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34 APRIL 2016 | EMSWORLD.com 4. Concurrent Illnesses Homeless individuals may have concurrent illnesses or medical conditions. Conditions that may be found among adults include dermatologic conditions (rashes, skin lice), respiratory infections, visual disturbances, heart disease, diabetes, decaying teeth, foot complications, sexually transmitted diseases/infections, HIV/AIDS and renal complications. 11–15 Children may experi- ence "failure to thrive," developmental delays, respiratory infections, ear infections, skin infections, neglect and abuse. 16–18 The presence of concurrent illnesses is likely to influence the patient's signs and symptoms as well as the treatment that is provided. 5. Head Injuries The rate of head injuries among the home- less and transient population is more than 20 times the general population. 21 Homeless males who consume significant amounts of alcohol over time tend to experience more head injuries and are also more likely to sustain a cerebral hemorrhage. 21 The poten- tial for the homeless patient to have a head injury and/or cerebral hemorrhage can add C o m m o n M e d i c a l C o n d i t i o n s o f t h e H o m e l e s s Cardiac and Cardiac-Related Conditions—Angina, myocardial infarction, endocarditis and hypertension. 25,26 » Symptoms—Substernal chest pain, chest pain that radiates to the shoulders, neck or jaw, dyspnea, shortness of breath, nausea, vomiting and general weakness. 25,26 » Assessment—Patient assessment should include a complete set of vital signs, including an EKG when cardiac conditions are being considered. Overall appearance, such as skin that appears ashen, pale, or gray that is cool and moist to touch, should be noted. Respiratory Conditions—Emphysema, pneumonia, bron- chitis and tuberculosis may be encountered, especially if the patient is a smoker. 27–29 » Symptoms—Specific symptoms can vary depending on the condition. Common findings include chills, fever, fatigue, chest pain, sore throat, coughing, night sweats, weakness, a loss of appetite, unexplained weight loss and shortness of breath. Tachypnea, dyspnea, accessory mus- cle use, tripod positioning, pursed-lip breathing, cyanosis, bradypnea and a failing respiratory drive, such as agonal respirations, may be present. Inability to speak in com- plete sentences due to breathlessness may be observed. » Assessment—Assessing complaints should include a complete set of vital signs as well as EKG and capnog- raphy. Breath sounds should be auscultated with each patient encounter. Providers should be especially atten- tive for the presence of wheezing, rales, rhonchi or the absence of breath sounds. 27–29 Digestive and Gastrointestinal Conditions— Gastrointestinal (GI) bleeding. » Causes—Upper GI bleeding tends to originate in the esophagus, stomach or duodenum. It can be caused by peptic ulcers, gastritis, esophageal varices, Mallory-Weiss tears, cancers and/or the inflammation of the GI lining from ingested substances such as alcohol. Lower GI bleed- ing tends to originate in the duodenum, large intestine, rectum and anus. Causes can include diverticular disease, gastrointestinal cancers, inflammatory bowel disease (IBD), infectious diarrhea, polyps, hemorrhoids and anal fissures. 30 » Symptoms—Depending on the type and location of the GI bleed, the patient's symptoms may start with vomiting blood or having bowel movements that may include black, tarry stools. Vomited blood may have an appearance similar to coffee grounds. Hemoptysis often indicates an upper GI source. Bright red or maroon stool can be the result of a lower GI source or from brisk bleed- ing from an upper GI source. Long-term GI bleeding may go unnoticed and can result in fatigue, anemia or black stools. Additional symptoms can include weakness and shortness of breath. 30 Complications from Alcohol (Cirrhosis)—Cirrhosis may lead to or contribute to a variety of complications including variceal bleeding in the esophagus and stomach, altered mental status, kidney failure, diabetes, changes in blood counts and the ability to clot, and decreased muscle mass. » Symptoms—Cirrhosis can lead to a loss of appetite, a lack of energy or feeling of fatigue, bruising easily, skin that has a yellow hue or the presence of jaundiced eyes, skin that is itchy, edema of the ankles, legs or abdomen, urine that has a brown or orange tint, mental status changes, bloody stools and fever. 31 Hepatitis—Hepatitis A, B, and C may be the result of numer- ous factors including the effects of the homeless lifestyle and the potential lack of hygiene. Hepatitis is caused by an exposure to a substance such as feces (hepatitis A), blood (hepatitis B & C) and other bodily fluids (hepatitis B & C). » Symptoms—Common symptoms can include jaun- dice skin, abdominal pain, decreased appetite, nausea, fever, diarrhea, fatigue, joint aches and muscle pain. Additional symptoms can include the redness on the palms of the hands, blood vessels just below the skin that look like tiny red spiders on the patient's chest, shoulders and face, edema of the abdomen, legs and feet, as well as possible variceal bleeding in the gastrointestinal tract. 32 H o m e l e s s m a l e s w h o c o n s u m e s i g n i f i c a n t a m o u n t s o f a l c o h o l o v e r t i m e t e n d t o e x p e r i e n ce m o r e h e a d i n j u r i e s a n d a r e a l s o m o r e l i k e l y t o s u s t a i n a ce r e b r a l h e m o r r h a g e .