stroke? or something else?

[DartmouthDave]

Hello,

ER Doc stated:

"What allergy medcine did he take?"

His behaviour could be due to their anticholinergic effect.

Also, a TIA 18 months ago? He is only 41. Can we get a little more information on this?

Lastly, with such a rapid onset. Being normal (but stressed) to a waxing and waning LOC with periods of bizarre behaviour would make me lean away from some of the slow more insidious causes presented.

Thank you

PS...

NYparamedic43 thank you for post a case study.

Edited December 2, 2011 by DartmouthDave

[nypamedic43]

EKG remained normal no matter what state of consciousness he was in. The allergy meds were over the counter. I remember seeing a Claritin box on the kitchen table. The old meds that were in the bathroom, to be honest, the only one that I remember is meclizine.

As for the TIA 18 months ago, the symptoms cleared within an hour of onset and he has had no other incidents with them.

[nypamedic43]

I'm gonna go ahead and tell you all what was going on with this guy.

When I checked up on him a couple hours later, the nurse told me that there was nothing physically wrong with him. He had had a "psychotic break" as she put it. It was brought on by unrelieved stress and his body just decided that it had had enough. He was released home after a few hours of observation...with new prescriptions and a lot of advise from the Doc.

[HERBIE1]

Thanks for the scenario, ny. Because of the history of a TIA, prehospitally I would definitely be thinking some type of cerebral event. As for age- I've had 35 year olds with massive hemorrhagic and thrombotic strokes.

In fact, recently had some poor guy= 42 year old who had classic appendicitis signs- still need to follow up on him. What was remarkable about this guy was his comment to me: "When it rains, it pours." (He's an over the road trucker, and he was in town on a delivery. I asked him what he meant and he said he just found out his wife- also 42- just had a stroke today. Apparently she had her first MI at 32, her 2nd MI at 37, and her first CVA at 40. Wow.

[nypamedic43]

I was really thinking that this guy had a bleed. His behaviour was so bizarre. He most definitly had me thinking...hurt my head

[Bernhard]

My first guess (but I didn't read the whole thread!) would be some kind of seizures/seizure aftermath, DD stroke and intoxication.

the nurse told me that there was nothing physically wrong with him. He had had a "psychotic break" as she put it.

Which may or may not be the real cause. A psychological diagnosis is often too fast and too easy for a hidden somatic background.

It was brought on by unrelieved stress and his body just decided that it had had enough. He was released home after a few hours of observation...with new prescriptions and a lot of advise from the Doc.

Did the patient see a real psychiatrist? Often they come up with astounding obvious somatic diagnoses...(they like that!)

[systemet]

It's hard isn't it --- the most likely explanation for all aberrant behaviour usually falls under "psych". But at the same time, we can't just sit back, and say, hey this is a behavioural issue for fear of missing something serious.

I was leaning towards some sort of complex partial, i.e. psychomotor seizure. I'm not sure how reasonable an idea that was. DartmouthDave brought up an excellent point with a potential anticholinergic toxidrome. These patients present like human ping-pong balls, and are often shaking, delirious, and actively clutching at things in air that others can't see.

Thanks for the post.

[nypamedic43]

I truly felt like there had to be a physical reason for this sudden bizzare behavior. Sudden onset of a diabetic problem, a bleed or an OD of some kind. With the Doc denying narcan, I felt like my hands were tied as far as trying to correct what was wrong. I know that they did a shit-ton of tests and a CT. His wife was scared to death and there wasn't anything that I could tell her that could put her mind at ease.

I do believe that a blanket diagnosis of "psych issues" are over used especially when there is no physical reason for the diagnosis. Dr. Lux hasnt been on duty since that day so I really wasnt able to pick his brain and by the time the weekend is over he probably wont remember the patient. Arnot is on diversion for almost everything and shipping patients to the hospital across town, so general illness, shortness of breath calls etc, are being diverted there. Cardiac, stroke and major trauma can still go to the Arnot as they are the stroke center and have the heart institute and OR suites with staff available.

I just thought that this was an interesting case and by the responses, I wasnt the only one a little stumped by him. It really was a good learning call.

Thanks everyone for participating

edited for spelling

Edited December 3, 2011 by nypamedic43

[Asysin2leads]

Brainstem dysfunction. Seems to fit.