Scenario disclaimer.
The purpose of this scenario is to challenge your technical medical knowledge and present conditions that are definitely “outside” the box. I really like the way some scenarios were presented started from the EMS standpoint and moving towards the hospital, so I am going to steal that format. (Imitation being the best form of flattery) Everyone is encouraged to participate, but honestly this is directed to challenge the regulars on the site who have demonstrated medical knowledge well above the average. This case is real and the only details modified were to make it more friendly to the North American members.
There is no need to type out this is beyond the scope of EMS and you would just transport, I am already aware of that.
There is no need to say you would be nice to the patient and hold his hand.
I will do my best to answer all questions as they arise.
Now that we got that out of the way:
Your patient is a 33 year old male. He complains of shortness of breath on exertion and feeling like he is going to pass out when he gets up from sitting too fast.
You arrive on scene to a lower socio-economic class residence, The dwelling appears to be clean, however, in slight disrepair, worn curtains and furniture, unrepaired drywall cracks, etc. The tv is small around 20 inches, and there is no THX stereo system. (nobody here on welfare)
You find the patient surrounded by his family (mother, father, and sister all who seem very upset with him and not very sympathetic) in his room, sitting on the bed, looking nervous. He appears dressed in clean cloths, though old, and is clean and shaven with no dirt under his nails, and overweight.
Vital Signs:
HR: 106 (sinus tach with <8 PVCs/min, some couplets)
BP: 170/110
RR: 14 non labored.
Temperature: 36.5
Spo2: 100% RA (normal waveform)
Capillary glucose: 80
A/B index is normal at 1.0. (not that I regularly do this on scene, but the lack of finding certainly complicates things)
Physical exam findings:
HEENT: Head and face are symmetrical with no deformities or enlarged lymph nodes. Face has a red hue to the skin suborbital extending about 5 cm to the lower part of the mandible and back to the ear. Sclera are white and have multiple small arteries evident. Ears are free of serumen, and tympanic membranes intact, no signs of inflammation or infection. Nose is unremarkable. Inspection of the mouth yields >20 dental carries and widespread destruction of the teeth. There are signs of inflammation throughout the oral cavity , (redness and swelling) Pt. states he takes NSAIDS for pain as needed, but teeth are not bothering him now. Enlargement of the tonsils is noted. Face and neck have obvious fat deposits, but are otherwise normal with no enlargement of the thyroid or local lymphatics. Carotid pulses are present bilaterally with no bruits.
Thorax: Gross signs of central obesity, gynecomastia on front, suprascapular fatpad posterior. No body hair, axillary nodes unremarkable, proportional dimensions of the chest. Lung sounds are clear bilaterally, heart sounds have an easily audible Mitral and Tricuspid regurgitation with a very abnormal clicking sound (not medically described) with the mitral tone. Upon percussion of cardiac boarders, there appears gross enlargement of the myocardium.
Abdomen: Is obese, soft, liver is extended 6cm past the costal margin, no splenomegaly evident, No caput medusa or other signs of poor circulation, diffuse purple striae (stretch marks) are noted circumferentially. Abdominal sounds are present. Genitals appear small, but there is no report of parasympathetic or sympathetic dysfunction upon questioning. Pubic hair is notably absent.
Upper extremities have lower level of obesity than central body, all pulses are present, musculature is atrophied but there is full range of motion without pain. Neuro is intact and redness on the skin similar to the face is noted distally. Body hair is absent
Lower extremities have bilateral pulses, neuro and range of motion normal, no pain, with +2 pitting edema and absent body hair.
The purpose of this scenario is to challenge your technical medical knowledge and present conditions that are definitely “outside” the box. I really like the way some scenarios were presented started from the EMS standpoint and moving towards the hospital, so I am going to steal that format. (Imitation being the best form of flattery) Everyone is encouraged to participate, but honestly this is directed to challenge the regulars on the site who have demonstrated medical knowledge well above the average. This case is real and the only details modified were to make it more friendly to the North American members.
There is no need to type out this is beyond the scope of EMS and you would just transport, I am already aware of that.
There is no need to say you would be nice to the patient and hold his hand.
I will do my best to answer all questions as they arise.
Now that we got that out of the way:
Your patient is a 33 year old male. He complains of shortness of breath on exertion and feeling like he is going to pass out when he gets up from sitting too fast.
You arrive on scene to a lower socio-economic class residence, The dwelling appears to be clean, however, in slight disrepair, worn curtains and furniture, unrepaired drywall cracks, etc. The tv is small around 20 inches, and there is no THX stereo system. (nobody here on welfare)
You find the patient surrounded by his family (mother, father, and sister all who seem very upset with him and not very sympathetic) in his room, sitting on the bed, looking nervous. He appears dressed in clean cloths, though old, and is clean and shaven with no dirt under his nails, and overweight.
Vital Signs:
HR: 106 (sinus tach with <8 PVCs/min, some couplets)
BP: 170/110
RR: 14 non labored.
Temperature: 36.5
Spo2: 100% RA (normal waveform)
Capillary glucose: 80
A/B index is normal at 1.0. (not that I regularly do this on scene, but the lack of finding certainly complicates things)
Physical exam findings:
HEENT: Head and face are symmetrical with no deformities or enlarged lymph nodes. Face has a red hue to the skin suborbital extending about 5 cm to the lower part of the mandible and back to the ear. Sclera are white and have multiple small arteries evident. Ears are free of serumen, and tympanic membranes intact, no signs of inflammation or infection. Nose is unremarkable. Inspection of the mouth yields >20 dental carries and widespread destruction of the teeth. There are signs of inflammation throughout the oral cavity , (redness and swelling) Pt. states he takes NSAIDS for pain as needed, but teeth are not bothering him now. Enlargement of the tonsils is noted. Face and neck have obvious fat deposits, but are otherwise normal with no enlargement of the thyroid or local lymphatics. Carotid pulses are present bilaterally with no bruits.
Thorax: Gross signs of central obesity, gynecomastia on front, suprascapular fatpad posterior. No body hair, axillary nodes unremarkable, proportional dimensions of the chest. Lung sounds are clear bilaterally, heart sounds have an easily audible Mitral and Tricuspid regurgitation with a very abnormal clicking sound (not medically described) with the mitral tone. Upon percussion of cardiac boarders, there appears gross enlargement of the myocardium.
Abdomen: Is obese, soft, liver is extended 6cm past the costal margin, no splenomegaly evident, No caput medusa or other signs of poor circulation, diffuse purple striae (stretch marks) are noted circumferentially. Abdominal sounds are present. Genitals appear small, but there is no report of parasympathetic or sympathetic dysfunction upon questioning. Pubic hair is notably absent.
Upper extremities have lower level of obesity than central body, all pulses are present, musculature is atrophied but there is full range of motion without pain. Neuro is intact and redness on the skin similar to the face is noted distally. Body hair is absent
Lower extremities have bilateral pulses, neuro and range of motion normal, no pain, with +2 pitting edema and absent body hair.
) and if I feel like playing on-scene, an orthostatic set of blood pressures. For the most part I am comfortable calling him stable and transporting. I am curious if there is a cardiac disturbance that arises with exertion, and his pitting edema at his age concerns me :wacko: .
