
headache, a rash, and a history 

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00:09:20,160 --> 00:09:22,000
of mosquito exposure in Central 
America. 

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00:09:23,320 --> 00:09:25,360
What's our final diagnosis, 
guys? 

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00:09:25,360 --> 00:09:30,440
You know it, Dengue fever. 
You order a dengue NS-1 antigen 

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00:09:30,440 --> 00:09:32,320
and IGN and both come back 
positive. 

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00:09:33,840 --> 00:09:36,760
She's managed outpatient with 
strict return precautions, 

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00:09:37,640 --> 00:09:41,360
hydration, and follow up. 
Fortunately, she recovers 

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00:09:41,360 --> 00:09:46,680
without complications. 
So let's wrap it up and go over 

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00:09:46,680 --> 00:09:47,880
what we learned from this case 
study. 

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00:09:48,120 --> 00:09:52,600
What can we take away from this?
We always go back to the 

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00:09:52,600 --> 00:09:54,920
history, right? 
We always want a thorough 

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00:09:54,920 --> 00:09:57,800
history, especially if they've 
traveled outside the country. 

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00:09:58,080 --> 00:10:02,760
We need to know our timing, 
geography, food, water and 

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00:10:02,760 --> 00:10:05,560
insect exposures. 
Something that may seem 

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00:10:05,560 --> 00:10:08,720
insignificant to the patient 
could make all the difference in

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00:10:08,720 --> 00:10:11,720
our differentials and ultimately
what we choose to order. 

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00:10:13,000 --> 00:10:16,360
A fever plus low white count and
platelets in a returning 

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00:10:16,360 --> 00:10:17,840
traveler. 
We always want to thank 

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00:10:17,840 --> 00:10:22,680
Arboviruses Retro orbital pain 
is classic for dengue, but is 

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00:10:22,680 --> 00:10:26,560
not always present early. 
And malaria is not the only 

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00:10:26,560 --> 00:10:28,280
thing out there. 
We tend to think malaria, 

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00:10:28,280 --> 00:10:30,160
malaria, malaria, it's not the 
only thing, although it should 

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00:10:30,160 --> 00:10:31,560
be part of your differential, 
right? 

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00:10:31,920 --> 00:10:34,960
But there are so many other 
possibly possible diagnosis that

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00:10:34,960 --> 00:10:39,360
we could be looking at. 
Remember Rachel's case look like

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00:10:39,360 --> 00:10:43,200
viral illness at first, but the 
labs and the timing gave her 

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00:10:43,200 --> 00:10:46,600
away. 
All right, guys, thank you so 

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00:10:46,600 --> 00:10:49,680
much for working with me through
this case today. 

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00:10:49,960 --> 00:10:52,480
I really enjoyed doing it with 
you and these are my favorite. 

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00:10:52,880 --> 00:10:55,360
And it's kind of like a mystery 
to see what we're going to get 

186
00:10:55,360 --> 00:10:57,160
at the end. 
They always seem to stick a 

187
00:10:57,160 --> 00:11:00,640
little bit better as far as 
learning, at least when I was in

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00:11:00,640 --> 00:11:02,600
school. 
And as a preceptor, I love to do

189
00:11:02,600 --> 00:11:06,760
this with my students. 
If you have any clinical 

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00:11:06,760 --> 00:11:09,320
mysteries that you've 
encountered, please DM us on 

191
00:11:09,320 --> 00:11:12,560
Instagram at the Success MP and 
please check out our digital 

192
00:11:12,560 --> 00:11:16,800
tools for clinical practice at 
successnp.etsy.com or on our 

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00:11:16,800 --> 00:11:18,360
website. 
Until next time. 

194
00:11:19,120 --> 00:11:21,960
Thanks for tuning into another 
episode of Success NP. 

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00:11:22,000 --> 00:11:25,080
We hope today's discussion has 
shed some light on the diverse 

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00:11:25,120 --> 00:11:28,160
career options or taught you how
to improve your clinical 

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00:11:28,160 --> 00:11:29,720
practice as a nurse 
practitioner. 

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00:11:30,120 --> 00:11:32,600
Remember, whether you're 
considering a specialization, 

199
00:11:32,720 --> 00:11:36,120
pursuing advanced certification,
or exploring non traditional 

200
00:11:36,120 --> 00:11:39,040
roles, there's a wealth of 
opportunities out there waiting 

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00:11:39,040 --> 00:11:41,360
for you. 
Be sure to subscribe to the show

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00:12:05,160 --> 00:12:08,600
Until next time, take care, stay
curious, and keep advancing your

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00:12:08,600 --> 00:12:11,680
careers as a nurse practitioner.
And just a friendly reminder, 

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00:12:11,840 --> 00:12:14,560
the information on this podcast 
is for educational purposes 

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00:12:14,560 --> 00:12:16,280
only. 
The information should not be 

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00:12:16,280 --> 00:12:18,880
used and substitute for 
professional care by a medical 

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00:12:18,880 --> 00:12:21,040
provider. 
The information on this podcast 

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00:12:21,040 --> 00:12:24,040
does not represent medical or 
professional advice or services.

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00:12:24,120 --> 00:12:24,920
Bye for now.