thegreypilgrim
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Alright nothing too crazy here guys - in fact it's fairly basic - I just want some input here to see if I was on the right track. I had this call as a medic intern.
Dispatch time: 0045
MDC reads: 42 y/o male. 123 Main St. Anytown 12345 c/c "Sick Person"
Arrive on scene to find a 42 year old male, well-nourished, slightly overweight (about 190 lbs. at about 5'8") laying on the bed. No family or friends on scene. BLS crew beat you on scene and opted not to cancel you.
Patient is alert & oriented complains only of sudden onset of severe nausea/vomiting and dizziness. States he has vomited 4 times already in a space of about 2 hours. Has been feeling "sick" for the past 3 days with just general malaise and feels like his "ears are plugged" but no fever. Today symptoms are markedly worse as he now claims he cannot stand up without feeling intensely nauseous and dizzy. Also states something similar has happened to him in the past, went to PCP for it but can't really remember what the Dx was...something to do with eustachian tubes.
Patient denies chest pain, dyspnea/shortness of breath, weakness, abdominal pain. No JVD or pedal edema. Patient has good CSM x 4 equal grips/pushes, no slurred speech, no facial asymmetry, no difficulty swallowing. No hematemesis, no hematuria, no melena/hematochezia, overall normal bowel movements. No pulsatile masses in abdomen.
Vitals are as follows:
BP - 130/86
P - 92
RR - 20 (unlabored and non-adventitious)
SpO2 - 98% (room air)
ECG - NSR no ectopy (sorry guys I don't have a copy)
Skins - pale, cool, & diaphoretic
Pupils - ERRL and consensual
History - Hyperlipidemia, GERD
Allergies - NKDA
Medications - Lipitor, Omeprazole, OTC antacids (Tums)
So, there it is. What are your thoughts as to the etiology of his symptoms and how you'd treat it. Just want to see how my thoughts match up to your guys'. Thanks.
Dispatch time: 0045
MDC reads: 42 y/o male. 123 Main St. Anytown 12345 c/c "Sick Person"
Arrive on scene to find a 42 year old male, well-nourished, slightly overweight (about 190 lbs. at about 5'8") laying on the bed. No family or friends on scene. BLS crew beat you on scene and opted not to cancel you.
Patient is alert & oriented complains only of sudden onset of severe nausea/vomiting and dizziness. States he has vomited 4 times already in a space of about 2 hours. Has been feeling "sick" for the past 3 days with just general malaise and feels like his "ears are plugged" but no fever. Today symptoms are markedly worse as he now claims he cannot stand up without feeling intensely nauseous and dizzy. Also states something similar has happened to him in the past, went to PCP for it but can't really remember what the Dx was...something to do with eustachian tubes.
Patient denies chest pain, dyspnea/shortness of breath, weakness, abdominal pain. No JVD or pedal edema. Patient has good CSM x 4 equal grips/pushes, no slurred speech, no facial asymmetry, no difficulty swallowing. No hematemesis, no hematuria, no melena/hematochezia, overall normal bowel movements. No pulsatile masses in abdomen.
Vitals are as follows:
BP - 130/86
P - 92
RR - 20 (unlabored and non-adventitious)
SpO2 - 98% (room air)
ECG - NSR no ectopy (sorry guys I don't have a copy)
Skins - pale, cool, & diaphoretic
Pupils - ERRL and consensual
History - Hyperlipidemia, GERD
Allergies - NKDA
Medications - Lipitor, Omeprazole, OTC antacids (Tums)
So, there it is. What are your thoughts as to the etiology of his symptoms and how you'd treat it. Just want to see how my thoughts match up to your guys'. Thanks.
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