Here Ye, Here Ye, All Ye Para-God's, Gather 'Round.

[Papa]

You and your partner are dispatched code 3 to a residence for a 38 year old female with a chief complaint of nausea and vomiting.

Your unit arrives at 5:45 am to an affluent neighborhood and locates the patient's home. You are greeted at the door by the patient's husband who greets you and urgently directs you to the master bedroom. You note the house is well kept, with no pets, no signs of smoking, and a fully stocked wine cabinet in the kitchen.

The husband is a CPA, and the patient is a kindergarten teacher.

You find the patient in a semi fowlers position in her bed. A trash can has approximately 200 cc's of fresh vomit. Partially digested food is present, along with trace amounts of undigested blood. Vomit is in all appearances, in other words "normal".

The patient is warm and dry, with slight turgor skin is slightly flushed. Vitals are obtained and found to be pulse: 106, regular in strength and rhythm, bp: 132/90, oral temp: 100.9 F, SPO2: 94, bgl: 58, RR 22 per minute, lung sounds: equal, clear bilaterally.

Patient reports "the worst nausea and vomiting of my life" for the past 6 days with little relief, except for maybe the worst part is in the morning,and the smell of the vomit makes her nausea much more worse. The patient is also approximately 9 weeks pregnant (G4P4A0), and has a prenatal physician. The patient is on lexapro for general anxiety. The patient is in excellent shape, and reports having lost weight since her pregnancy began, because of all the vomiting. She is able to keep some meals down, most likely in the late evening. The patient is a little slow to answer questions, but is responding appropriately.

You notice the patient has conjugate gaze palsy, and has slight diffuculty ambulating to stretcher

Patient also reports "bright red specks of blood in stools", but does not remember when she first noticed it, or if there was any blood in her last bowel moment approximately 1 hour ago.

Physical exam finds bruising on the patient's back, left shin, and the backs of both of the patients arms. In addition her feet and ankles are swollen. Inspection of the abdomen is negative for pain, tenderness, pulsating masses, swelling, guarding, tenderness, rigidity and swelling.


You notice the patient has conjugate gaze palsy, and has slight difficulty ambulating to stretcher

What is your plan of attack here? thoughts, questions, comments, concerns?

Treatments you will administer? how sick is this patient? will you transport priority? what level hospital will you be transporting too.

And most importantly diagnosis.

 

[Papa]

Also patient denies any pertinent past medical history, and had no complications with any previous pregnancies.

It is bedtime for me, let me know if you think any relevant information is missing. i think everything you need to play should be there, but I do make mistakes

 

[johnrsemt]

9 weeks pregnant, I am thinking maybe morning sickness.

Bruising is a concern.

IV, fluid, maybe D5 if you carry it; oral glucose allowing it to absorb into mucose membranes; Zofran. transport.
Pt doc needs to put her on ODT Zofran. (my last medical director's wife lived on it for about 6 months when pregnant with the twinfants).

 

[zzyzx]

Hyperemesis gravidarum is the first thing that comes to mind. Not sure about the swelling as she's too early in her pregnancy for pre-eclampsia. The bit of blood in the vomit would not be unexpected, but I'm not sure about the possible blood in her stools. What are is her BP and other vitals? Would be interested in her labs as well.

 

[zzyzx]

Never mind---just saw the vitals. To clarify, has she been vomiting a lot for days or mostly just feeling nausea?

 

[boingo]

Hope she gets some hellp soon...She's sick.

 

[zzyzx]

I have to admit that I just Googled conjugate gaze palsy and that gave me another clue, but I won't give it away since I cheated.

If you were to ignore that symptom and the vomiting, you might also consider that she may be septic.

 

[awildstein]

I see two possibilities that would also explain the conjugate gate palsy. One: hyperemisis due to pregnancy has lead to a thiamine deficiency and thus Wernike's encephalitis. Or, two: the patient is suffering from a lesion in the temporal area of her brain. Pregnancy means a much greater risk of throwing clots (and rarely, Lexapro use does as well).
This is certainly not an easy one!

 

[HMartinho]

She had a sudden weight gain?

I'll give oxygen via nasal cannula 3 lpm, transport in recovery position and monnitoring BP, pulse, temp, pulse ox and resp.

 

[abckidsmom]

Taking a stab. I'm going with some kind of autoimmune thrombocytopenia, combined with hyperemesis gravidarum.

I wonder if the constant vomiting has actually raised ICP enough to cause an intracerebral injury?

I'm just thinking out loud here, and really don't have any more of a working diagnosis.

Also, I just would like to clarify: if she's currently pregnant with her fourth child, and has 3 living children, she's G4P3A0. Missing this is something I see a lot on QA review. G=pregnancies P=actual children for Parenting A=abortions.

 

[medicsb]

Hope she gets some hellp soon...She's sick.

I see what you did there!

 

[Papa]

9 weeks pregnant, I am thinking maybe morning sickness.

Bruising is a concern.

IV, fluid, maybe D5 if you carry it; oral glucose allowing it to absorb into mucose membranes; Zofran. transport.
Pt doc needs to put her on ODT Zofran. (my last medical director's wife lived on it for about 6 months when pregnant with the twinfants).

Well, that is a nice thought, but that hardly makes for an interesting scenario, now does it?

They say when you hear hoof beats, think horses, not zebras. But the one time you hear hoof beats and don't turn around and look, your *** is going to get mauled by a zebra.

This is that time.

 

[Papa]

Never mind---just saw the vitals. To clarify, has she been vomiting a lot for days or mostly just feeling nausea?

Mostly nauseous, but vomit is fairly often as well.

 

[Papa]

I have to admit that I just Googled conjugate gaze palsy and that gave me another clue, but I won't give it away since I cheated.

If you were to ignore that symptom and the vomiting, you might also consider that she may be septic.

If we were to ignore ALL of her signs and symptoms, we may consider that she is Perfectly fine and go back to quarters. It is fairly early in the morning afterall.

 

[Papa]

She had a sudden weight gain?

I'll give oxygen via nasal cannula 3 lpm, transport in recovery position and monnitoring BP, pulse, temp, pulse ox and resp.

Weight loss. She claims to weigh less now, than she did before the pregnancy.

Well I guess if you do almost nothing for the patient, you can't really harm them now can you? Could you not answer almost every scenario with vitals, o2 monitor iv and transport?

 

[Papa]

This is certainly not an easy one!

Hence, the summoning of the resident para gods.

 

[Papa]

Also, I just would like to clarify: if she's currently pregnant with her fourth child, and has 3 living children, she's G4P3A0. Missing this is something I see a lot on QA review. G=pregnancies P=actual children for Parenting A=abortions.

Unless she had that thing where there are 2 little womb dwelling parasites that often look alike.

Twins?

 

[HMartinho]

Weight loss. She claims to weigh less now, than she did before the pregnancy.

Well I guess if you do almost nothing for the patient, you can't really harm them now can you? Could you not answer almost every scenario with vitals, o2 monitor iv and transport?

In Portugal is what we do, unless you are a pre-hospital nurse or physician. I'm just an EMT-B, I can provide BLS only, and keep me away from drugs/medicines.

 

[Nervegas]

Honestly, my thought is either A) Thiamine deficiency - the conjugate gaze being one of the classic Wernicke's signs, or B) a potential for a brain lesion (bruising makes me think of a clot?). Regardless, she is what I would consider sick. Treatment? IV TKO, O2, Monitor, Zofran, and contact MC for possible Thiamine admin. Would be transporting this one code O(Opticom for those who don't know) unless traffic becomes a problem in which case I would expedite to code 3, nearest lvl 3 or better medical center.

 

[systemet]

What is your plan of attack here? thoughts, questions, comments, concerns?

Hyperemesis gravidium stands out as an obvious suspect. Others have mentioned the possibility of thiamine deficiency, leading to neurological sequelae.

With the prolonged period of vomiting, it would be nice to know what her 'lytes are doing -- but of course that information is rarely available to us.

I'd like to know more about the "bruising". Is there a fall history here? Is it suspicious for spousal abuse? Can it be explained? And are these true contusions, or are they purpura? Are we seeing findings and history suggestive of some sort of anemia / thrombocytopenia? Besides the obvious blood in stool / vomitus. Is some sort of coagulopathy at play?

She's hypoglycemic (barely) at 3.2 mmol/L. This could also explain an abnormal neuro exam, and should be corrected. But I'm suspecting that it's not going to be that simple.

Other potential badness: intracranial hemorrhage, neoplasm, subdural, CNS infection, occult GI hemorrhage.

Treatments you will administer?

IV access, see if the patient will tolerate drinking / eating some form of sugary fluid, and some complex carbs. (Not to elicit a cancellation -- they're going to the ER). If they won't, maybe 100ml of D5W. See if normalisation of the bG corrects the neuro deficits.

I'd withhold antiemetics unless the patient is actively vomiting / requesting them. If so, I'd discuss the potential risk to the pregnancy, advise against them for simple nausea.

If vomiting, I'd consider zofran, but would actually probably patch and discuss this with an MD first. [*I know people hate patching, but this is actually not a bad situation in which to get a more educated opinion]

To an ER with neuro.

how sick is this patient?

Probably quite sick. If the abnormal neuro exam remains once the bG has been normalised, and it's truely abnormal (i.e. this isn't baseline), there's something bad happening in the CNS.

will you transport priority?

What's the transport time?

Probably not.

what level hospital will you be transporting too.

Somewhere with CT / neuro.

And most importantly diagnosis.

Nausea / vomiting NYD? AMS?

I guess working diagnosis: hypoglycemia secondary to hyperemesis gravidium.

Differentials: as above.