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. (This is basic information and demonstrates and potential lack of financial means. In the US a person’s ability to pay for healthcare often directly equates to their priorities and health status. Many former middle class families that never used or discussed social programs are often at a loss for options when they find themselves economically struggling. Additionally, households with 2 working parents often do not have any idea what their teenagers lives are like.)
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.(subjective feeling of cold, often seen in shock) 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(could be distracting to heat injury, but also a subtle sign of hypovolemia), though she is pale in the face(pale cool skin indicative of shock) and has multiple purpuric lesions on her arms.(gross capillary permeability) 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. (indicative of shock, tachycardia, weak central pulse, absent peripheral pulse)
BP: 80/60 (narrowing pulse pressure another easily identifiable sign of cardiovascular collapse)
Respiratory rate is 24/min and shallow (respiratory insufficiency)
Temperature is 40C rectal. (builds upon the differential of septic shock. Fever, hypotension, purpura)
Capilary blood glucose: 60 (she hasn’t eaten in days and bacteria often utilize glucose as a metabolite, a bigger problem still is the lack of glucose impairs mental function and causes breakdown of RBCs further complicating the hemodynamic picture )
Weight is 47kg height 5’5” (need weight for drug dosing, height demonstrates body proportion)
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave. (another sign of shock)
Spo2: 89 on room air (respiratory insufficiency caused by some etiology)
ETCO2: 30 (lower than normal CO2 reading, indicating abnormal gas exchange or airway compromise)
GCS: E4 V4 M5 (13, slightly impaired neuro function)
Physical exam:
Hair is oily and matted (recent lack of bathing), skin is pale and cool to the touch,(shock) nothing noted about the ears. Pupils are dilated and sluggish.(impaired neurological reaction, consider forms of insult like both forms of stroke) Sclera has diffuse blood throughout (extravascular bleeding), mucous membranes are dry(dehydration secondary to volume loss), slight bleeding from the gum line(vascular permeability), face and head is otherwise symmetrical with no obvious deformity or masses upon palpation.(eliminates lymphoid findings indicating early onset of sepsis) Trachea is midline without shift, (no pneumo) JVD is noted (physiologic in reclined position but does give a clue about potential insufficiency) and skin is also pale on the face/neck. (shock) Thyroid and lymph nodes are not enlarged (rapid onset sepsis) carotid pulse is present and weak. (shock)
Exposing her chest you observe multiple purpuric regions (>2cm in diameter) (sepsis or other form of capillary permeability like late DIC), breathing is shallow and rapid at a rate of about 24/minute,(acidosis compensation) breasts appear at stage 5 development.(stage of full adult breast development in female, not normally seen until 17 or older, breasts fully develop in pregnancy also) Breath sounds are diminished with crackles in the bases,(in this case from blood/fluid in the alveoli) Heart tones exhibit a gallop and sound distant.(new onset cardiogenic shock) Apex of the heart is at the normal level,(rules out hereditary cardiac malformations) lungs also within normal topographic parameters.(same with lungs) Back has similar purpura legions. Skin is cool to the touch. (by now you should get the sepsis/DIC picture)
The abdomen appears similar to the chest, however it is slightly distended,(blood, air, and swollen) locally warm to the touch in the lower quadrants,(localization of inflammation) involuntary muscle guarding is noted on palpation (a very specific sign of a surgical abdominal pathology), you decide not to auscultate bowel sounds,(because that would be useless in the current situation) liver in 2cm beneath normal margin,(liver edema from right heart insufficiency and/or liver malfunction) spleen not palpable.(Rule out pathology of splenomegaly) Diffuse echymosis in the gluteal region(dependant sign of bleeding), constant trickling bloody discharge from the vagina,(active bleeding from the internal genitalia which gives a clue to potential injury to highten index of suspicion but is nonspecific) and subcutaneous emphysema in the mons pubis area . (Trauma is the number 1 cause of air in the subcutaneous tissue if the trauma is not externally visible, this should be a clue of potential occult injuries)
There appears no indication of external trauma with an exhaustive exam. (Should raise index of suspicion on potential urogenital injuries)
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. (reinforcing massive bleeding and shock)
she's seriously ill and seriously time critical. 
