Interesting call

slb862

slb862

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called for a 44 yo f acting strange.

UAF 44 yo f, sitting, at home, early evening. Warm outside. Pt. stated she didn't feel right. Police has had no dealing with her prior.
Prior to arrival, pt. had vomited x1, complains of headache right between the eyes. Photophobia. Teenage son comes home from school and finds her sleeping on couch. EMS called about4 hours after son comes home.

Noted slurring of speech, uncoordinated in movements, and confusion. Pupils reactive at 4mm. No fever, no CP, no SOB. No recent illness. No diarrhea, no urgency to urination. Denies trauma. Blood sugar 100. Cincinnati Stroke score-negative. Denies ETOH, Denies street drug use. No allergies. Medications-xanax (which she had not taken since Feb.) No PMH - except anxiety.

Pt. ambulated to ambulance with assistance, very unsteady gait.
VS- BP-normal, P-100 R- 24. 3 and 12 lead EKG shows Sinus Rhythm. IV established. Pt. complains of pain 8/10 to head and abdomin area, along with nausea, enroute to hospital. Zofran 2mg for nausea, Fentanyl 50mcg for pain, and total of 2mg Lorazepam for anxiety. No changes in VS.
Hospital- ETOH .00, Head CT - negative, drugs - none, Lab- nothing out of the norm. (some more labs were ordered like amonia) No to mennigitis. Admitted to hospital. Pt. took a turn for the worse, and was transferred to a higher level of care. Any guesses?

I now know what caused this to happen...
Please ask questions if needed.

Thanks, it has been a long time since I have been here. Happy EMS Week to all. Stay Safe out there!!
 
Septic?

I have also heard of high ammonia levels causing people to act a little weird.

Stroke (The Cincinnati stroke test doesn't get them all)?


Good case.
 
Noted slurring of speech, yet a noted neg stroke scale?
 
truetiger said:
Noted slurring of speech, yet a noted neg stroke scale?
Click to expand...

Thats what I was thinking.....pretty sure that is a positive stroke scale finding. As to my own differential....if I was in that position with that presentation and vitals....I dunno....I would be thinking stroke probably but its definitely confusing. Sepsis is a possibility but I would expect the vitals to start reflecting it a little more.......

Some kind of tumor?......poisoning of some kind?......
 
Cerebral aneurysm, maybe?

I thought sepsis too, but when I've come across it in the field they typically have elevated vitals (but that's just been my experience, which doesn't mean much).
 
Last edited by a moderator:
Not sepsis, not a migraine, not a tumor, or cerebral aneurysm. I used the Cincinnati Stroke scale as a basis, since that was negative, I felt the need to go in a different direction. Good thoughts though. My partner and I were truely stumped.
 
My vote is a cerebellar stroke, or a complicated migraine. How exactly did the ED rule these out? If they did, then I guess its time to get weird. First zebra that popped in my head reading this was AIP, but I would find it strange if her first attack was at 44 years old.
 
It's lupus!!!!!!

/House reference.
 
Things to consider that I noticed.

BP is not normal when the pt is borderline tachy.

I saw no information on LMP, pregnancy, recent surgery/abortion.
 
I'm probably far off, but I'll take a swing at it.

Mono

I've currently had/going through it the last month or so. Besides the other fun infections it brought with it, I've had many of these symtoms listed but primarily in the Incubation stage of the virus. Mono is a twisted infection to say the least.
 
What was her physical exam like? Full Neuro exam?

What was she doing prior to this?
Any out of ordinary activities in past couple days?
Any exposure to toxins in past few days at work or home? Fumes? CO?
Eat anything strange/different recently?
Anyone else in household recently sick or become sick?
When y'all arrived any clues in the house/environment...well kept?

In the ED what else was done, MRI? LP?
 
I was thinking migraine to start, than possibly a cerebral aneurysm or CVA.

but it wouldn't be the last two, since the CT scan was negative, and you usually don't deteriorate enough to be transferred from a migraine.

hmmmm
 
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