ERDoc Posted June 14, 2006 Posted June 14, 2006 A 49y/o female calls because she has been feeling, "some vertigo," has been unable to concentrate/focus, and says she doesn't always see things. This has been happening on occasion since she was in an MVA 1.5 months ago. She states that over the last 3 days it has been getting progressively worse.
madmedic8522 Posted June 14, 2006 Posted June 14, 2006 she sounds a&ox3 so far, is she? vs and PE, pmhx, Rx, allergies? start with some universal cardiac care, o2 via NC 2-6 lpm, EKG, d-stick, iv. was she seen for the mvc, and if so what (if anything) was found? how is her vision, other than noted above, anything else with that? ENT anything remarkable there? good neuro exam, any deficit? what about some orthostatic vs, if the above doesn't show anything significant. any family on scene? do they know of any sz activity? any N&V?
Asysin2leads Posted June 14, 2006 Posted June 14, 2006 Increased cranial pressure caused by a subacute hematoma compressing the second nerve, or optic nerve? I think I should get a cookie if I'm right.
Ridryder 911 Posted June 14, 2006 Posted June 14, 2006 Perform a detailed neuro exam.. obviously nothing will be acutely performed in the field. In the ER, I would get a CT without and await radiologist findings. Get the number for neuro on call. I agree, sounds like she had a slow bleed and now may have some ICP. R/r911
AZCEP Posted June 14, 2006 Posted June 14, 2006 Can we get some more details about the MVA? Injuries sustained, treatment received, position in the vehicle, vehicle damage, etc. Was she placed on any medications following the accident? Any other medical history?
ERDoc Posted June 14, 2006 Author Posted June 14, 2006 She says she was the driver in a low speed MVA. She was hit from behind while stopped at a light. Minor damage to the car. She took the ambulance trip to the ER, but she was not boarded or collared. She had a slight whiplash injury that since gotten better. She was wearing her seat belt and the airbag did not deploy. She was told to take some motrin for pain and vicodin for breakthrough, but never needed the vicodin. She denies any blurred vision, but states that some things to the left seem to disappear and occasionally startle her. She also starts to tell you about a bump on her head that she got when she was on a cruise 6 months ago that has not gone away. Her PMD felt it was a cyst and prescribed milrinone. She denies n&v. Family states there is no history of seizures and they have not witnessed any. PMH is significant for breast ca, s/p mastectomy and chemo 1.5 years ago. She has seasonal allergies for which she takes zyrtec. VS 92 146/84 16 99% on RA She is A&OX3, GCS=15 Pt seems anxious with hurried speech, her hands seem to tremble Visual acuity is 20/20 in both eyes with her glasses on EKG shows STach at 106 FS=106 She has 2+ reflexes througout 5/5 strength in all extremities No asterixis. Pt can do heel to shin and rapid repetitive movements without difficulty. ENT exam is unremarkable. Your ambulance is not one of the really cool ones with a CT scanner or lab. Anything else you want to know about the history or the physical? Do you think this is something legitimate or is it supratentorial?
chbare Posted June 14, 2006 Posted June 14, 2006 Something does not add up. Milrinone for a cyst? We need to verify the accuracy of her history. Take care, chbare.
Punisher Posted June 14, 2006 Posted June 14, 2006 Intimal tear of the vertebral artery secondary to hyperextension injury causing impaired posterior cranial circulation? The loss of vision on one side and lack of other neurological symptoms (other than the trembling of the hands) would seem indicate something involving the cerebellum or occipital lobes.....that's just my guess...... The other consideration would be something along the lines of some form of intracranial infectious process- given the "cyst". What is the patient's temp? And why would the doc prescribe milrinone (Primacor)? Am I missing something in regards to some new off label use?
ERDoc Posted June 14, 2006 Author Posted June 14, 2006 Rectal temp is 98.4 She has the bottle milrinone and says that her PMD says it was for what he thought was cyst on her head. You probe a little further and she says that the reason she decided to call today was that because when she was driving with her father he yelled at her to watch out for a car that was coming straight at her that she never saw. She also noted over the last two days she has been hitting the bushes on the right side of the road when she drives.
chbare Posted June 14, 2006 Posted June 14, 2006 Is there a history of cardiomyopathy or heart failure? What does it say on the bottle? I am still confused as to why she would have been on milrinone for a head cyst. Any recent surgery? Consider a neoplasm with mets, pituitary tumor, intracranial pathology related to her accident, thrombosis, or medication/substance related. History of drug abuse and is she on any other medications? Take care, chbare.
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