Today's Scenario

[TTLWHKR]

I got this from a med student flash card that my wife had in her study bag..

Male Patient, 20 years of age, collapsed in his dorm, c/c "Feels Faint", began to feel lightheaded 2 hours prior to requesting EMS transport to ER. Nausea & Vomiting, denies any blood in vomit, stools or urine, slight diaphoresis, skin is moist, cool and pale. Pupils are equal and reactive, no sensitivity to light. No meds, no medical history, no allergies; does not smoke or drink, denies recreational drug use. Was sitting when he began to feel sick, had severe dizziness while ambulating, and fell. Denies LOC, or pain from fall, refused to be immobilized by EMS. Also c/o LRQ & URQ Pain, abdomen is non rigid, no point tenderness..

Sinus Tach on monitor
BP: 138/90
HR: 110-120
RR: 20
TMP: 100.0
BGL: 90 mg/dl

---------------
My theory was the flu.. Wife said, nope, not even close, try again...

and wouldn't tell me, no matter how much I guessed.. AND she hid the answer cards. :angry:

 

[AnthonyM83]

Okay, keeping in mind I'm just past the halfway point of my class and haven't read the drug chapter, yet:

My first guess would be patient is under the influence of drugs, possibly ecstacy. This would explain elevated heart, respiration, and temperature rates, as well as poor pupillary reactions and dizziness. If patient was at a rave, this could explain the low blood sugar.

ACTUALLY, If he has low blood sugar, I should automatically be considering the possibility of hypoglycemia, FIRST (I tend to always think of the far off possibilities, I need to keep this in check). So, this would also explain the nausea, vomiting, dizziness, pupils, diaphoresis, HR, RR, light headedness, and not going along with immobilization suggestion (Alt. Mntl Sts?/Dec. LOC?).

I should ask specifically about history of same symptoms, family history or diabetes or similar symptoms, last oral intakes.

Get him some fruit juice (I forget the one kind that's not recommended) with sugar or glucose gel. Administer O2 on non-rebreather. Have him lie down (except when drinking the juice). Take vitals and blood sugar again.


That's the 2nd scenario I've ever done...so be nice?

 

[TTLWHKR]

Originally posted by AnthonyM83@Oct 15 2005, 01:48 AM
Okay, keeping in mind I'm just past the halfway point of my class and haven't read the drug chapter, yet:

My first guess would be patient is under the influence of drugs, possibly ecstacy. This would explain elevated heart, respiration, and temperature rates, as well as poor pupillary reactions and dizziness. If patient was at a rave, this could explain the low blood sugar.

ACTUALLY, If he has low blood sugar, I should automatically be considering the possibility of hypoglycemia, FIRST (I tend to always think of the far off possibilities, I need to keep this in check). So, this would also explain the nausea, vomiting, dizziness, pupils, diaphoresis, HR, RR, light headedness, and not going along with immobilization suggestion (Alt. Mntl Sts?/Dec. LOC?).

I should ask specifically about history of same symptoms, family history or diabetes or similar symptoms, last oral intakes.

Get him some fruit juice (I forget the one kind that's not recommended) with sugar or glucose gel. Administer O2 on non-rebreather. Have him lie down (except when drinking the juice). Take vitals and blood sugar again.


That's the 2nd scenario I've ever done...so be nice?

My first guess would be patient is under the influence of drugs, possibly ecstacy. This would explain elevated heart, respiration, and temperature rates, as well as poor pupillary reactions and dizziness. If patient was at a rave, this could explain the low blood sugar.

Pupils are equal/reactive/non sensitive.. So that means normal for the average person.

As a diabetic, I'd say that 90mg/dl isn't bordering hypoglycemia. Maybe the 70's would be orange juice territory.

My first guess would be patient is under the influence of drugs, possibly ecstacy.

No drugs

 

[ffemt8978]

What's his orthostatic vitals?

 

[RALS504]

Well since we are in a hospital lets get some labs done. I will be paying attention to his white blood count and H & H. I am wondering if his appendix is about to rupture. Can he stand and bounce on his heals or tollerate you lightly striking his heels while he is supine? When was his last bm and does he have active bowels sounds in all quadrants?

 

[TTLWHKR]

Originally posted by ffemt8978@Oct 15 2005, 02:23 AM
What's his orthostatic vitals?

It's a flash card...

I'm giving you everything that I know. Because she won't provide the answer forms. :angry:

 

[Wingnut]

My first guess would be appendicitis or food poisoning, but your wife says it's not even close to flu.... Maybe there's a gas leak in the dorm? CO poisoning?

 

[emtbuff]

I'm agreeging with wingnut about the appendicitis. I don't know if Paramedics can check for rebound tenderness which I was told was a sign of appendicitis from nursing. Or it could also be a bowel obstruction. Check for bowel sounds.


What is his pulse ox??

I would also agree with wingnut about the gas leak but If it was enough some one on the squad would probley notice the smell of gas. CO poisioning is another possibility if it would be during the winter months. I would also susupect this if others in the dorm were ill also.

Also recheck vitals after moving the pt. Start a line for fluids and medications.

I would also check to see how he has been eating, sleeping, and if he has been ill resently with any other problems.

 

[TTLWHKR]

Originally posted by emtbuff@Oct 15 2005, 04:56 PM

What is his pulse ox??

Oops, I thought I had that down there...

SAO2 95%

 

[TTLWHKR]

2nd Card.. I still need the third card for the outcome, I guess these scenarios are that they have 3 ways to treat, if they don't pick 1, the patient dies, one of the three causes death, one treats them, and the other has a serious, but not deadly outcome.. That's how I translated what Jenn told me. So to make it short and sweet, I chose Treatment Route 2.


2nd Card Info:

You haven't pinpointed your patients illness, however you're on the right path.

The patient is now disoriented, with an altered level of consciousness.

Treatment: IV NS Bolus 1000 for 1 hour; LR drip 750 titrate to BP; Oxygen 4L
abd X-Ray, PSA, Labs

Vitals:
HR: 136
BP: 98/64
RR: 28
TMP: 102.5
BGL: 80
SAO2: 96%

PSA:
Positive

Labs:
No drugs or chemicals
Elevated white cell
Anemic

Physical exam:
abdominal tenderness, distension, b.s. present, unkn last bm, heme positive, patient is excessively pale, very diaphoretic,

Possible treatments:
IV Antibiotics
IV Dye
X-ray with contrast
Abdominal Ultrasound



--------------------------------------
I realize this is for medical students, not EMS, but still it's fun to read them.

 

[AnthonyM83]

What's PSA stand for? The prostate antigen test?

Prostate cancer? Or urinary infection?
Go with the ultrasound?

 

[AnthonyM83]

Okay, thinking about it more:

If he has elevated white blood cell count, that points toward some type of infection or something the body's fighting. An appendix would cause this, right? But we've learned the pain starts in the umbilicus and then moves to the RLQ, but the quadrants in this scenario are way off.

Could it be a rupture of something else? What else ruptures in that area? Stomach? Intestines? If it's a GI problem, could the explain falling BGL? (digestion stopped)

The falling BP, elevated temp, decreasing LOC indicates going into shock...sepsis? volemic?

I'd still go with the ultrasound to try and figure out the cause...in the meantime keep the IV going...whatever else might stop the BP drop...vasoconstrictors?


These cards are kinda fun...

 

[Margaritaville]

If not appendicitis I am thinking G.I. Bleed.

Possibly Diverticulitis or Diverticulosis. The only thing is that Pain with these is usually on the left side.

Still, think it is some kind of GI Bleed.

 

[emtbuff]

I also would continue the fluids. With his B/P dropping I would consider some type of internal bleeding. But with the pain in right side it could still be appendix.
The gall bladder is on the right side also so it could be something with the gall bladder.

 

[TTLWHKR]

Card Three, Day Three:

Patients Vitals:
HR: 160
BP: 92/60
RR: 24
TMP: 104.8
BGL: 66mg/dl
SAO2: 98%

X-Ray shows some fluid in the URQ, and a pencil point sized dot. Blood in the stool.
X-Ray of the right flank shows a 1/2" object, smaller than a pin.

What could it be?
Work HX: The patient does not work, he is a student, however he does spend time working in the college machine shop on a grinder.
His mother says that while using a wire brush to clean the grinder, he had a sharp pain in his side, approx 1 week prior. There was no sign of injury, except a tiny speck of blood on his abdomen.

Surgical Outcome.

A 1/2" wire brush strand was found below his right lung, just into the diaphragm. It tore through the ascending color, the gall bladder and the liver before halting in muscle tissue. The 3mm tear caused bleeding into the abdomen and colon. The wire was old and rusted, thus causing pain and sepsis in the wound, yet not show any sign of damage externally. Enough blood was lost to cause the body to go into slow hypovolemic and septic shock.

The patient will survive.

 

[Wingnut]

Wow.


Purty cool cards ...Please sir, may we have another??

 

[Chimpie]

Someone needs to call Dr. House.

 

[TTLWHKR]

Originally posted by Chimpie@Oct 16 2005, 04:34 PM
Someone needs to call Dr. House.

Who?

 

[Jon]

Originally posted by Chimpie@Oct 16 2005, 05:34 PM
Someone needs to call Dr. House.

I don't watch the show, but I concur...

I guess this is proof that sometimes, when you hear hoofbeats, it really is a zebra???


And I was thinking along the infection route..... then the elevated white count and increasing temp were leading me there, and the altered LOC was starting to sound like a bad infection....

I was also thinking of internal bleeding with the anemia and hypotension...

But this outcome was bizzare....


Lets see another

Jon

 

[TTLWHKR]

What show?