Mystery Diagnosis

[JMedic]

ems is dispatched to a local supermarket for a patient with shortness of breath. ambulance paramedics arrived to locate a woman seated complaining of swelling to the face and trouble breathing. this patient has no known allergies and the only medication she is on is motrin with she took this morning without problems. patient also reports feeling light headed and dizzy.

physical assessment is as follows:

respiration rate elevated at approximately 24 to 30.

pulse rate is 100 and weak in the extremities.

blood pressure is low and 70 over 40.

no significant ortho static changes noted.

no cyanosis noted to the distal body or lips

no hives or itching sensation noted anywhere on body

airways open and self maintain

skin is pale cool diaphoretic

no bite marks or insect scars on body

lung sounds are clear in all fields throughout treatment

treatment is as follows:

Ekg twelve lead nsr without ectopy.

Spo2 low 80s room air

02 via nrfm 15lpm

Pt placed trendelenburg on stretcher.

ongoing assessment;

with in approximately 15 to 20 minutes of ems care patient symptoms and signs diminish completely including shortness of breath. patience skin color improves in the blood pressure is up to 110 over 70 and pulse rate is strong in radial areas.

what could this be?

reminder :only treatment given by ems was continuous hi flow oxygen and monitoring

patient has no significant past medical history. patient eats drinks and sleeps appropriately. blood sugar normal. Pt is post menopause. patient reports to have minor symptoms of constipation throughout the past 2 days but has no loose stool or excessive vomiting or any vomiting at all. extremity checks come back on remarkable 4 examination of poor vasculature.

[ambodriver]

Perhaps a clot that resolved on its own. Id encourage a trip to the ER with a line in case the episode were to return. I'd grab the doc and make sure he knew what was going on and what I had observed.

[DFIB]

ems is dispatched to a local supermarket for a patient with shortness of breath. ambulance paramedics arrived to locate a woman seated complaining of swelling to the face and trouble breathing. this patient has no known allergies and the only medication she is on is motrin with she took this morning without problems. patient also reports feeling light headed and dizzy.

physical assessment is as follows:

respiration rate elevated at approximately 24 to 30.

pulse rate is 100 and weak in the extremities.

blood pressure is low and 70 over 40.

no significant ortho static changes noted.

no cyanosis noted to the distal body or lips

no hives or itching sensation noted anywhere on body

airways open and self maintain

skin is pale cool diaphoretic

no bite marks or insect scars on body

lung sounds are clear in all fields throughout treatment

treatment is as follows:

Ekg twelve lead nsr without ectopy.

Spo2 low 80s room air

02 via nrfm 15lpm

Pt placed trendelenburg on stretcher.

I would be interested in what areas of the supermarket she had been through. The potential for allergens in supermarkets are great, fruit from all over the world, cleaning products and packages that have been stored in warehouses all over the country. The absence of hives and itching is troubling but shouldn't exclude an allergic reaction. Did the hospital run a tryptase level or ELISA panel?

[hatelilpeepees]

I dont know why you would do orthostatics on someone whose B/P is 70, since the purpose of orthostatics is to find if there is a need for fluids. With that being said, it is even more uncommon that someone without an orthostatic change would benefit from trendelenburg, which is the only treatment rendered. Therefore, I say it must be an allergic reaction that was rectified by removing the patient from the thing that caused the allergy. No other disease process could be remedied by oxygen and trendelenburg alone. It would not shock me to find that the patient had tried a free sample of something that induced the reaction, or if it was a delayed reaction to the advil. Although this type of reaction is possible due to being close to something and breathing in a scent, it is more likely that something was ingested or held.

[croaker260]

Depending on the time from motrin to onset of s/s, perhaps an anaphylactoid reaction? NSAIDS (motrin and ASA particularly) are associated with certain ideopathic and anaphylactoid reactions as "triggers" required for onset, particularly in exercise induced anaphylaxis. Often S/S will not become readily apparent as they are masked by the hypotension. Once the hypotension is addressed, the patient seems to "erupt" with erythemia, etc.

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Edited August 9, 2011 by croaker260

[Lone Star]

I'd be leaning toward an anaphylactic reaction to a previously unknown allergen. We've seen people develop seasonal allergies that have never had them before, so why wouldn't that apply here?

One question I would like answered is, "Which department of the supermarket was she in when the symptoms started?". Another question is, "Is this a regular supermarket like A&P/Kroger's/IGA, or is it a store like a Super Walmart?

Could it have been induced by another patron? We've all come across those people who seem to think that perfume/cologne is something you bathe in. I had an incident at school where I got into the elevator to go to my classroom, and found that someone who had used the elevator before me had so much perfume on that it was actually suffocatingly heavy in that little metal box.

Based on no urticaria isn't sufficient evidence to rule out anaphylactic reaction. Complaint of 'light headed and dizzy' may be a result of hyperventilation. Did they complain of tingling in the distal extremities?

What was the ambient temp both inside and outside the store?

Any complaint of N/V?

I think that initial treatment would include monitor/high-flow /O₂, IV (NS/KVO), transport.