# 38 year-old male altered mental status



## EMTinNEPA (Mar 3, 2011)

You are working on a non-transport capable paramedic intercept vehicle and are dispatched along with the local volunteer BLS service for a 38 year-old male in seizures.  You arrive on scene to find the patient awake and alert, but lacking orientation to time and place.  Repetitive statements and questioning suggest short-term memory loss.  The patient's family states that they found the patient semi-responsive with "drainage" from the mouth and nose and that they did not witness any seizure activity.  The patient denies complaints of chest pain, shortness of breath, weakness, dizziness, nausea, vomiting, or flu-like symptoms.  The patient complaints of thirst.

Past medical history of anxiety and chronic back pain.

Medications are Percocet and Xanax.

Allergy to walnuts.

VITALS
BP - 80/60
HR - 120
RR - 16
O2 Sat - 86% on room air, 94% on 4lpm via nasal cannula
EKG - Sinus tachycardia without ectopy

Physical exam
HEENT: Normocephalic.  No drainage or bleeding from ears, nose, or mouth, Pupils PEARL at 2mm.  Negative JVD.  Trachea midline.
CHEST: Normal and symmetrical movement on inspiration and expiration.  Lungs clear and equal to auscultation.
ABDOMEN: Soft, non-tender, non-distended.
BACK/SPINE: Unremarkable.
PELVIS: Unremarkable.
EXTREMITIES: Unremarkable.

BLS arrives on scene at the same time you do.  Your closest hospital is approximately 20 minutes away.

What are your differentials and how would you proceed in treating this patient?


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## abckidsmom (Mar 3, 2011)

Can we check his blood glucose before we dig in here?


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## MasterIntubator (Mar 3, 2011)

He probably took too many of his drugs


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## fast65 (Mar 3, 2011)

BG? Anything that suggests he may have OD'd? Any chance he hit his head during the seizure activity, seems like he might have a concussion.


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## abckidsmom (Mar 3, 2011)

My thoughts:

Sugar issues, further assessment required (either hyper- or hypoglycemia.)
CVA
Sz (any trauma?)
Any fever?
Drug OD
Psych issues

Need more info.


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## fast65 (Mar 3, 2011)

abckidsmom said:


> My thoughts:
> 
> Sugar issues, further assessment required (*either hyper*- or hypoglycemia.)
> CVA
> ...



The complaint of thirst makes start thinking of hyperglycemia, but that's just my initial thought right now.


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## 46Young (Mar 3, 2011)

Drug abuse is a possiblilty. I'd like a BGL and a 12 lead. you didn't mention any indication for spinal motion restriction. Besides the hypotension, there's nothing that needs to be addressed onscene that can't be done enroute to the hospital. You've got a 20 minute txp. Do everything enroute. O2's already on, I'd get IV access, hang a bag at KVO to start, then do a BGL and a 12. You should have the driver pull over when you record the 12 to avoid artifact. I'd like to know why he's hypotensive before I just go and give a bolus.


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## MasterIntubator (Mar 3, 2011)

46Young said:


> You should have the driver pull over when you record the 12 to avoid artifact.



Do you really do this?


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## 46Young (Mar 3, 2011)

MasterIntubator said:


> Do you really do this?



We did this on IFT cath lab jobs when I worked at NS-LIJ. We had a goal of less than ten minutes from arrival at the ED to transporting. I'd typically attatch the 12 in the bus, since so much of our time was spent getting report, changing over the pumps, getting to and from the ED, etc. It takes less than a minute to pull over to the side of the road, hit the button, and then resume transport when the monitor advisies analyzing. 

As far as 911, I like to get a 12 onscene in the house within the first five minutes if indicated. I usually have plenty of help, all of which can properly position a 12. Our txp times run from 5-20 minutes in most cases. I run a repeat 12 at the ED, after turning off the vehicle, before taking the pt out of the bus. For the OP, it's unknown if that crew can place a 12. He's 20 minutes from the closest hospital. He didn't say if it was a stroke center, trauma center, or STEMI center. Twenty minutes is plenty of time to get things done. Although a cardiac event is low on my list of differentials, the 12 can show other things. That's why I said I would do one on the way to the hospital, rather than add on to that 20 min txp time. I've had many 12's ruined by artifact from bumps in the road, rig vibrations, the pt adjusting themselves after said bumps, etc. Stopping on the side of the road only takes a minute, if that. If it's unsafe to do so at the moment, I'll have the driver keep going, run a 12 in motion, and pull over if needed due to the quality of the previous 12.


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## Mobey (Mar 3, 2011)

Temp?


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## MrBrown (Mar 3, 2011)

Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.


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## 46Young (Mar 3, 2011)

MrBrown said:


> Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.



True. He could be in now decompensated shock presumeably from osmotic diuresis per his mental status, BP, and pulse rate.


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## abckidsmom (Mar 3, 2011)

MrBrown said:


> Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.



I'm with you, Brown, dear.  But at 38?  I don't know.

Seems like we'll just never know.  Maybe we should imagine up some details so that we can think more clearly.


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## 46Young (Mar 3, 2011)

abckidsmom said:


> I'm with you, Brown, dear.  But at 38?  I don't know.
> 
> Seems like we'll just never know.  Maybe we should imagine up some details so that we can think more clearly.



Yeah, the OP left us hanging.


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## MrBrown (Mar 3, 2011)

abckidsmom said:


> I'm with you, Brown, dear.  But at 38?  I don't know.



Diabetes doesnt discriminate 

Irs nice you think so affectionatly of Brown, but Brown is taken. sorry love, Mrs Brown is not the life-insurance sharing kind


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## Rykielz (Mar 3, 2011)

EMTinNEPA said:


> You are working on a non-transport capable paramedic intercept vehicle and are dispatched along with the local volunteer BLS service for a 38 year-old male in seizures.  You arrive on scene to find the patient awake and alert, but lacking orientation to time and place.  Repetitive statements and questioning suggest short-term memory loss.  The patient's family states that they found the patient semi-responsive with "drainage" from the mouth and nose and that they did not witness any seizure activity.  The patient denies complaints of chest pain, shortness of breath, weakness, dizziness, nausea, vomiting, or flu-like symptoms.  The patient complaints of thirst.
> 
> Past medical history of anxiety and chronic back pain.
> 
> ...



The two key points that I've seen from the information you've given thus far, is that he is complaining of thirst (which as pointed out by several people, could be an indicator for hyperglycemia) as well as a low SPO2 indicating hypoxia. Your gonna want to find out what his BS is as well as look at his skin signs. From there I'd want to know if he has a headache or any blurred vision. Also it'd be nice to know what color the "drainage" from his mouth or nose is. It's hard to identify a diagnosis without that information.


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## abckidsmom (Mar 3, 2011)

MrBrown said:


> Diabetes doesnt discriminate
> 
> Irs nice you think so affectionatly of Brown, but Brown is taken. sorry love, Mrs Brown is not the life-insurance sharing kind



abckidsdad feels the same way, don't worry.  fraternal affection.  

I would have been completely on the diabetes team if he'd been having a respiratory rate north of 20.  The slow, even breathing convinces me not.  But then again, maybe his respiratory rate was more along the lines of WNL.  (we never looked)


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## 46Young (Mar 3, 2011)

abckidsmom said:


> abckidsdad feels the same way, don't worry.  fraternal affection.
> 
> I would have been completely on the diabetes team if he'd been having a respiratory rate north of 20.  The slow, even breathing convinces me not.  But then again, maybe his respiratory rate was more along the lines of WNL.  (we never looked)



I thought about the resp rate as well. I'll add another diagnostic on my wish list: ETCO2 capnography/capnometry.


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## abckidsmom (Mar 3, 2011)

46Young said:


> I thought about the resp rate as well. I'll add another diagnostic on my wish list: ETCO2 capnography/capnometry.




Keep dreaming, we're not getting any more details.  We are a needy bunch here, only a few are up to presenting a scenario.  (You'll note I never have.)  I learn more about what I potentially miss here than what others are catching, lol.

It's all educational, though.


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## Veneficus (Mar 3, 2011)

abckidsmom said:


> We are a needy bunch here, only a few are up to presenting a scenario.



Like any other skill, you can't get better without practice.


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## abckidsmom (Mar 3, 2011)

Veneficus said:


> Like any other skill, you can't get better without practice.



I know.  Can you point me to some reading on presenting patients?  Preferably an online resource?


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## Veneficus (Mar 3, 2011)

abckidsmom said:


> I know.  Can you point me to some reading on presenting patients?  Preferably an online resource?



No online resources that I know of. I actually learned it by watching others and making my own mistakes. 

One of the best doctors here actually makes a game out of listening to your presentation and asking some totally off the wall question and strangely enough you never forget to present that finding again.

The medical case presentations in trade journals like NEJM are very good resources. 

I have made mention several times here. There is no guesswork in a properly presented scenario, your skill at logically correlating the findings and searching for specific ones should lead you to the answers. Even if you have to ask for additional findings, it should be no different than looking at an actual patient.

To skilled examiners and historians, subtle findings make big differences. List everything you observed and important things you didn't.


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## EMTinNEPA (Mar 4, 2011)

Sorry, all.  Busy night at work.

Blood glucose is 135mg/dL.
12-lead shows sinus tachycardia without ectopy and does not indicate any type of cardiac event.
No headache.
No blurred vision.
No trauma involved here.
When asked where the patient's medications are kept, the family does not know, and the patient can't remember.
Los Angeles and Cincinnati pre-hospital stroke screens are negative.
The patient is afebrile.
No history of any psychiatric disorder.  The patient had no behavioral disturbances until found in this state.
Unfortunately, the "drainage" was not available to view (family cleaned it up before arrival), and they state that they forget what color it was.  Yes, that really was the answer I got.

EDIT: Also, the closest hospital is not only a stroke center, but a STEMI center, a Level II trauma center... has pretty much everything except a burn unit and a NICU.


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## MasterIntubator (Mar 4, 2011)

Still smells like drugs to me.  They seem to be lying.... hiding something.  A little Narcan chaser would be on my list to start with.  And a nose hose...

Other differencials....  even though the vitals don't always suggest it...
Organophosphates
Family hiding something
Brain bleed
Family hiding something
Ethylene glycol
Family hiding something
Something hereditary missed earlier in life
........


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## MediMike (Mar 4, 2011)

2mm pupils...


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## DrankTheKoolaid (Mar 4, 2011)

*re*

Let us not forget Diabetes Insipitus will also cause Hypovolemic Shock which this patient is in.  And the (f)bgl can be normal.

Actually let me expand on that.

While noted above the pupils are 2mm   the resp are not depressed at 16.
Nothing noting oral mucosa status / breath or skin turgor.
The hypoxia can easily be from poor perfusion from his shock status
The "drooling" can easily be attributed from him  displaying the "Q" sign while obtunded from the hypotension.  But it was never said if the patient was found sitting upright slumped over or what and then lowered to the ground which would help redistrubute enough volume to increase cerebral perfusion to awake him albeit still altered.

While this may not be the final diagnosis.  Dont pigeon hole yourselves because of his medications.


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## usalsfyre (Mar 4, 2011)

Corky said:


> ...the resp are not depressed at 16...



I would argue that considering the hypoxemia a RR of 16 is indeed depressed. He's sick enough to significantly alter his PaO2 and he's not attempting to compensate?

Naloxene is probably appropriate based on physical findings and history. Fluid bolus, say a liter of warm LR. Strip him down and do a physical exam, looking for signs of infectious process. Any odors noted? Alcoholism history? Outside of a stroke screen, how's his other neuro look? Visual acuity, nystagmus, is he able to ambulate? Transport non-emergent looking for signs of deterioration as always.


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## DrankTheKoolaid (Mar 4, 2011)

usalsfyre said:


> I would argue that considering the hypoxemia a RR of 16 is indeed depressed. He's sick enough to significantly alter his PaO2 and he's not attempting to compensate?
> 
> QUOTE]
> 
> The hypoxia is a relative pulse oximeter reading known to be innacurate when associated with hypotension.  ABG with actual arterial numbers would be nice.  But then again I treat patients and not machine readings.  He would be treated like any other patient in shock in the field. High flow O2, low fowler's supine, Fluid challenge based on BP/Mentation/skin signs.  Consider pressors if fluid didnt work and if that failed consider a hydrocortisone dose for adrenal insufficieny / unknown steriod use.   Full secondary en route etc etc etc


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## MrBrown (Mar 4, 2011)

Testing Browns visual acutiy may result in a negative number 

Brown would drag him out to the vehicle, put a drip in him and start a bag of fluid and see if we can get the pressure up a bit.


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## abckidsmom (Mar 4, 2011)

Also, people who only have a history of back problems and whose only stated medications are narcotics have a high drama index.  I would be fairly suspicious of a drama component, or a drama component fueling a toxicological component.

I'm staying on the toxicology team, but I don't really suspect narcotics to be the offending agent.  

As far as treatment goes, I'd consider management of his airway if he needed it, and would start an IV and give a little fluid.  

Like someone else mentioned, I'm not putting a whole lot of stock in that low SpO2 because of his hypotension, but I'd put him on oxygen regardless of everything I've ever read here.


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## Rykielz (Mar 5, 2011)

Now that we've got a better picture, I'm gonna say the pt overdosed on some medication. I've seen several suicidal pt's try this route and end up with similar, if not exact signs/symptoms (i.e. seizing, ALOC, drooling, hypotension). I think it's fair to surmise this based off the fact that the family seems like their trying to cover something up, the pt's pupils are constricted, and they can't locate his medications. I bet when they do some blood work and/or pump his stomach they'll find the goodies.


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## EMTinNEPA (Mar 5, 2011)

My treatment of this patient consisted of IV fluids, O2, and 12- and 15-leads... when the patient's pressure did not respond to oxygen and fluids, I administered 2mg of Naloxone.  Within a few minutes, the patient was considerably less lethargic.  His pupils dilated to 6mm and his pressure rose to 120/70.  He remained confused, which made me suspect that there was more than opiates in his system.  Upon arrival at the hospital, his pupils had constricted back down to 3mm and his pressure was at 100.  The fact that these symptoms began returning about the time I would suspect the Naloxone to start wearing off confirmed that he had indeed overdosed.  The ER physician shared my opinion, but unfortunately I wasn't able to follow up.  Very interesting case for me, and the first time I'd ever seen an overdose present that way.

Thanks for participating, everyone!


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## Veneficus (Mar 5, 2011)

EMTinNEPA said:


> My treatment of this patient consisted of IV fluids, O2, and 12- and 15-leads... when the patient's pressure did not respond to oxygen and fluids, I administered 2mg of Naloxone.  Within a few minutes, the patient was considerably less lethargic.  His pupils dilated to 6mm and his pressure rose to 120/70.  He remained confused, which made me suspect that there was more than opiates in his system.  Upon arrival at the hospital, his pupils had constricted back down to 3mm and his pressure was at 100.  The fact that these symptoms began returning about the time I would suspect the Naloxone to start wearing off confirmed that he had indeed overdosed.  The ER physician shared my opinion, but unfortunately I wasn't able to follow up.  Very interesting case for me, and the first time I'd ever seen an overdose present that way.
> 
> Thanks for participating, everyone!



If I had to guess, naloxone drip with discharge.


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## MasterIntubator (Mar 5, 2011)

Good job!  In our area, these are very common, and happen almost every shift.  You will soon gain the crapometer plug-in and that will forever help you when given certain key words/facts/symptoms.
They even happen in the 'house of God'... keep on your toes!!


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