stroke? or something else?

[nypamedic43]

I've never posted a scenario so bear with me. I had this patient today and will set up the call before I give info.

Called to expedite to a mental health patient by PD. Upon arrival, an officer met me in the driveway and told me that the patient "wasnt right". According to the wife, the patient had not taken any medications and was not a diabetic. Speaking with the wife, she told me that the patient was under a lot of stress lately and that he was sitting at the kitchen table while she was in the bathroom drawing a bath. She came out of the bathroom and the patient had gone into the bedroom, put on undershorts, socks and a work shirt then went into the bathroom and got into the tub, with his clothes on. Wife swore up and down that he hadnt taken any meds except for his allergy medication. She also stated that there was some old medication in the bathroom, but she only had it because she didnt know how or where to dispose of it and she was sure that he hadnt taken any of it.

I walked into the bedroom and found the patient flopped over on the bed with a state trooper standing next to him. The ficer told me that the patient was out cold but just a couple minutes ago the patient sat up, very confused and kept repeating that he had to go to work and then passed out again. He did this again a couple of times while I waited for additional help to extract him from the house. I got a uick medical history from the wife, checked a blood glucose, attempted a Cincinnatti Stroke Scale and did our Fibrinolytic Risk Assessment.

Findings:

blood glucose was 94 mg/dcl.

pulse 78 weak but regular.

respirations 18 regular and nonlabored

skin was cool and dry excpet for the wet clothes

got him out of the house, onto the stretcher and into the ambulance. as we were getting ready to run for the ED, the wife came out and stated that the patient had a TIA 18 months ago and had a nervous breakdown in 1998.

BP 150/100

cardiac monitor normal sinus rhythm

12 lead NSR with no ectopy

lung sounds clear in all fields

IV established and bloods drawn

pupils were pinpoint at 2 and reactive

med control denied narcan as the patient was relatively stable except for the altered mental status.

reassessment of vital signs were BP 142/90,pulse 62 weak but regular, respirations 18 and non labored.

the patient continued to pass out and come to with the confused conversation that he had to go to work.

thoughts?

[Happiness]

I would think Cardiac, I had a patient do the same thing and he had the big jammer in the ER. Did you notice any belching? Our pt was consistanly burping. He survived and had a pace maker implanted.

[nypamedic43]

^{nope there wasnt any belching and the 12 lead showed nothing but could be a NON STEMI. I have the answer because I checked up on him a couple of hours later...but want to play with this a bit lol}

[tcripp]

PMH?

temp?

Edited December 2, 2011 by tcripp

[Happiness]

oh ok i actully thought you were asking a question duhhhhh

[Kaisu]

blood values please. I know, I know, that is not available to us in the rig but I would want to rule out renal and/or hepatic failure, infection, etc

I've seen some renal failure patients with high ammonia act pretty funky.

[DwayneEMTP]

Were you able to complete your stroke scale? How was his diction, facial expressions, bilat extremity movement in general?

Febrile? A trial of Narcan doesn't seem unreasonable assuming that you'd just touch him with .2 or so to see if you got any reaction.

A TIA and a nervous breakdown makes the 'no meds' history questionable in my mind. What kind of environment were they living in? Socioeconomic strata?

Dwayne

[nypamedic43]

Toni the past medical history is a TIA 18 months ago and a nervous breakdown in '98. CM, when I talked to the nurse, the lab values were all normal

Dwayne I was not able to complete the stroke scale because of his AMS but he did obey commands when awake and there was no deviated stare to the right or left. Temp was normal per the nurse, his diction was okay as was his facial expression and he moved his extremities with purpose. The house was very clean and neat and just by looking around the economic status seemed fine as well.

I looked at the old meds that were in the bathroom...no blood thinners or anti depressants

I asked for 2 of narcan and medical control denied the request

Edited December 2, 2011 by nypamedic43

[Kaisu]

OK.. the next thing I would want to rule out is seizures. I once knew of the nicest nun you can imagine, except when she had these bizarre seizures where she came out with curses and swearing that made me blush (I KNOW!). After this activity, she reverted back to the sweet nun she was, with no recall of her colorful phrases and behavior.

[nypamedic43]

no history of seizures CM. you?? blush?? LOL!! and that poor sweet lady :/