Alt mental status

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folpak

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You are dispatched to 84 y/o F with altered mental status. Upon arrival you are directed into the home by a woman who says "My mother wont respond to me anymore." As you enter the back bedroom you find a woman who is laying supine in bed.
Your partner starts to gather vitals as you are questioning the daughter. The only information you can gather from the crying daughter is that she gave her mother a hot bath and was dressing her when she started to act "funny", she is also normally AOx3 or 4 (what ever you prefer).

Hx includes MI 1 year ago, Hyperthyroidism, Anemia, COPD, DM I-insulin dependent, hip Fx, malnutrition, chronic pain, bowel obstruction.

BV: B/P 100/62, HR 54 thready, Resp 10 shallow, lungs diminished BiLat, GCS is E4,V2,M4, SpO2 is 90 (pt on 2lpm home O2), BGL 120.

MEDS unknown, daughter cant find the list.

What else would you like to know and what should you be doing?
 
Pupils?
Is she compliant with her medications?
Family history?
Can we send someone to raid the medicine cabinet?
 
compliant yes, Family Hx includes diabetic, MI, CVA, pupils are constricted, daughter is looking for the list/Rx containers... no extra hands to look at this time.
 
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What's her temperature? How does she smell? Pupils? Was the bath unusually hot?

I'm gonna go for pupils and the medicine cabinet first (edit: OK, never mind if I can't send someone--I won't be leaving the patient). Could be altered because she took too many pain meds. In the meantime, a quick stroke assessment seems in order. AMS+hyperthyroidism+malnutrition (possibly indicative of generally poor or intermittent care) would make me wonder about thyroid storm as well, but the symptoms don't fit. Diabetic emergency is a bit more like it, and I'd inquire further about her history there, although the BGL isn't all that scary. Low hemoglobin seems possible, and I'd inquire further into what kind of anemia she has. Regardless, we're heading to the hospital, and I'll be administering some O2.
 
Not sure what to call this but I'm leaning towards 10LPM O2 via NRB while we look for meds.

Would like to have RSI capable backup come towards me too.
 
(It's kind of late in the evening that I write this, so it's a little jumbled, almost stream of consciousness thing. Bear with me.)

How's the house? I'd have noted this one way or another while on the way in... How long ago did this start happening?

Check pupils, see if they're reactive and if she's purposely looking at things. Otherwise, BGL looks OK, VS may be a little low, or even be normal for her. I'm not too happy with the HR, breathing rate, depth, and SPO2. Check if grossly warm or cold.

My thinking: Put patient on high conc. O2 (Here it's 15L/NRB). Ask what the daughter means by "funny". Have her act it out if necessary. Send the daughter to raid the med cabinet. (grab everything her mom takes) Recheck VS. Do a stroke exam as best as possible. Check temperature. Obvious signs of trauma or infection? ETOH? How long was she in the tub and how warm was it? Skin signs?

She could be dehydrated and be having an electrolyte imbalance... she could be having a stroke...

My feeling is that she doesn't need to be in the house, she needs to be evaluated in an ED, where they have a proper lab... Consult with OLMD while on scene, preparing to transport, or while en-route to the ED. One of the things that concerns me is that she went from being OK to ALOC pretty quickly, if the daughter is to be believed. Sometimes, what's "normal" is what was 5 years ago... so you have to ask if that's recent behaviors, not just distant past with a steady decline to the current state.

Without more info, I'd have a hard time narrowing things down further...
 
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as stated above in my first response her pupils are constricted and she is not responsive enough for a stroke assessment (check out the GCS). she has been put on NRB, SpO2 is now 95..... I would wait on RSI for now MrBrown. her skin temp is warmer than normal but remember she was just in a nice warm bathtub, she is also dressed in a T-shirt and pair of light pants. No obvious trauma and daughter was at her side at all times, she is normally ambulatory with assistance and AOx3-4, No ETOH, no strange smells to body or breath and she was in the tub for about 25-30 min (it helps her achey body). ALT mental status been progressively worse since leaving the bath aprox 15-20 min ago.

The bag of meds are found... o what relief. in the bag you find bottles Plavix, ASA, Albuterol, Insulin, Lantus, multi vit, Tapazole (methimazole)thyroid). maybe a few others.. not important at this time.

In the mean time the daughter is hysterical and borderline nervous break down and is having a tough time answering questions.

Did i miss any requests?
 
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please describe the findings of a physical exam.

What does the woman look like? Emaciated? Hiar loss? Goiters or gross abnormalities? What is her rectal temp?

What does the skin look like? The abd? is it distended?

Does the daughter know the renal status?

Senility?

Babinski reflex?

Tetany?

Can she hear?

If her eyes are open do they move?

exothalmus?

Did she take her meds today? (speaking of, keep in mind when handed a bunch of meds they may not all be current)

What does her heart sound like? Pulsus paradoxis?

Does she have a prolonged expiratory wheeze?

Is the water still in the tub?

How much of the methimazole is left in the bottle, when was it refilled?

Does she have a "dolls eyes" finding?

Myxedema?

What does the EKG look like?

Bowel/bladder habits?

What was done for the MI?

there are simply not enough findings to rule out:
Neuro insult.
Cardiac insult
hypo/hyper thermia
PE
shock/hypovolemia
hypothyroid from OD.
electrolyte imbalance

help me out, pretend i know how to physically examine the patient and give me some findings.
 
i will tell you one thing after all those nice questions lol. you may be thinking to hard.. much simpler than most of those things. Without trying to give it away it is something you should pick up on it with in a visual assessment of the pt but im not telling unless someone asks :P FYI a basic EMT could diagnose this, no ALS assessment tools needed.

Also as a side note all the meds looked like they were taken as prescribed
 
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Veneficus said:
please describe the findings of a physical exam.

What does the woman look like? Emaciated? Hiar loss? Goiters or gross abnormalities? What is her rectal temp?

What does the skin look like? The abd? is it distended?

Does the daughter know the renal status?

Can she hear?

If her eyes are open do they move?

Did she take her meds today? (speaking of, keep in mind when handed a bunch of meds they may not all be current)

Does she have a prolonged expiratory wheeze?

Is the water still in the tub?

How much of the methimazole is left in the bottle, when was it refilled?

Bowel/bladder habits?

What was done for the MI?

help me out, pretend i know how to physically examine the patient and give me some findings.
Click to expand...

first of all thats a heck of a assessment veneficus.
Appears to be in poor health but clean and kept, skin is flushed/pale. Abd not distended. temp is 98.6F. no wheeze only diminished. some hair loss but she is old. renal status is good. she is responsive to pain only. Bowel movement today. CABG. water in tub has cooled by now.

RESP are 8 now...
 
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Chonic pain, pin point pupils, decreased resp. drive? Can we get a trial of Naloxone?
 
well you gave small dose of narcan en route and Pt RESP increase to 11-12 and somewhat responsive to verbal stimuli but its a long transport and the Pt condition returns to previous Vsigns and symptoms fairly quickly. something overlooked during assessment?.. Im going fishing :) so you have plenty of time to assess during the transport lol.
 
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folpak said:
The bag of meds are found... o what relief. in the bag you find bottles Plavix, ASA, Albuterol, Insulin, Lantus, multi vit, Tapazole (methimazole)thyroid). maybe a few others.. not important at this time.
Click to expand...

What is the opioid that is not important at this time?
 
The fentanyl patch stuck to her whatever (shoulder, arm, stomach etc).

Or, the multiple fentanyl patches, because who ever was putting them on didn't realize they had to take the old ones off.
 
Aidey is the million dollar winner :D and she overdosed most likely from the hot bath.
 
the other meds were not important because there were not any pain patches in the bag full of daily meds and i also wanted you to think :P
 
folpak said:
the other meds were not important because there were not any pain patches in the bag full of daily meds and i also wanted you to think :P
Click to expand...

But I can see medication patches.
 
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