# Here Ye, Here Ye, All Ye Para-God's, Gather 'Round.



## Papa (Oct 4, 2011)

You and your partner are dispatched code 3 to a residence for a 38 year old female with a chief complaint of nausea and vomiting.

Your unit arrives at 5:45 am to an affluent neighborhood and locates the patient's home. You are greeted at the door by the patient's husband who greets you and urgently directs you to the master bedroom. You note the house is well kept, with no pets, no signs of smoking, and a fully stocked wine cabinet in the kitchen.

The husband is a CPA, and the patient is a kindergarten teacher.

You find the patient in a semi fowlers position in her bed. A trash can has approximately 200 cc's of fresh vomit. Partially digested food is present, along with trace amounts of undigested blood. Vomit is in all appearances, in other words "normal".

The patient is warm and dry, with slight turgor skin is slightly flushed. Vitals are obtained and found to be pulse: 106, regular in strength and rhythm, bp: 132/90, oral temp: 100.9 F, SPO2: 94, bgl: 58, RR 22 per minute, lung sounds: equal, clear bilaterally.

Patient reports "the worst nausea and vomiting of my life" for the past 6 days with little relief, except for maybe the worst part is in the morning,and the smell of the vomit makes her nausea much more worse. The patient is also approximately 9 weeks pregnant (G4P4A0), and has a prenatal physician. The patient is on lexapro for general anxiety. The patient is in excellent shape, and reports having lost weight since her pregnancy began, because of all the vomiting. She is able to keep some meals down, most likely in the late evening. The patient is a little slow to answer questions, but is responding appropriately.

You notice the patient has conjugate gaze palsy, and has slight diffuculty ambulating to stretcher

Patient also reports "bright red specks of blood in stools", but does not remember when she first noticed it, or if there was any blood in her last bowel moment approximately 1 hour ago.

Physical exam finds bruising on the patient's back, left shin, and the backs of both of the patients arms. In addition her feet and ankles are swollen. Inspection of the abdomen is negative for pain, tenderness, pulsating masses, swelling, guarding, tenderness, rigidity and swelling. 


You notice the patient has conjugate gaze palsy, and has slight difficulty ambulating to stretcher

What is your plan of attack here? thoughts, questions, comments, concerns?

Treatments you will administer? how sick is this patient? will you transport priority? what level hospital will you be transporting too.

And most importantly diagnosis.


----------



## Papa (Oct 4, 2011)

Also patient denies any pertinent past medical history, and had no complications with any previous pregnancies.

It is bedtime for me, let me know if you think any relevant information is missing. i think everything you need to play should be there, but I do make mistakes


----------



## johnrsemt (Oct 4, 2011)

9 weeks pregnant, I am thinking maybe  morning sickness.

Bruising is a concern.

IV, fluid,  maybe D5 if you carry it;   oral glucose allowing it to absorb into mucose membranes;  Zofran.   transport.
  Pt doc needs to put her on ODT Zofran.  (my last medical director's wife lived on it for about 6 months when pregnant with the twinfants).


----------



## zzyzx (Oct 4, 2011)

Hyperemesis gravidarum is the first thing that comes to mind. Not sure about the swelling as she's too early in her pregnancy for pre-eclampsia. The bit of blood in the vomit would not be unexpected, but I'm not sure about the possible blood in her stools. What are is her BP and other vitals? Would be interested in her labs as well.


----------



## zzyzx (Oct 4, 2011)

Never mind---just saw the vitals. To clarify, has she been vomiting a lot for days or mostly just feeling nausea?


----------



## boingo (Oct 4, 2011)

Hope she gets some hellp soon...She's sick.


----------



## zzyzx (Oct 4, 2011)

I have to admit that I just Googled conjugate gaze palsy and that gave me another clue, but I won't give it away since I cheated.

If you were to ignore that symptom and the vomiting, you might also consider that she may be septic.


----------



## awildstein (Oct 4, 2011)

I see two possibilities that would also explain the conjugate gate palsy. One: hyperemisis due to pregnancy has lead to a thiamine deficiency and thus Wernike's encephalitis. Or, two: the patient is suffering from a  lesion in the temporal area of her brain. Pregnancy means a much greater risk of throwing clots (and rarely, Lexapro use does as well). 
This is certainly not an easy one!


----------



## HMartinho (Oct 4, 2011)

She had a sudden weight gain?

I'll give oxygen via nasal cannula 3 lpm, transport in recovery position and monnitoring BP, pulse, temp, pulse ox and resp.


----------



## abckidsmom (Oct 4, 2011)

Taking a stab.  I'm going with some kind of autoimmune thrombocytopenia, combined with hyperemesis gravidarum.

I wonder if the constant vomiting has actually raised ICP enough to cause an intracerebral injury?

I'm just thinking out loud here, and really don't have any more of a working diagnosis.

Also, I just would like to clarify:  if she's currently pregnant with her fourth child, and has 3 living children, she's G4P3A0.  Missing this is something I see a lot on QA review.  G=pregnancies P=actual children for Parenting A=abortions.


----------



## medicsb (Oct 4, 2011)

boingo said:


> Hope she gets some hellp soon...She's sick.



I see what you did there!


----------



## Papa (Oct 4, 2011)

johnrsemt said:


> 9 weeks pregnant, I am thinking maybe  morning sickness.
> 
> Bruising is a concern.
> 
> ...



Well, that is a nice thought, but that hardly makes for an interesting scenario, now does it?

They say when you hear hoof beats, think horses, not zebras. But the one time you hear hoof beats and don't turn around and look, your *** is going to get mauled by a zebra.

This is that time.


----------



## Papa (Oct 4, 2011)

zzyzx said:


> Never mind---just saw the vitals. To clarify, has she been vomiting a lot for days or mostly just feeling nausea?



Mostly nauseous, but vomit is fairly often as well.


----------



## Papa (Oct 4, 2011)

zzyzx said:


> I have to admit that I just Googled conjugate gaze palsy and that gave me another clue, but I won't give it away since I cheated.
> 
> If you were to ignore that symptom and the vomiting, you might also consider that she may be septic.



If we were to ignore ALL of her signs and symptoms, we may consider that she is Perfectly fine and go back to quarters. It is fairly early in the morning afterall.


----------



## Papa (Oct 4, 2011)

HMartinho said:


> She had a sudden weight gain?
> 
> I'll give oxygen via nasal cannula 3 lpm, transport in recovery position and monnitoring BP, pulse, temp, pulse ox and resp.



Weight loss. She claims to weigh less now, than she did before the pregnancy.

Well I guess if you do almost nothing for the patient, you can't really harm them now can you? Could you not answer almost every scenario with vitals, o2 monitor iv and transport?


----------



## Papa (Oct 4, 2011)

awildstein said:


> This is certainly not an easy one!



Hence, the summoning of the resident para gods.


----------



## Papa (Oct 4, 2011)

abckidsmom said:


> Also, I just would like to clarify:  if she's currently pregnant with her fourth child, and has 3 living children, she's G4P3A0.  Missing this is something I see a lot on QA review.  G=pregnancies P=actual children for Parenting A=abortions.



Unless she had that thing where there are 2 little womb dwelling parasites that often look alike.

Twins?


----------



## HMartinho (Oct 4, 2011)

Papa said:


> Weight loss. She claims to weigh less now, than she did before the pregnancy.
> 
> Well I guess if you do almost nothing for the patient, you can't really harm them now can you? Could you not answer almost every scenario with vitals, o2 monitor iv and transport?



In Portugal is what we do, unless you are a pre-hospital nurse or physician. I'm just an EMT-B, I can provide BLS only, and keep me away from drugs/medicines.


----------



## Nervegas (Oct 5, 2011)

Honestly, my thought is either A) Thiamine deficiency - the conjugate gaze being one of the classic Wernicke's signs, or B) a potential for a brain lesion (bruising makes me think of a clot?). Regardless, she is what I would consider sick. Treatment? IV TKO, O2, Monitor, Zofran, and contact MC for possible Thiamine admin. Would be transporting this one code O(Opticom for those who don't know) unless traffic becomes a problem in which case I would expedite to code 3, nearest lvl 3 or better medical center.


----------



## systemet (Oct 5, 2011)

Papa said:


> What is your plan of attack here? thoughts, questions, comments, concerns?



Hyperemesis gravidium stands out as an obvious suspect.  Others have mentioned the possibility of thiamine deficiency, leading to neurological sequelae.  

With the prolonged period of vomiting, it would be nice to know what her 'lytes are doing -- but of course that information is rarely available to us.  

I'd like to know more about the "bruising".  Is there a fall history here?  Is it suspicious for spousal abuse?  Can it be explained?  And are these true contusions, or are they purpura?  Are we seeing findings and history suggestive of some sort of anemia / thrombocytopenia? Besides the obvious blood in stool / vomitus.  Is some sort of coagulopathy at play?

She's hypoglycemic (barely) at 3.2 mmol/L.  This could also explain an abnormal neuro exam, and should be corrected.  But I'm suspecting that it's not going to be that simple.

Other potential badness: intracranial hemorrhage, neoplasm, subdural, CNS infection, occult GI hemorrhage.




> Treatments you will administer?



IV access, see if the patient will tolerate drinking / eating some form of sugary fluid, and some complex carbs.  (Not to elicit a cancellation -- they're going to the ER).  If they won't, maybe 100ml of D5W.  See if normalisation of the bG corrects the neuro deficits.

I'd withhold antiemetics unless the patient is actively vomiting / requesting them.  If so, I'd discuss the potential risk to the pregnancy, advise against them for simple nausea.  

If vomiting, I'd consider zofran, but would actually probably patch and discuss this with an MD first. [*I know people hate patching, but this is actually not a bad situation in which to get a more educated opinion]

To an ER with neuro.



> how sick is this patient?



Probably quite sick.  If the abnormal neuro exam remains once the bG has been normalised, and it's truely abnormal (i.e. this isn't baseline), there's something bad happening in the CNS.



> will you transport priority?



What's the transport time?  

Probably not.



> what level hospital will you be transporting too.



Somewhere with CT / neuro.



> And most importantly diagnosis.



Nausea / vomiting NYD? AMS?

I guess working diagnosis: hypoglycemia secondary to hyperemesis gravidium.

Differentials: as above.


----------



## boingo (Oct 8, 2011)

Any follow up?


----------



## Smash (Oct 8, 2011)

Papa said:


> Mostly nauseous, but vomit is fairly often as well.



Pedantic point of the day:  The patient is probably not nauseous, she is nauseated.

Despite it's common usage, nauseous is an adjective that describes something that causes nausea: someone who is nauseated is no more nauseous than someone who is poisoned is poisonous.

This particular pearl of pedantry brought to you by the letter orange, the number Pi and 6 shots of bourbon.


----------



## tssemt2010 (Oct 8, 2011)

sepsis keeps entering my mind, yes she is sick, but i wouldnt consider her to be an urgent patient, IV tko, maybe shoot a quick 12 lead to rule anything out, give some zofran and be on our way to the hospital


----------



## abckidsmom (Oct 8, 2011)

Smash said:


> Pedantic point of the day:  The patient is probably not nauseous, she is nauseated.
> 
> Despite it's common usage, nauseous is an adjective that describes something that causes nausea: someone who is nauseated is no more nauseous than someone who is poisoned is poisonous.
> 
> This particular pearl of pedantry brought to you by the letter orange, the number Pi and 6 shots of bourbon.



Pedanticism:  making dorks smile since 1611:


----------



## jjesusfreak01 (Oct 8, 2011)

Nervegas said:


> Would be transporting this one code O(Opticom for those who don't know) unless traffic becomes a problem in which case I would expedite to code 3



I need to confirm this with the medics from my local Opticom enabled city, but I believe we only use it here when we're going L&S anyways.


----------



## tssemt2010 (Oct 8, 2011)

jjesusfreak01 said:


> I need to confirm this with the medics from my local Opticom enabled city, but I believe we only use it here when we're going L&S anyways.



i know of a certain FD that always has their opticom on


----------



## Nervegas (Oct 9, 2011)

jjesusfreak01 said:


> I need to confirm this with the medics from my local Opticom enabled city, but I believe we only use it here when we're going L&S anyways.



It isn't an official transport method, but we use it to expedite if we feel its one of those on the fence calls that could go either way. Yes, I know of a few FD's and PD's that run O all the time now that the new infra-red ones aren't visible to the naked eye.


----------



## IRIDEZX6R (Oct 9, 2011)

Nervegas said:


> It isn't an official transport method, but we use it to expedite if we feel its one of those on the fence calls that could go either way. Yes, I know of a few FD's and PD's that run O all the time now that the new infra-red ones aren't visible to the naked eye.



Hmm my rigs were opticom equiped but it was part of the L&S setup, are your guys on a separate switch?


----------



## Nervegas (Oct 10, 2011)

IRIDEZX6R said:


> Hmm my rigs were opticom equiped but it was part of the L&S setup, are your guys on a separate switch?



Yup, Master switch, Pri/Sec, Wig Wag and then Opticom.


----------



## Handsome Robb (Oct 10, 2011)

Nervegas said:


> Yup, Master switch, Pri/Sec, Wig Wag and then Opticom.



Similar setup to ours. 

We are in the process of replacing our fleet. The plan is in January to start buying 1 new chassis for the next ~24 months. None of the new ambulances will have Opticom. It just doesn't work here. 

I'm excited for our new Chevys.


----------



## Farmer2DO (Oct 20, 2011)

tssemt2010 said:


> sepsis keeps entering my mind, yes she is sick, but i wouldnt consider her to be an urgent patient, IV tko, maybe shoot a quick 12 lead to rule anything out, give some zofran and be on our way to the hospital




Sepsis certainly is a possibility, but if you think it is, I question your opinion that she isn't urgent.  She meets 3 of the 4 criteria for SIRS.  At any ED in my city that makes her an ESI 1 in triage.





zzyzx said:


> Hyperemesis gravidarum is the first thing that comes to mind. Not sure about the swelling as she's too early in her pregnancy for pre-eclampsia. The bit of blood in the vomit would not be unexpected, but I'm not sure about the possible blood in her stools. What are is her BP and other vitals? Would be interested in her labs as well.




I'm worried about the bruises and some sort of coagulopathy.  Pre-eclampsia CAN happen before 20 weeks if there is a hydatidform mole in the uterus instead of a viable fetus.  It can also cause hyperemesis.  A coagulopathy could also explain an intracranial hemorrhage, and the conjugate gaze palsy.




Papa said:


> Well, that is a nice thought, but that hardly makes for an interesting scenario, now does it?
> 
> They say when you hear hoof beats, think horses, not zebras. But the one time you hear hoof beats and don't turn around and look, your *** is going to get mauled by a zebra.
> 
> This is that time.



Agreed.


----------



## rowinggurl (Oct 28, 2011)

As a medic student this is my thinking, please let me know if im thinking wrong.

Pt is a 38 y/o female. Once you get past the age of 35 chances of miscarrage and/or birth defects increase. Pt has a fever of 100.9 (if I recall right). Could be caused from a miscarrage and the fetus poisoning her. She was also hypoglycemic. No hx of gestational diabetes? Or could the hypoglycemia be caused from the fever???

As for the bruises - any possibility of abuse or falls? 

I don't know if this could explain anything, but how long ago did she give birth to the last child?


----------



## shockinainteasy75 (Oct 30, 2011)

The slight hypoglycemia i would relate to the fact she isnt eating or drinking and is vomiting on a regular basis, i would expect a healthy person to be at this BGL with no intake and that amount of emesis. Along with the undigested blood in the emesis probably related to the excessive vomiting creating tears in the esophogas. Ill agree with the hyperemesis gravidum. The bruising would make me suspicious for abuse or regular falls due to the irregular pattern of brusing. She could be septic or sick with a common ailment exagerated by her pregnancy and lowered immune to go with it. Either way, I would trans asap, IV, NS KVO, consider zofran after consult, Oral glucose if she was able to follow directions, 12 lead, O2 NC, 2lpm titrated to >95%. Transporting pri 2 to a facility with in house L&D staff.


----------

