# Weird case



## HMartinho (Aug 23, 2011)

Im here to tell a weird case that I had:

15 yo male with dyspnoea, chest pain and lethargic. 

- BP: 105/60
- HR: 120 
- RR: 30
- Spo2: 70%
- Capilary refill is about 5 seconds
- Normal breath sounds, there is no crackles or wheezes.
- pupils normal and reactive to light.
- There is no history of asmtha or pulmonary disease.

What is your guess? What do you do in this case?


----------



## truetiger (Aug 23, 2011)

Medical history? EKG? Recent illness?


----------



## HMartinho (Aug 23, 2011)

truetiger said:


> Medical history? EKG? Recent illness?



In Portugal, only doctors and nurses can do ECG. When the nurse came to help us, the monitor showed sinus tachycardia. He has always been healthy until now. Only one episode of the influenza A few months ago.


----------



## truetiger (Aug 23, 2011)

With the limited information given, PE comes to mind. As far as treatment goes, lets get that hypoxia corrected and see about treating that chest pain with some fentanyl.


----------



## fast65 (Aug 23, 2011)

Recent surgeries or trauma? Possible allergies? Did you do a complete physical exam? 

I'm kinda thinking it may be a PE

Sent from my mobile command center


----------



## Handsome Robb (Aug 23, 2011)

I'm going to jump on the PE bandwagon as well. What kind of pain? Can the pt point to it or is it generalized? Skin signs? Sudden onset? 

Truetiger pretty much covered it. Get the sats up and make the patient comfortable. Start a fibrinolytic checklist if your area uses them.


----------



## johnrsemt (Aug 24, 2011)

Everyone jumped to PE  which is a good differential diagnosis;  but how about Asthma?  
  Asthma with no history means it is the first time.
  Asthma with no wheezing means it has gone to the point that the patient is not moving enough air to wheeze any longer.

  I would start with oxygen,  NRB  10-15L/m and if that didn't help in a few (5-6) minutes; I would do a breathing treatment.
   Not going to hurt them in the long run  a 15 yo can handle an increased HR from 120 up to 140-150.    If it is asthma it is a quick cure;  and if not,  you have ruled out another possibility.


----------



## Sasha (Aug 24, 2011)

johnrsemt said:


> Everyone jumped to PE  which is a good differential diagnosis;  but how about Asthma?
> Asthma with no history means it is the first time.
> Asthma with no wheezing means it has gone to the point that the patient is not moving enough air to wheeze any longer.
> 
> ...



I would think of his breathe sounds are normal, then youre not past the point of asthma wheeze and its likely not asthma. 

Is there room on the PE bandwagon for me?

Sent from LuLu using Tapatalk


----------



## fast65 (Aug 24, 2011)

johnrsemt said:


> Everyone jumped to PE  which is a good differential diagnosis;  but how about Asthma?
> Asthma with no history means it is the first time.
> Asthma with no wheezing means it has gone to the point that the patient is not moving enough air to wheeze any longer.
> 
> ...



I briefly considered that, however, he said that LS were normal, not absent. So to me that says he's moving air just fine, but there's a problem with gas exchange.

Sent from my mobile command center


----------



## firetender (Aug 24, 2011)

johnrsemt said:


> I would start with oxygen, NRB 10-15L/m and if that didn't help in a few (5-6) minutes;


 
Why o2 for someone probably hyperventillating? Much info missing here, especially psychological assessment. This did not come out of nowhere. What about street drugs?

Report more thoroughly please.


----------



## truetiger (Aug 24, 2011)

Probably hyperventilating?


----------



## usalsfyre (Aug 24, 2011)

firetender said:


> Why o2 for someone probably hyperventillating?



The profound hypoxia suggested by the SpO2 of 70% is enough for me....


----------



## HMartinho (Aug 24, 2011)

usalsfyre said:


> The profound hypoxia suggested by the SpO2 of 70% is enough for me....



Yes, it's true. This patient had a very severe hypoxia. During the transport to hospital, even with O2 15 l / min by NRM, SpO2 was only 86%. Even so the nurse decided do not intubate (I don't know why). 

At the hospital, after the chest MRI, arterial blood gas and pulmonary angiography, the doctor diagnosed a PE, which is very weird. He was not obese, did not smoke, had no recent fractures. Just had a healthy life. Not to mention that he was very young.

just another proof that these problems can occur at any age.


----------



## usalsfyre (Aug 24, 2011)

Any recent episodes of being relatively immobile? Flights, car or train trips? Marathon CE sessions?


----------



## HMartinho (Aug 24, 2011)

usalsfyre said:


> Any recent episodes of being relatively immobile? Flights, car or train trips? Marathon CE sessions?



Ouch... Our mistake. We forgot to ask him these questions...h34r::unsure:


----------



## truetiger (Aug 24, 2011)

I wouldn't call it weird, its not common but it happens.


----------

