Campus Conundrum

[MrBrown]

You are called to a local frat house for a seizing female about 20. Her frat sisters report she was feeling unwell with nausea /vomiting the last few days, uanble to pee and had been having cramps. Tonight she was partying when she began to complain of a rapidly worsening headache and started to seize shortly thereafter.

Patient is unconscious w GCS 4 (1/1/2)
BP is 160/100
PR is 84 reguar
RR is 20 NL
SPO2 is 98% RA
BGL is 6 mmol or 108ml/dl
Temp is 37°C or 98°F
Normal 12 lead although there might be some T wave inversion
No track marks
Pupils dialated
No rash or other signs of meningitis

The local hospital is twenty minutes down the road.

You are whatever level of provider you wish to be and those handy fellows Brown and Oz from helicopter are sitting on thier bum watching telly should you require them.

 

[jjesusfreak01]

I dunno, sepsis following UTI?

 

[Lifeguards For Life]

high flow 02 right? 25lpm via NRB? and 6lpm through a nasal cannula under that just to be safe?

 

[Emtpbill]

Abdomen soft? Any masses?

 

[mikie]

medications? medical hx?

 

[Sandog]

With a GCS of 4 and possible stroke symptoms, I would call for Mr. Brown and his jumpsuit

 

[Handsome Robb]

What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?

 

[Sandog]

What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?

Dilated, see OP. ^_^

 

[lightsandsirens5]

Hmmm.....brain tumor? I dunno.

There are some s/s of stroke, I don't know. I'll prolly call out Brown and Oz anyhow.

"Control, 803, ILS, clear and transporting one, requesting air intercept for transfer to Sacred Heart. Coordinates to follow shortly, contact is 582 on LERN, 803."


Hey Brown.......we need a picture of your bird sometime.

 

[jrm818]

Abdomen soft? Any masses?

Like a baby? What's the pt. look like - tall/short, petite/obese, abdomen grossly distended, flat, etc?

If we're still on scene, can we get any more history out of the frat sisters? Hopefully she's not a very private person. Is the pt. regularly sexually active? Any chance we know if shes been having periods lately? Any vaginal bleeding, discharge, etc?

Any history of drug use - today or in the past? Ditto also on prescription meds? What sort of etoh intake today?

What did the seizure look like? How long did it last? How long did it take us to get there/how long has she been unconscious?

In the absence of any further history its going to be a bit tough to make any sort of definitive diagnosis.

Stroke is a possibility I suppose, but in a 20 y/o its sort of low on my list.

For now I think supportive treatment is all that can be done. Maintain airway, think about working on the BP, get a line and prepare to terminate any further seizures, think about intubation I suppose (assuming the pt. doesn't start coming around).

Working differential list:

eclampsia
drug intake with a red herring history
seizure disorder, again with a red herring history
renal derangement/shutdown leading to electrolyte issues
stroke, but the rest of the history doesn't really fit with that
brain tumor
something different

If she isn't pregnant I'm really grasping at straws without a better history

 

[CAO]

I'm in the boat of trying to get a little more from her sisters.

Did she ever get checked out for her prior complaints?

Was somebody with her the whole time she was partying? Any chance anybody slipped anything into her drink?

Any recent surgeries?

 

[CAO]

Forgot to ask.

Is the posturing bilaterally equal?

 

[MrBrown]

I dunno, sepsis following UTI?

Nope

high flow 02 right? 25lpm via NRB? and 6lpm through a nasal cannula under that just to be safe?

Sure, why not I mean we all know it makes a difference right?

Abdomen soft? Any masses?

Yes and no

medications? medical hx?

No meds and nothing her frat sisters know

What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?

HEMS are ten minutes away, of course being a wholesome Republican party approved all American college town ... the volunteer fire department to set up a landing zone are thirty minutes away.

Like a baby? What's the pt. look like - tall/short, petite/obese, abdomen grossly distended, flat, etc?

The patient is a well nourished, healthy looking 20yof about 140lbs and 5'5" tall

If we're still on scene, can we get any more history out of the frat sisters? Hopefully she's not a very private person. Is the pt. regularly sexually active? Any chance we know if shes been having periods lately? Any vaginal bleeding, discharge, etc?

Unknown but she said that she was having trouble peeing ie unable to produce urine

Any history of drug use - today or in the past? Ditto also on prescription meds? What sort of etoh intake today?

Nothing that anybody will admit too apart from some standard drinks

What did the seizure look like? How long did it last? How long did it take us to get there/how long has she been unconscious?

The seizures lasted a few minutes and were tonic/clonic style without a postictal phase

Did she ever get checked out for her prior complaints?

Was somebody with her the whole time she was partying? Any chance anybody slipped anything into her drink?

Is the posturing bilaterally equal?

She didn't get checked out (broke college student) and she was alone for a period but nobody knows who with.

Here is some bloodwork:

Serum osm 200
CSF is hyperosmolar
Urine NA is 40
Urine osm is 250
FENa .14
UP Creat 150
Preg neg
BAC 0
BGL 6

 

[Melclin]

Hyponatraemia?

Bet she's been on the bickies and hasn't been eating properly. But of course, I'd have to refer to the good doctor.

EDIT: Just saw the last post. Now I'm confuseded. I wanna press her about the ectasy. But if she hasn't been weeing then I'm stumped.

 

[Aidey]

What was her K+?


Acute renal failure. Hyponatremia can be present because of all the extra potassium.

 

[jrm818]

Darn, I was hoping she was one of those pregnant and didn't know it girls you see on TV....guess that's out the window....

That moves us down my list to a renal issue. I agree with the hyponatremia guess, and will go ahead and throw out a vote for renal shutdown leading to osmotic dilution and enough electrolytic imbalance to cause the sz and current ALOC.

The anuria suggests to me that there's something obstructive going on. My other thought (aided by google) was that inappropriately high ADH secretion could at least greatly diminish urine output, but her urine is pretty dilute (only slightly more concentrated than her serum) so the low/nil urine output is probably due to lack of flow through the kidney.

It seems to me that obstructive renal shutdown would explain the cramping, serum hypo-osmolarity, and would indeed eventually cause hyponatremia, higher FENa (or so says google), and could account for the proteinurea, raised creatine, and even the hypertension (thank you renin).

Beyond this I'm way out of my depth, I'm not sure I know how to sort through the possibilities obstruction-wise...but very interested to hear the next update. Further testing is called for I suspect....

 

[CAO]

At this point in my training, I want to point at the sodium too.

The BP's has me wondering, though.

Gah...there's so much more I need to learn.

 

[MrBrown]

Brown will have to start posting harder scenarios ......

 

[jrm818]

Does that mean someone won the prize??

Was this a real case? I'm interested to know what caused her problems in the first place, and what the outcome is.

 

[lightsandsirens5]

Brown will have to start posting harder scenarios ......

You cannot say that and then not tell!

And if you do start posting harder ones, that means that every time we solve one, you must remove one letter from the back of your jumpsuit. Ie. Brown's jumpsuit says DOCTOR. Brown posts scenario. EMTLife community solves scenario. Brown must alter jumpsuit to now read: DOCTO. This will continue for Five more scenarios until brown has a blank jumpsuit and everyone thinks he is the garbage truck driver. :-D