# Case Study: Help!?!



## JasonA (Apr 11, 2007)

My instructor canceled class, again. So she sent us these case studies. We are not going to be graded on them, so its ok to help me. She said that we are going to talk about them tomarrow night in class, but, for reasons that I would like to keep to myself, I would rather yall go over what I think first. Oh, and I know, she is not good at spelling or gramar, but you can get the idea. 

The last two I feel really confident about. The first one....:wacko: :huh:

Case Study 1

You respond to a 52 y.o. woman complaining of dyspnea, especially bad at night accompanied by a nocturnal productive cough and fatigue. Your general impression is that he is “sick”.  You patient assessment reveals that she is tachypneic at 32/min and tachycardic at 110/min. She is also hypertensive at 162/102, A & O x 3 and confused, slightly pale with cyanotic lips, PERRL and has good sensory, motor and a cap-refill or 4 seconds.  She feels nauseous, has some abdominal pain, sunken eyes, is weak and has been urinating frequently.  She has not had much of an appetite but has been drinking tea, water and some hot chocolate.   She is allergic to sulpha drugs, takes lipitor 10 mg, lasix 10 mg and crestor 5 mg daily for hypertension and high cholesterol.  She is also diabetic type II and her BG levels read 72. She also takes nitroglycerine for her heart when needed and one baby aspirin daily. Upon auscultation you detect rales her lower lobes. 

What is her condition and what is your treatment? 


Possible Hypoglycemia/COPD

This patient is possibly hypoglycemic, as shown by a BGL of 72. It is possible that hypoglycemia is the cause of all of her signs/symptoms. Lowered LOC, confusion, and abdominal pain are signs of hypoglycemia. It is possible that she has chronically overdosed on Aspirin. As that would account for most of her signs and symptoms. 

She does have possible COPD, which would account for the rales, cyanosis, cough and dyspnea. Her mental status could be altereted due to hypoxia.

I feel that it would not be wise to try and decided which one is the cause. I would transport with highflow 02, and consider D50 or an alternate method of raiseing her BGL.





Case Study 2

You respond to an 80 y.o. man complaining of weakness.  Your patient assessment reveals that he is tachycardic at 122/min, tachypneic at 36/min, A & O x 4, diaphoretic, pale, cool and clammy, peripheral edema, ascites and had a bout of epistaxis last night.  He is allergic to penicillin, is on Zocor daily, Nitrostat when needed, has a nitro patch, baby aspirin daily, Albuterol 2 puffs morning and night, Flovent 1 puff morning and night, 40 mg lasix and a fiber pill daily. He has not had much of an appetite but has been drinking plenty of fluids. 

What is his condition and what is your treatment?


Possible over-use of MDI

Weakness could be any number of things; age related, heart or lung related, it is also possibly an effect of the MDI usage. Tachycardia is a side effect of Albuterol, as is tachypnea. Pale, cool, and clammy skin is an effect of Albuterol, is could also be from his under-lying heart condition. Peripheral edema and ascites are most likely per-existing conditions, and have no relevance to the current situation. This is evidenced by his use of Zocor, Nitrostat, Aspirin, Lasix, and a nitro patch. Epistaxis is a side-effect of Albuterol, as is loss of appetite. His use of two MDIs daily is concerning. In general only one should be used daily, with a fast acting inhaler for sudden onset of symptoms. 

Interventions is this situation are limited to high-flow 02 via a non-rebreather mask at 15lmp. Transport.





Case Study 3

You respond to a 3 y.o. female who’s mother is complaining of dyspnea accompanied by a harsh high-pitched cough.  You patient assessment reveals that she appears sick is tachypneic at 38/min, tachycardic at 118/min normal blood pressure, is running a fever of 102 degrees has a cough and is drooling and is pale and has cyanotic lips. She is also congested and has signs and symptoms of a cold. 

What is her condition and what is your treatment?


Possible Epiglottis

The harsh, high pitched, cough is suggestive of an upper-airway obstruction. The elevated respiration rate suggests insufficient respiratory function. The heart rate is within normal limits for a 3 year old. Fever, cough, and the signs/symptoms of a cold are all consistent with Epiglottis. Drooling is cause by the in-ability to swallow. Cyanosis is cause by the airway being obstructed. Pale is a sign of being sick, also of cyanosis.

There is not much an EMT-B can do in this situation. Provide high-flow 02, via a non-rebreather mask at 15lpm. Transport in a position of comfort. Be ready to provide ventilation via BVM should respirations become even more insufficient.


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## JasonA (Apr 11, 2007)

Instead of COPD, I meant CHF in the first one.


Is it possible that that prevalant condition is Hypovolemia/Dehydration due to the Lasix?

That would account for the high HR, RR, as well as the lowered LOC. Weakness is in there too. The BP is high for compensated shock, but the is on Lipitor and Crestor. Then again, if she is a CHFer, would it even be possible for it to be high?

Cyanonis from poor perfusion, and the sunken eyes. Are abd pain and nauseous a sign of dehydration? Or would you think that would be from the ASA?


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## JasonA (Apr 12, 2007)

I will answer myself.

#1: TB
#2: MI/CHF
#3: Croup/Epilogttitis


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## VentMedic (Apr 12, 2007)

JasonA said:


> Case Study 2
> You respond to an 80 y.o. man complaining of *weakness*.  Your patient assessment reveals that he is *tachycardic *at 122/min, *tachypneic* at 36/min, A & O x 4, *diaphoretic, pale, cool and clammy*, *peripheral edema*, *ascites* and had a bout of *epistaxis* last night.  He is allergic to penicillin, is on Zocor daily, Nitrostat when needed, has a nitro patch, baby aspirin daily, Albuterol 2 puffs morning and night, Flovent 1 puff morning and night, 40 mg lasix and a fiber pill daily. He has not had much of an appetite but has been drinking plenty of fluids.
> 
> What is his condition and what is your treatment?
> ...



Okay JasonA, since I covered the other two cases on the other forum, here is CASE #2.
*Right heart failure* 
Symptoms and Signs include: *Peripheral edema *(fluid build-up in dependent portions of the body), *ascites* (fluid in the abdominal cavity), nocturia (due to increased venous return with leg elevation), Jugular venous distention, *Epistaxis* (due to an increase in venous pressure), Hepatomegaly, hepatojugular reflux, right ventricular heave, *palpitations, fatique and weakness*.  

Of course, this is just one possible diagnosis. There are others. Can't do labs or an echocardiogram on the street easily. An ECG may have chronic changes and without a previous record, hard to compare for acute. 

Albuterol (Beta2 adrenergic bronchodilator) rarely presents the side effects mentioned if pt is using 2 puffs BID. The Flovent MDI is a corticosteriod, anti-inflammatory maintenance med. I usually recommend pts take at least one puff of their bronchodilator a few minutes prior to their maintenance MDIs to assure a deeper deposition of the particles. The MDI therapy is on the conservative side.

Again I stress, treat symptoms as they present and listen to the pt. SOAP, but don't go over board with "diagnosis" during assessment. It is too easy to get distracted by trying to fit what you see into a particular "diagnosis". Like I've said on the forums before, it would be nice if all ailments fit neatly into the diseases studied at the EMT-B and P levels. 

You're thinking things through which is great. Don't jump way ahead of yourself. You have so much to learn and appreciate at the Basic level. Mastering the skills and knowledge you will learn at Basic will get you through many tough calls. BLS before ALS. 

Just remember, watch the pt, monitor the vitals, O2 as appropriate and/or per protocol, position of comfort if possible.  If your EMS system requires you to call for ALS transport, determine if the pt's condition warrants.

Good luck.


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## Alexakat (Apr 12, 2007)

VentMedic said:


> ...Again I stress, treat symptoms as they present and listen to the pt. SOAP, but don't go over board with "diagnosis" during assessment. It is too easy to get distracted by trying to fit what you see into a particular "diagnosis". Like I've said on the forums before, it would be nice if all ailments fit neatly into the diseases studied at the EMT-B and P levels.



My comment too...as EMS professionals, we don't "diagnose" conditions, although we may have our ideas on what's going on, diagnosing medical conditions is ED physician's job.  

We treat the symptoms.  If they don't have an airway, do what you can to give 'em one (position, adjunct if necessary).  If they're not breathing, breathe for them (BVM).  If there's no pulse, start chest compressions & get the AED.  If they're bleeding profusely, do what you can to stop it, etc.  And initiate safe, rapid transport.  It really is that simple.  When I first started, I got hung up on trying to figure out all this complex stuff & got really nervous about "what could it be...???"  Yes, know when to call for ALS or additional resources, but stay focused on the basics.  Good BLS is paramount.  

Enjoy your class!  It is a fascinating adventure!


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## FF/EMT Sam (Apr 12, 2007)

JasonA said:


> Case Study 1
> 
> You respond to a 52 y.o. woman complaining of dyspnea, especially bad at night accompanied by a nocturnal productive cough and fatigue. Your general impression is that he is “sick”.  You patient assessment reveals that she is tachypneic at 32/min and tachycardic at 110/min. She is also hypertensive at 162/102, A & O x 3 and confused, slightly pale with cyanotic lips, PERRL and has good sensory, motor and a cap-refill or 4 seconds.  She feels nauseous, has some abdominal pain, sunken eyes, is weak and has been urinating frequently.  She has not had much of an appetite but has been drinking tea, water and some hot chocolate.   She is allergic to sulpha drugs, takes lipitor 10 mg, lasix 10 mg and crestor 5 mg daily for hypertension and high cholesterol.  She is also diabetic type II and her BG levels read 72. She also takes nitroglycerine for her heart when needed and one baby aspirin daily. Upon auscultation you detect rales her lower lobes.
> 
> What is her condition and what is your treatment?



Step #1: Put the patient on O2
Step #2: Call for ALS
Step #3: Load and go
Step #4: Contact Medical Control and ask for their opinion.  If I were you, I would want to give oral glucose, but my protocols would require an order for it since her glucose is >60.


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## VentMedic (Apr 12, 2007)

JasonA,
Even doctors are cautious about "diagnosising" at first presentation. In the ED, we continue to treat the symtoms at they appear. Labs and X-Rays give us a little more information and those results can be treated. "Misdiagnosis" can haunt a doctor. He may work through a possible dx out loud, but may chart differently. Pts are usually admitted under their chief complaint or symptom, or a relatively broad dx such as Pneumonia or COPD. Signs, symptoms and risk factors can easily be argued for PNA and COPD. If the doctor admits for HTN, he/she is covered by a set of vitals. Does not mean the pt is plagued by chronic HTN. In the notes the doctor may list 10 different possible diagnoses. Most will play it safe by running through protocols of differential testing. Then, specialists are called to continue the process. Again, they are cautious about labeling the pt with a disease immediately. Symptoms and results from lab work will continue to be treated. 

As the complex pt in Case 1 appears, she has a lot going on. Many tests later it may come down to one tidy diagnosis. However, you are going to support her ABCs. If you feel she has something contagious, there is nothing wrong in protecting yourself and others. A pt coughing when you are in close range justifies that regardless of the disease process. 

When giving report, you are going to state her complaint, symptoms and your treatment which with a good report will be obvious. ED staff members can be turned off if you start with a diagnosis in your report. Collecting good data by verbal communication and physical assessment is key at any level. 

You saw on the other forum how over diagnosis can lead to confusion and divert you from your primary goal. Treat the pt, not exerts from a text book that can be taken out of context and miss the bigger picture. Copy and paste doesn't cut it in pt care. 

I had a  patient 2 weeks ago. 20 something college educated professional female, chills, sweats, bloody sputum, isolated infiltrate on CXR, serious hypoxia to where we thought she would be intubated. A very high flow O2 system adverted that. Three days and MANY tests later including a full TB work-up, her dx was Systemic Lupus Erythematosus and Pulmonary Hypertension.  That took everyone by surprise and with great sadness.

Your enthusiasm is refreshing. Don't stop the learning process. Master the BLS! I can not emphasize that enough.


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## Ridryder911 (Apr 12, 2007)

I agree with Ventmedic. The basic EMT curriculum is not in-depth enough to make diagnosis rather than to treat s/s. This is why it is considered more of a first aid course. With more in-depth education some states have "field diagnosis, clinical impressions" which is comparable to preliminary diagnosis. 

Diagnosis in the ED is usually considered a "rule out", until further information can be obtained and a more conclusive diagnosis is made. That is why is there is usually multiple diagnosis on a patient. 

I as well agree with Vent on his interpretation of the scenarios. This was classic presentation and symptoms of CHF, including the medication(s) pointing the past history of the patient, which should had raised your suspicion even more. Although T.B. has some of the symptoms, there are some conflicting ones as well. 

Yes, study as much as possible, but as well focus on the initial BLS treatment as Vent described. 

R/r 911


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## JasonA (Apr 12, 2007)

Thanks, Guys.

Vent, 

Thanks for taking the time to explain it better. I will try to keep in mind not to get disctracted next time she throws something like this at us. We were never really told anything about DX patients. What you posted really clears it up.

I might ask my instructor what she was wanting us to learn from this. I am thinking it was seeing how easily we got confused.

Thanks again.


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## TKO (Apr 14, 2007)

JasonA said:


> I will answer myself.
> 
> #1: TB
> #2: MI/CHF
> #3: Croup/Epilogttitis




Were those the answers provided by your instructor?  I would have thought the first one to be Bacterial Pneumonia.  Of course, the info given isn't enough to be positive of anything (as already well described why).  In that situation, I would be looking for more information such as color of cough-sputum and fever, etc.

Case studies rarely give all the information, which is a reminder why it is important to concentrate on what you do have to work with.  And when it comes to the exams, don't get lost with the House M.D. solutions where something simpler will suffice.


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## Ridryder911 (Apr 14, 2007)

A couple of clues were given... nocturnal dyspnea, only pleuritic type pain. This usually rules out T. B., as T.B. is consistent and does not increase ShOB at different intervals. 

I agree it is a confusing scenario and actually without diagnostic assistance may be both CHF and Pneumonia and dehydration  with electrolyte imbalance. Since the Hx. indicates past CHF and HTN, etc.. and it does not describe the sputum, nor the skin temp. This patient has multiple problems as most real patients do. 

T.B. would be the last consideration of my Dx.  Does not describe the sputum as "rusty colored" and as well the auscultation presented was rales, (by the way is not a common adventitious lung sound in COPD or T.B.) Remember, T.B. patients usually have a increasing malaise type history (over a period of time) with increasing cough as the tubercle basically gets larger and larger. Examine a CXRE with T.B.






 Note the round looking circles, (kinda reminds of you of swiss cheese) those are tubercles, that actually encapsulate the lung tissue.

Remember as well CHF usually will produce APND ( acute paroxysmal nocturnal dyspnea) (that was on my NREMT/P oral board) because of activity during the daytime and the cardiac function will become weaker at nighttime reducing the pre-load and after load. This is why we have those 3 a.m. calls of Shob. As well, you usually find them in the recliner with major edema in the feet (position dependent). Increasing shortness of breath, so they sit in a recliner, and poor pump action to reduce lymphatic fluid flow: hence increase edema. The ascites is can be associated with pulmonary congestion as well and one can detect this easily by checking for hepatojugular reflux, which is as well increased in CHF as discussed by Ventmedic.

The sunken eyes, etc.. can be related to dehydration as well as other symptoms related to electrolyte imbalances. Chronic Lasix administration will produce such and I did not see a K+ supplement (which should be ordered on all patients with Lasix > 10mg p.o.). 

Yes, it is possible for the patient to be in CHF and be dehydrated at the same time. Thus produces a double edge sword... give fluids increase pulmonary edema or restrict and remove fluids and increase dehydration/electrolyte imbalance and cause potential life threatening problems associated with such? 

The patient as well could have community acquired pneumonia (CAP) which is common finding in elderly people. Especially those with underlying histories as described.

Again, I routinely seen patients with all those illnesses together. In reality it is not that uncommon to see a CHF/Pneumonia with dehydration and electrolyte imbalances. 

I believe the instructor was attempting to make a point of a multi complex patient that is routinely seen in the field setting. Very few patients have just one diagnosis and one problem as the text attempts to categorize. Be prepared to examine the patient as a whole with potential multiple problems and treat accordingly and per severity. Again, this is why education is so vital .. a wrong Dx. and Tx. could cause damage to potentially be lethal. 

R/r 911


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## VentMedic (Apr 14, 2007)

Case Study 1

You respond to a 52 y.o. woman complaining of *dyspnea*, especially bad at night accompanied by a *nocturnal productive cough *and *fatigue*. Your general impression is that she is “sick”. You patient assessment reveals that she is tachypneic at 32/min and tachycardic at 110/min. She is also hypertensive at *162/102*, A & O x 3 and *confused*, slightly pale with *cyanotic lips*, PERRL and has good sensory, motor and a cap-refill or 4 seconds. She feels *nauseous*, has some *abdominal pain*, *sunken* *eyes*, is *weak* and has been *urinating fre*quently. She has not had much of an appetite but has been *drinking tea, water and some hot **chocolate.* She is allergic to sulpha drugs, takes lipitor 10 mg, *lasix *10 mg and crestor 5 mg daily for hypertension and high cholesterol. She is also diabetic type II and her BG levels read 72. She also takes *nitroglycerine* for her heart when needed and one baby aspirin daily. Upon auscultation you detect *rales* her *lower lobes*. 


As RidRyder elaborated on, nocturnal dyspnea due to lying down flat and  pulmonary fluid accumulation in the lungs would point toward a cardiac orgin.

GI causes also can have noc productive cough. It would go along with the tea and choc milk (both caffeine stimulants) could be GERD. This can also lead to a whole set of pnuemonitis problems. Bibasilar rales; chronic aspiration at night or fluid accumulation of a cardiac nature. Bibasilar rales can be chronic in some people. Abdominal pain; bowel disorders, bladder infection, renal disease (also leads to HTN), acid-base problem and/or electrolyte problems for confusion Cyanosis; pulmonary hypertension or any assortment of V/Q mismatching.  Chronic undiagnosed sleep disorders can produce/enhance cardiac disorders and HTN. 

Chicken or the egg?

But then, I'm going treat the immediate needs first and see how long it takes the hospital doctors to come up with one or more diagnoses.

ABCs; list it out. Take care of the priority problems that YOU can help at the BLS. 

RidRyder's last paragraph pretty much sums up the lesson.


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## TKO (Apr 15, 2007)

I concur completely.  But remember that sometimes a pt calls in the evening because they tolerate more discomfort when they aren't tired but when it comes time to sleep and they are tired and can't tolerate not getting to sleep they decide this may be a good time to call EMS.

Military trials have shown that a soldier will sell their mother out just to get some sleep.

This info on TB (while a minor statistic but growing) has been very informative.  But your BLS tmt is the same as for pneumonia, except that you need to be aware of the possibility of TB with a coughing pt and BSI becomes much more important.

Good case study.  Again, don't look for zebras when you hear the thunder of hooves -- look for horses.


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## medichopeful (May 17, 2012)

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My thoughts exactly! :unsure:


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