38 year-old male altered mental status

[abckidsmom]

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?

 

[Veneficus]

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.

 

[EMTinNEPA]

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.

 

[MasterIntubator]

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
........

 

[MediMike]

2mm pupils...

 

[DrankTheKoolaid]

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.

 

[usalsfyre]

...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.

 

[DrankTheKoolaid]

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

 

[MrBrown]

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.

 

[abckidsmom]

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.

 

[Rykielz]

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.

 

[EMTinNEPA]

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!

 

[Veneficus]

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.

 

[MasterIntubator]

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!!