# Generalized weakness and SOB



## LACoGurneyjockey (Jun 27, 2017)

You respond code 3 for difficulty breathing to find a 71 year old male sitting in his recliner at home. The patients daughter meets you at the door to tell you her father can't breath and is extremely weak. She came to check on him this morning after he hasn't been feeling well for 2 days. When she tried to get him out of bed, he defecated on himself and was unable to support his own weight. She dragged him out to the living room recliner where you find him. She says he has diabetes, high blood pressure, and hyperthyroidism.
The patient states he feels mostly fine, just can't catch his breath. He tells you this is just because of the heat, and repeats that he is fine. It is a comfortable room temperature inside, and about 70-80 degrees outside. He is oriented but slow to respond, and whispers very quietly whenever he speaks, which per the daughter is not his normal. You notice he is breathing about 40/min and shallow. He is extremely pale, with cool moist skin. He consents to treatment and you obtain vital signs. His blood pressure is 154/92, pulse is 70 and irregular, and spo2 is 95% on room air. Blood glucose is 128 and he shows a-fib on the monitor. He denies any history of a-fib or any cardiac hx. A 12 lead is attached.
What more would you like to know about his history? What are your priorities of treatments, if any? You have an 8 bed community hospital with very limited capability 5-10min away, and a large trauma/stemi/stroke capable hospital a little over an hour away. What's your destination decision and why? What's your differential diagnosis?


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## E tank (Jun 27, 2017)

Lung sounds? Heart sounds?


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## NomadicMedic (Jun 27, 2017)

What's his temperature. What's capnography look like? What's his detailed history and meds.


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## VentMonkey (Jun 27, 2017)

Call for the helicopter because the CAH will wind up calling for them anyhow (we both know this). Given the co-morbidities, and NOS arrhythmia I vote for the SRC.

Also, more info please...and thank you.


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## SpecialK (Jun 27, 2017)

I need no further information to decide he (a) requires immediate referral to ED and (b) ambulance transport is appropriate.

People who have no history of AF shouldn't be in AF.

I perhaps spy maybe 1 mm of ST depression in V4-6 so let's do a posterior ECG to make sure it's not a posterior STEMI.

I wouldn't provide him with any specific treatment at this stage.

Also, why does his ECG have "not for diagnosis" written on it? I've never seen that before.  What on earth else are you supposed to do with it?


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## MonkeyArrow (Jun 27, 2017)

He's diabetic and the 12 lead is concerning for hyperkalemia with peaked T-waves and a non-specific interventricular conduction delay.


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## Old Tracker (Jun 27, 2017)

Has he been taking his meds for the hyperthyroidism?


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## LACoGurneyjockey (Jun 27, 2017)

Lung sounds are clear in all fields and equal bilaterally. Temp is normal, with etco2 in the 20-25 range and unremarkable waveform. Been taking his meds, and shows you a bag of metformin, lisinopril, metoprolol and synthroid. Neither he nor his daughter can say much more about his history, other than that he sees his primary doctor regularly and "hasn't had any wrong for a while".
Any more specific info? Differentials?


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## VentMonkey (Jun 27, 2017)

Thyroid storm.


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## CWATT (Jul 2, 2017)

VentMonkey said:


> Call for the helicopter because the CAH will wind up calling for them anyhow (we both know this). Given the co-morbidities, and NOS arrhythmia I vote for the SRC.



So many acronyms...     CAH?  NOS?  SRC?


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## VentMonkey (Jul 2, 2017)

CWATT said:


> So many acronyms...     CAH?  NOS?  SRC?


Lol.

1. CAH= Critical Access Hospital
2. NOS= New OnSet
3. SRC= STEMI Receiving Center.


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## CALEMT (Jul 2, 2017)

New onset of A-Fib with left axis deviation and a left anterior fascicular block. Some ST elevation in lead 1 and AVL and a little depression in V5 and V6. Either way I don't like it, still going to a STEMI center.


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## DrParasite (Jul 3, 2017)

CWATT said:


> So many acronyms...     CAH?  NOS?  SRC?


too many TLA for me to understand either.
[QUOTE="LACoGurneyjockey, post: 649703, member: 18785"Blood glucose is 128 and he shows a-fib on the monitor. He denies any history of a-fib or any cardiac hx. A 12 lead is attached.[/QUOTE]Agree with @SpecialK.   New onset of Afib is not a good sign, and warrants a trip to the ER, preferably one with cardiac resources (I guess we are taking the ride to the STEMI hospital).

D/D: dehydration, thyroid issue, new onset A-Fib... either way,  probably a nice easy  ride to the ER with IV access established, and maybe some fluid if I'm thinking dehydration


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## RocketMedic (Jul 8, 2017)

How's urine output? The timeline here is actually driving me towards renal failure or sepsis, as is the ECG and breathing. I don't like the a-fib, but it's perfusing, so meh. Ventilate, IV, fluids and calcium, rapid trip to good hospital.


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## LACoGurneyjockey (Jul 8, 2017)

He hasn't been able to get out of bed for over 24hrs and has not urinated on himself.
About 30 minutes after first making contact, his mental status began to rapidly deteriorate. He became hypotensive at 70/40, a fib in the 120 range with no other EKG changes, and can no longer make appropriate words. 
Wound up with new onset renal failure, a K of 8.9, and was intubated at the receiving facility, with a levo and epi drip, awaiting dialysis when we cleared.


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## VentMonkey (Jul 8, 2017)

LACoGurneyjockey said:


> Wound up with new onset renal failure, a* K of 8.9*.


very fortunate that they didn't arrest.


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## Tigger (Jul 10, 2017)

To me that EKG combined with the history makes me think me think HyperK. Those T waves are ugly.


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