# Alt mental status



## folpak (Apr 30, 2010)

You are dispatched to 84 y/o F with altered mental status. Upon arrival you are directed into the home by a woman who says "My mother wont respond to me anymore." As you enter the back bedroom you find a woman who is laying supine in bed.
 Your partner starts to gather vitals as you are questioning the daughter. The only information you can gather from the crying daughter is that she gave her mother a hot bath and was dressing her when she started to act "funny", she is also normally AOx3 or 4 (what ever you prefer). 

 Hx includes MI 1 year ago, Hyperthyroidism, Anemia, COPD, DM I-insulin dependent, hip Fx, malnutrition, chronic pain, bowel obstruction. 

 BV: B/P 100/62, HR 54 thready, Resp 10 shallow, lungs diminished BiLat, GCS is E4,V2,M4, SpO2 is 90 (pt on 2lpm home O2), BGL 120.

 MEDS unknown, daughter cant find the list.

 What else would you like to know and what should you be doing?


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## JPINFV (Apr 30, 2010)

Pupils?
Is she compliant with her medications?
Family history?
Can we send someone to raid the medicine cabinet?


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## folpak (Apr 30, 2010)

compliant yes, Family Hx includes diabetic, MI, CVA, pupils are constricted, daughter is looking for the list/Rx containers... no extra hands to look at this time.


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## Seaglass (Apr 30, 2010)

What's her temperature? How does she smell? Pupils? Was the bath unusually hot? 

I'm gonna go for pupils and the medicine cabinet first (edit: OK, never mind if I can't send someone--I won't be leaving the patient). Could be altered because she took too many pain meds. In the meantime, a quick stroke assessment seems in order. AMS+hyperthyroidism+malnutrition (possibly indicative of generally poor or intermittent care) would make me wonder about thyroid storm as well, but the symptoms don't fit. Diabetic emergency is a bit more like it, and I'd inquire further about her history there, although the BGL isn't all that scary. Low hemoglobin seems possible, and I'd inquire further into what kind of anemia she has. Regardless, we're heading to the hospital, and I'll be administering some O2.


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## MrBrown (Apr 30, 2010)

Not sure what to call this but I'm leaning towards 10LPM O2 via NRB while we look for meds.

Would like to have RSI capable backup come towards me too.


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## Akulahawk (Apr 30, 2010)

(It's kind of late in the evening that I write this, so it's a little jumbled, almost stream of consciousness thing. Bear with me.)

How's the house? I'd have noted this one way or another while on the way in... How long ago did this start happening?

Check pupils, see if they're reactive and if she's purposely looking at things. Otherwise, BGL looks OK, VS may be a little low, or even be normal for her. I'm not too happy with the HR, breathing rate, depth, and SPO2. Check if grossly warm or cold. 

My thinking: Put patient on high conc. O2 (Here it's 15L/NRB). Ask what the daughter means by "funny". Have her act it out if necessary. Send the daughter to raid the med cabinet. (grab everything her mom takes) Recheck VS. Do a stroke exam as best as possible. Check temperature. Obvious signs of trauma or infection? ETOH? How long was she in the tub and how warm was it? Skin signs?

She could be dehydrated and be having an electrolyte imbalance... she could be having a stroke...

My feeling is that she doesn't need to be in the house, she needs to be evaluated in an ED, where they have a proper lab... Consult with OLMD while on scene, preparing to transport, or while en-route to the ED. One of the things that concerns me is that she went from being OK to ALOC pretty quickly, if the daughter is to be believed. Sometimes, what's "normal" is what was 5 years ago... so you have to ask if that's recent behaviors, not just distant past with a steady decline to the current state.

Without more info, I'd have a hard time narrowing things down further...


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## folpak (Apr 30, 2010)

as stated above in my first response her pupils are constricted and she is not responsive enough for a stroke assessment (check out the GCS). she has been put on NRB, SpO2 is now 95..... I would wait on RSI for now MrBrown. her skin temp is warmer than normal but remember she was just in a nice warm bathtub, she is also dressed in a T-shirt and pair of light pants. No obvious trauma and daughter was at her side at all times, she is normally ambulatory with assistance and AOx3-4, No ETOH, no strange smells to body or breath and she was in the tub for about 25-30 min (it helps her achey body). ALT mental status been progressively worse since leaving the bath aprox 15-20 min ago.

The bag of meds are found... o what relief. in the bag you find bottles Plavix, ASA, Albuterol, Insulin, Lantus, multi vit, Tapazole (methimazole)thyroid). maybe a few others.. not important at this time. 

In the mean time the daughter is hysterical and borderline nervous break down and is having a tough time answering questions.

Did i miss any requests?


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## Veneficus (Apr 30, 2010)

please describe the findings of a physical exam.

What does the woman look like? Emaciated? Hiar loss? Goiters or gross abnormalities? What is her rectal temp?

What does the skin look like? The abd? is it distended? 

Does the daughter know the renal status?

Senility?

Babinski reflex?

Tetany?

Can she hear?

If her eyes are open do they move? 

exothalmus?

Did she take her meds today? (speaking of, keep in mind when handed a bunch of meds they may not all be current)

What does her heart sound like? Pulsus paradoxis?

Does she have a prolonged expiratory wheeze?

Is the water still in the tub?

How much of the methimazole is left in the bottle, when was it refilled?

Does she have a "dolls eyes" finding?

Myxedema?

What does the EKG look like?

Bowel/bladder habits?

What was done for the MI?

there are simply not enough findings to rule out:
Neuro insult.
Cardiac insult
hypo/hyper thermia
PE
shock/hypovolemia
hypothyroid from OD.
electrolyte imbalance

help me out, pretend i know how to physically examine the patient and give me some findings.


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## folpak (Apr 30, 2010)

i will tell you one thing after all those nice questions lol. you may be thinking to hard.. much simpler than most of those things. Without trying to give it away it is something you should pick up on it with in a visual assessment of the pt but im not telling unless someone asks  FYI a basic EMT could diagnose this, no ALS assessment tools needed. 

Also as a side note all the meds looked like they were taken as prescribed


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## folpak (Apr 30, 2010)

Veneficus said:


> please describe the findings of a physical exam.
> 
> What does the woman look like? Emaciated? Hiar loss? Goiters or gross abnormalities? What is her rectal temp?
> 
> ...



first of all thats a heck of a assessment veneficus. 
Appears to be in poor health but clean and kept, skin is flushed/pale. Abd not distended. temp is 98.6F. no wheeze only diminished. some hair loss but she is old. renal status is good. she is responsive to pain only. Bowel movement today. CABG. water in tub has cooled by now.

RESP are 8 now...


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## JPINFV (Apr 30, 2010)

Chonic pain, pin point pupils, decreased resp. drive? Can we get a trial of Naloxone?


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## folpak (Apr 30, 2010)

well you gave small dose of narcan en route and Pt RESP increase to 11-12 and somewhat responsive to verbal stimuli but its a long transport and the Pt condition returns to previous Vsigns and symptoms fairly quickly. something overlooked during assessment?.. Im going fishing  so you have plenty of time to assess during the transport lol.


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## Veneficus (Apr 30, 2010)

folpak said:


> The bag of meds are found... o what relief. in the bag you find bottles Plavix, ASA, Albuterol, Insulin, Lantus, multi vit, Tapazole (methimazole)thyroid). maybe a few others.. not important at this time.



What is the opioid that is not important at this time?


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## Aidey (Apr 30, 2010)

The fentanyl patch stuck to her whatever (shoulder, arm, stomach etc).

Or, the multiple fentanyl patches, because who ever was putting them on didn't realize they had to take the old ones off.


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## folpak (Apr 30, 2010)

Aidey is the million dollar winner  and she overdosed most likely from the hot bath.


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## folpak (Apr 30, 2010)

the other meds were not important because there were not any pain patches in the bag full of daily meds and i also wanted you to think


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## JPINFV (Apr 30, 2010)

Veneficus said:


> What is the opioid that is not important at this time?



The one that gives away completely the classic signs of an opioid overdose?


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## folpak (Apr 30, 2010)

Veneficus said:


> What is the opioid that is not important at this time?



anyone can read a pill bottle. but it wouldnt have made for a very fun scenario


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## Veneficus (May 1, 2010)

folpak said:


> the other meds were not important because there were not any pain patches in the bag full of daily meds and i also wanted you to think



But I can see medication patches.


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## MrBrown (May 1, 2010)

folpak said:


> Aidey is the million dollar winner  and she overdosed most likely from the hot bath.



you can overdose from a bath?

*eyes his bath tub suspiciously :unsure:


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## Veneficus (May 1, 2010)

I think he is trying to point out that with the bath there is an increase in transdermal absorbtion.

But we'll have none of that talk about downregulation of pain receptors, fecal elimination of fentynal, lesions in the CNS that could cause the same presentation, or even a grossly apparent finding on a physical exam. 

Or you could be like me and get sucked into looking at complex pathological interactions and mixed medications.

and i don't agree with giving narcan to this lady either.


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## JPINFV (May 1, 2010)

Veneficus said:


> and i don't agree with giving narcan to this lady either.



Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?


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## MrBrown (May 1, 2010)

JPINFV said:


> Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?



I agree with you JP I think its maybe a little better to as you say "take the edge off" most ODs than to totally wake them up as then they're often restless/disorentaited/agitated and harder to manage.


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## Veneficus (May 1, 2010)

JPINFV said:


> Just curious (and, for the record, I'm not advocating slamming her with it, just taking the edge off of the OD), but why?



Once you remove the medication patches you will be reducing her pain relief as well as the rate of absorbtion now that she is not in the tub. Even without slamming it, which I don't think anyone here would do. You might have a patient in pain which you cannot control nd the effects of that. Since an opioid will last longer than narcan will, in order to keep the edge off you will need to keep readministering it or set up a drip.

All of the harmful effects of narcan studies I have seen (including pulmonary edema) were demonstrated in the elderly, not 20 year old heroin addicts. 

If you can simply remove the source and ventilate the patient for the time (probably about 1/2 hour or so, which is a majority of your transport here it seems) it takes for her to come around without adding a chemical to the mix, why not just manage her airway? Her HR is a little low, but her BP is still in a reasonable range for somebody of her age. 

Speaking of HR and BP, when her hert does start suddenly increasing contractility and rate you are going to stress the myocardium by acutely making it work harder. She has a hstory and management of hyperthyroid, which is going to add yet more stress to that. Similar in thinking to: you would not want to acutely reverse hyperglycemia, why would you acutely reverse this in a frail person?

Let's say you do start to get an onset or exaxerbation of pulmonary edema? Are you going to start adding furosimide to fix that?

I am not saying narcan is wrong, but in this case it could take you down a path you don't want to go. If you just support her breathing you can eliminate all of that potential. Pathology doesn't happen in a bubble, patients develop compensatory mechanisms over a long time, and if you start rapidly changing their stasis, you can not only make things worse for them, but can cause a really big headache for yourself.


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## Aidey (May 1, 2010)

The reason I got this is because I've had this patient, complete with hysterical family member. It was quite the facepalm case...not to tease you Veneficus but the fire medic did exactly what you did and went off into left field and was ready to activate the stroke team (ignoring the slow onset of decreased LOC...but that is another issue). The look on his face when I pulled off the patches was priceless. 

It was a 20 something Granddaughter was taking care of grandmother with dementia. She was basically winging it as she went along (she had taken over for another family member who just up and left...lots of family drama). She called because grandmother had been deteriorating for a couple weeks and now was too out of it to eat. 

She ended up having 4-5 fent patches on. We didn't give her narcan, we just removed the parches and transported her. If I remember right she had no acute medical issues aside from the OD. It ended up being a social services issue mostly. I believe the hospital arranged for a few days of emergency in home care until something permanent could be found.


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## Veneficus (May 1, 2010)

Aidey said:


> The reason I got this is because I've had this patient, complete with hysterical family member. It was quite the facepalm case...not to tease you Veneficus but the fire medic did exactly what you did and went off into left field and was ready to activate the stroke team (ignoring the slow onset of decreased LOC...but that is another issue). The look on his face when I pulled off the patches was priceless.
> 
> It was a 20 something Granddaughter was taking care of grandmother with dementia. She was basically winging it as she went along (she had taken over for another family member who just up and left...lots of family drama). She called because grandmother had been deteriorating for a couple weeks and now was too out of it to eat.
> 
> She ended up having 4-5 fent patches on. We didn't give her narcan, we just removed the parches and transported her. If I remember right she had no acute medical issues aside from the OD. It ended up being a social services issue mostly. I believe the hospital arranged for a few days of emergency in home care until something permanent could be found.



it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality. 

If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.


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## folpak (May 1, 2010)

Veneficus said:


> it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality.
> 
> If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.



Veneficus, all you had to do was ask if there were patches, but i never seen anyone say they removed a shirt or anything to LOOK. Back to the basics with a proper Basic assessment. i wasnt really looking looking for the treatment of this pt so much as what was wrong.. it was my pt who was treated properly. i was just seeing if anyone would figure it out and no you would not see them right off the bat because she had clothes on. BTW a little Narcan worked great, 0.5mg I think it was...its been a while. she was awake and talking to us feeling great afterwards.

..... pt is hypotensive with no other symptoms or problems.... give a bolus.. how much fun is a scenario like that? i think im in the wrong forum.


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## Veneficus (May 1, 2010)

folpak said:


> all you had to do was ask if there were patches. i wasnt really looking looking for the treatment of this pt so much as what was wrong.. it was my pt who was treated properly. i was just seeing if anyone would figure it out and no you would not see them right off the bat because she had clothes on..



Please refer to my comments about not doing a proper or complete exam. If you are not visualizing patients, especially very sick ones, then you are simply providing poor medical care. it could probably take me the better part of a page to list every single thing I can notice on inspection, so with the exception of all but the rarest signs, I just request anything that is apparent would be provided.




folpak said:


> ..... pt is hypotensive with no other symptoms or problems.... give a bolus.. how much fun is a scenario like that? i think im in the wrong forum.



I usually don't respond to simple scenarios, but I figured that because you had a patient with a history of multiple pathologies that don't work and play well together, it would be something more engaging than:

"I'm going to withhold information like meds because the scenario is harder when you don't have all the information that would make a difference in your dx an treatment." 

That is no different than hypotensive/give a bolus.

The more you know, the more informtion you need to exclude things. A basic can figure out an OD because they have nothing else to choose from relating to metabolism, toxicology, or interconnected pathology.


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## folpak (May 1, 2010)

lets face it, 98% of pt's have a very simple problem. yes, a lot of times ALS in nature but yet simple. our job is to keep folks alive until they arrive . 
I was bored one day and found a forum but not bored enough to argue EMS. so long B)B)


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## alphatrauma (May 1, 2010)

Veneficus said:


> ... but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking.



Reason # 101 why I rarely participate in this sort of thread.


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## Veneficus (May 1, 2010)

alphatrauma said:


> Reason # 101 why I rarely participate in this sort of thread.



yea, i try not to either, but like I said, I had high hopes for this one, it has so much potential. 

Sorry I scared him


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## Aidey (May 1, 2010)

Veneficus said:


> it is not teasing, no worries, but it frustrates the hell out of me when people post scenarios and leave out key bits of information to try and get you to "guess" what they are thinking. Obiously if you lift up somebody's shirt or are looking for abnormalities, if you see 4-5 medication patches on them, that is a readily apparent abnormality.
> 
> If you don't move/remove clothing and do an incomplete exam, that is another matter entirely.



It reminds me of EMT/Paramedic school where if you didn't ask for it specifically they didn't tell you.


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## Veneficus (May 2, 2010)

Aidey said:


> It reminds me of EMT/Paramedic school where if you didn't ask for it specifically they didn't tell you.



I guess that works when there isn't a lot to ask for. But I have no intention of typing out qestions asking whether or not the skin is pulled tight and there are creases around the mouth and all the hundred or so pieces of information I can get just by looking at somebody.


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